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 The level of coverage is the same as network provider. The level of coverage is the same as network provider. Education Asthma Management $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% 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: Your copayment Does the 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. 20% YES 40% 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. 20% YES 40% YES 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. 20% YES 40% 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 20% YES 40% 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: 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. 20% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 NO 40% YES Hospital based clinic visits for adults $40 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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: 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) Primary Care Physician (PCP) (continued) 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. $25 NO Podiatrist Services Routine foot care is not covered. $40 NO 40% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40% YES Specialist Visits Routine and non- routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?

Early Intervention Services (EIS). For children Coverage provided for members from birth to 36 months months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO The level of coverage is the same as network provider. The level of coverage is the same as network provider. Education - Asthma Management Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% YES 150 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 Experimental and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Investigational 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. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Gender Affirming Services* Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing Services Hearing exam $30 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid. 20% YES 40% YES - After deductible The level of coverage is the same as network provider. Home Health Care In your home Care* 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. 200% YES 40% YES - After deductible Not Covered Hospice Care Inpatient/in your home 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. 200% YES 40% 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. - After deductible Not Covered Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20leukocyte antigen testing 0% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network provider For a covered heath care service you pay: Providers Non-network provider For a covered health care Providers (*) Preauthorization may be required for this service you pay or for certain services in the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Infertility Inpatient/ Services* Inpatient/outpatient/in a doctorphysician’s office office. Three (3) infertility treatment in-vitro fertilization cycles will be covered per benefit plan year with a total of eight (8) infertility treatment in-vitro fertilization 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. 20% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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: Your copayment Does the - After deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 NO 40% YES Hospital based clinic visits for adults $40 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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: 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) Primary Care Physician (PCP) (continued) 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. $25 NO Podiatrist Services Routine foot care is not covered. $40 NO 40% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40% YES Specialist Visits Routine and non- routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?Not Covered

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. YES The level of coverage is the same as network provider. Education Asthma Management $0 NO 400% YES 20% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Hearing Exam 0% YES 20% YES Diagnostic Testing 0% YES 20% 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. 0% 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. 20% YES 40% 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. 200% YES 40% YES 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. 20% YES 40% 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 20% YES 40% 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: 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 0% YES 20% YES of service and site of service. See Summary of Pharmacy Benefits for details. Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $150 YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES 20% 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. 200% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% 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. 0% YES 20% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. $200 Copay per admission YES 20% YES Inpatient Physician Hospital Visits Inpatient 200% YES 4020% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. $200 Copay per admission YES 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 NO 40% YES Hospital based clinic visits for adults $40 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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: 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) Allergist & Dermatologist $40 YES 20% YES Hospital based clinic visits for adults $40 YES 20% YES House Calls rendered by Primary Care Physician (PCP) (continued) 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. $25 NO 35 House Calls rendered by Specialist $40 YES 20% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 YES 20% YES PCP does NOT practice with PCMH model of care. $35 YES Primary Care Physician (PCP) PCP practices with PCMH model of care. $15 YES 20% YES PCP does NOT practice with PCMH model of care. $35 YES Podiatrist Services Routine foot care is not covered. $40 NO 40YES 20% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40YES 20% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Office Visits (continued) Specialist Visits Routine and non- routine visits. $40 NO 40YES 20% YES Organ Transplants 200% YES 4020% YES Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. $40 YES 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES 20% YES 40Prescription 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 0% YES 20% YES Infused drugs 0% YES 20% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?.

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 The level of coverage is the same as network provider. The level of coverage is the same as network provider. Education Asthma Management $0 NO 400% 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 $40 NO 400% YES Not Covered Not Covered Diagnostic Testing 200% YES 40% 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. 200% 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: Your copayment Does the 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. 200% YES 40% 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. 200% YES 40% 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. 200% YES 40% 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 200% YES 40% 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. 200% YES 20% YES Not 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. 200% YES 40% 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. 200% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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? Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 200% YES 40% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 200% YES 40% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 30 NO 40% YES Not Covered Not Covered Hospital based clinic visits for adults $40 30 NO 40% YES Not Covered Not Covered House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES Not Covered Not Covered PCP does NOT not practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 30 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) 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) (continued) Subsequent non- See Prevention and Early Detection Services for coverage of annual preventive office visits in the calendar year - visit. 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. $25 NO Podiatrist Services Routine foot care is not covered. $40 30 NO 40% YES Not Covered Not Covered Retail Clinics See Section 3.23 – Office Visits for details. $40 30 NO 40% YES Not Covered Not Covered Specialist Visits Routine and non- routine visits. $40 30 NO 40Not Covered Not Covered Organ Transplants 0% YES Organ Transplants 20% YES 40% 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? Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 200% YES 40% YES Not Covered Not Covered Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 200% YES 40Not 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 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?.

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 The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management $0 NO 400% YES Not Covered Not Covered Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Hearing Exam $40 NO 400% YES Not Covered Not Covered Diagnostic Testing 200% YES 40% 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. 20% YES The level of coverage is the same as network provider. 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? 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. 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. 20% YES 40% 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. 200% YES 40% YES 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. 20% YES 40% 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 20% YES 40% 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. 0% YES Not 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 Testing Human Leukocyte Antigen Testing 0% 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. 200% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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? 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 200% YES 40% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 200% YES 40% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Office Visits Allergist & Dermatologist $40 NO 400% YES Not Covered Not Covered Hospital based clinic visits for adults $40 NO 400% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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? Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Primary Care Physician (PCP) (continued) Subsequent non- preventive Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits in rendered by a PCP, except the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- annual preventive care office visits in the calendar year - PCP does not practice with PCMH model of carevisits. $25 NO Podiatrist Services Routine foot care is not coveredNot Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. $40 NO 400% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40Not Covered Not Covered House Calls rendered by Specialist 0% YES Specialist Visits Routine and non- routine Not Covered Not Covered Pediatric Clinic 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. $40 25 NO 40Not Covered Not Covered Office Visits (other than Subsequent submitted claims for sick office visits in a benefit year. 0% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Not Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% YES 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, other than Specialty Prescription drugs, dispensed office visits for Behavioral Health and administered by a licensed health care provider annual preventive care) Primary Care Physician (other than a pharmacistPCP) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit One (1) routine adult physical examination per in a benefit year per member will be 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% NO 40% YES Well woman annual preventive visit One (1) Not Covered Not Covered Specialist Visits Routine and non- routine gynecological examination per benefit year per female member will be coveredvisits. 0% NO 40YES Not Covered Not Covered Organ Transplants 0% 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. 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? Prevention Pregnancy Services and Early Detection Services (continued) Pediatric preventive office visit WellNursery Care Pre-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugsnatal, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enemadelivery, and fecal occult blood tests, screening for gestational diabetes, and human papillomaviruspostpartum services. 0% NO 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women 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. For prescription Are included in the allowance for the medical service being rendered. Injectable drugs purchased 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Prescription Drugs Purchased at a pharmacyRetail, see the Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits. 0% NO 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services Benefits for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?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. The level of coverage is the same as network provider. Education Asthma Management $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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. 2010% YES 4030% 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. 2010% YES 40% YES 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. 20% YES 40% 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 20% YES 4030% 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: 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. 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. 2010% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 4030% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 2010% YES 4030% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 2010% YES 4030% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 50 NO 4030% YES Hospital based clinic visits for adults $40 50 NO 4030% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 4030% YES PCP does NOT practice with PCMH model of care. $25 35 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 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 40% 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: 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. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) (continued) 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. $25 35 NO Podiatrist Services Routine foot care is not covered. $40 50 NO 4030% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 50 NO 4030% YES Specialist Visits Routine and non- routine visits. $40 50 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 4030% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 2010% YES 4030% YES Infused drugs 2010% YES 4030% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?

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 The level of coverage is the same as network provider. The level of coverage is the same as network provider. Education Asthma Management $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% 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: Your copayment Does the 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. 20% YES 40% 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. 20% YES 40% YES 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. 20% YES 40% 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 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing 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. 20% 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 20% YES 40% YES Benefits for details. Coverage varies based on type of hemophilia service. 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 20% YES 40% YES 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 20% YES 40% YES of service and site of service. 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% 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. 20% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% YES Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 NO 40% YES Hospital based clinic visits for adults $40 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $25 15 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 40% 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: 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) Pediatric Clinic visit For a member nineteen (continued19) and older $25 NO Primary Care Physician (PCP) (continued) 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 - 40% YES PCP does not NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO Podiatrist Services Routine foot care is not covered. $40 NO 40% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40% YES Specialist Visits Routine and non- routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES 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. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% YES Prescription drugs, other than Specialty Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. 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, 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?.

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 The level of coverage is the same as network provider. NO The level of coverage is the same as network provider. Education Asthma Management $0 NO 40% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 55 NO 40% YES Diagnostic Testing 20% YES 40% 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. 20% 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: Your copayment Does the 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. 20% YES 40% 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. 20% YES 40% YES 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. 20% YES 40% 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 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20% YES 40% 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. 20% YES 20% YES 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. 20% YES 40% 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. 20% YES 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 55 NO 40% YES Hospital based clinic visits for adults $40 55 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 20 NO 40% YES PCP does NOT practice with PCMH model of care. $25 40 NO House Calls rendered by Specialist $40 55 NO 40% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 20 NO 40% YES PCP does NOT practice with PCMH model of care. $25 40 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 40% 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: 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) Primary Care Physician (PCP) (continued) Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 20 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $25 40 NO Podiatrist Services Routine foot care is not covered. $40 55 NO 40% YES Retail Clinics See ClinicsSee Section 3.23 – Office Visits for details. $40 50 NO 40% YES Specialist Visits Routine and non- non-routine visits. $40 55 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? 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 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per benefit year. 0% NO 40% YES 1 per benefit year. Pediatric preventive clinic 0% NO 40% YES clinic Diabetes education Individual and group sessions are covered. 0% NO 40% YES education sessions are covered. Nutritional counseling Unlimited visits per counseling benefit year when prescribed by a physician. 0% NO 40% YES physician. Smoking cessation counseling For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 40% YES Summary of Pharmacy Benefits. Adult Immunization 0% NO 40% YES Pediatric Immunization Pediatric 0% NO 40% YES Travel Immunization Travel 0% NO 40% YES Immunization Allergy injections Applies to injection injections only including administration. 20% YES 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) 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 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES 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 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 40% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive Prevention and Sterilization Early Detection Services for women (continued) Surgical services, including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES Manual breast pumps In conjunction with birth. 0% NO 40% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative servicesservices . 20% YES 40% YES Surgery Services Inpatient 20% YES 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 25 NO 40% 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply?