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

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Hospital emergency room $150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing $30 Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered Hospital emergency room $150 200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 50 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered Hospital emergency room $150 200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 50 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 020% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered Hospital emergency room $150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing $30 Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered Hospital emergency room $150 200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 45 Not Covered Hearing diagnostic testing $30 Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered

Early Intervention Services (EIS). Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. Asthma management 0% Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered Hospital emergency room $150 200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $40 Not Covered Hearing diagnostic testing $30 0% Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered