Common use of Emergency Room Benefits Clause in Contracts

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 35% 35% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptives) 35% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 35% 35% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptives) 35% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6%

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3530% 3530% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3530% $100 per visit plus 3530% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35$250 per admission plus 30% 35$250 per admission plus 30% 10 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptivescontracep- tives) 3530% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3530% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3530% Not covered Vasectomy 3530% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Calen- dar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational oc- cupational therapist. 3530% Not covered 12 13 Medical supplies 3530% Not covered 12 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3530% Not covered 12 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Injectable Services Calendar Year visit limitation.) 3530% Not covered 12 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3530% Not covered 13 14 General Inpatient care 3530% Not covered 13 14 Inpatient Respite Care You pay nothing Not covered 13 14 Pre-hospice consultation You pay nothing Not covered 13 14 Routine home care You pay nothing Not covered 13 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35$250 per admission plus 30% 35$250 per admission plus 30% 14 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- pliessupplies, including Subacute Sub acute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Bar- iatric Surgery Benefits for Residents of Designated Counties in California sectionsec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Sub acute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices Services whether rendered in a Hospital or a free-standing Skilled Nursing Facili- tyFacility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3530% 50% Inpatient Services to treat acute medical complications of detoxification 35$250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory labor- atory services 3530% 50% of up to $500 per day 14 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3530% 50% of up to $300 per day 14 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3530% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3530% 50% of up to $300 per day Inpatient Hospital Services 35$250 per admission plus 30% 50% of up to $500 per day 14 15 Office location 35% $35 per visit 50% Outpatient department of a Hospital 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Pro- viders 18 Inpatient Hospital services 35$250 per admission plus 30% 50% of up to $500 per day 18 day18 Inpatient Professional services 35% You pay nothing 50% Residential care for Mental Health Condition 35$250 per admission plus 30% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 3530% 50% Behavioral Health Treatment in an office setting 3530% 50% Electroconvulsive Therapy (ECT) 18 3519 30% 50% Intensive Outpatient Program 18 3519 30% 50% Partial Hospitalization Program 19 3520 30% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3530% 50% Transcranial magnetic stimulation 3530% 50% Professional (Physician) office visits 35% $35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics orthot- ics Services. Office visits 35% $35 per visit 50% Orthotic equipment and devices 3530% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 64

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 35% 35% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 $500 per admission Family Planning and Infertility Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility bene- fit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauterine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contra- ceptivesimplantable contraceptives) 35% Not covered You pay nothing Diaphragm fitting procedure When administered You pay nothing Elective abortion $100 per surgery Implantable contraceptives You pay nothing Infertility Services Diagnosis and treatment of cause of Infertility (in an office location, this is in addition to the Physician office visit Copayment. 35vitro fertiliza- tion and artificial insemination not covered) 50% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered You pay nothing Insertion and/or removal of intrauterine device (IUD) You pay nothing Intrauterine device (IUD) You pay nothing Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered You pay nothing Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits $75 per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. surgery Home health care agency Services, Services (including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is ) Up to a combined Benefit maximum of 90 100 visits per Member per Calendar Year for all Home Health per Member by home health care agency providers. $20 per visit Medical supplies and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the laboratory Services are first provided even if the Calendar Year medical Deductible has not been met. You pay nothing Hemophilia home infusion Services provided by a hemophilia infusion provider Hemophilia Infusion Provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/You pay nothing Hemophilia therapy home intravenous injectable therapy infusion nursing visit provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under Hemophilia Infu- sion Provider and prior authorized by the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse Plan (Home infusion agency nursing Nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 35% 35% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 $100 per admission Family Planning and Infertility Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility bene- fit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauter- ine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contra- ceptivesimplantable contraceptives) 35% Not covered You pay nothing Diaphragm fitting procedure When administered You pay nothing Elective abortion $100 per surgery Implantable contraceptives You pay nothing Infertility Services Diagnosis and treatment of cause of Infertility (in an office location, this is in addition to the Physician office visit Copayment. 35vitro fertili- zation and artificial insemination not covered) 50% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered You pay nothing Insertion and/or removal of intrauterine device (IUD) You pay nothing Intrauterine device (IUD) You pay nothing Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered You pay nothing Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits $50 per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. surgery Home health care agency Services, Services (including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is ) Up to a combined Benefit maximum of 90 100 visits per Member per Calendar Year for all Home Health per Member by home health care agency providers. You pay nothing Medical supplies and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the laboratory Services are first provided even if the Calendar Year medical Deductible has not been met. You pay nothing Hemophilia home infusion Services provided by a hemophilia infusion provider Hemophilia Infusion Provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/You pay nothing Hemophilia therapy home intravenous injectable therapy infusion nursing visit provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under Hemophilia Infu- sion Provider and prior authorized by the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse Plan (Home infusion agency nursing Nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6nothing

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at the applicable Pre- ferred denied and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. 35% 35% You pay nothing Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective retrospective review. If this review determines that Services were provided for a medical condition condi- tion that a person would not have reasonably believed was an emergency medical condition, Benefits will may be paid at denied and the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will would not be subject to any Calendar Year medical Deductiblecovered. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed Billed as part of Inpa- tient Inpatient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 You pay nothing Family Planning and Infertility Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc.), the facility Copayment listed under the appropriate facility bene- fit Benefit in the Summary this Sum- xxxx of Benefits will also apply, except for insertion and/or removal of intrauter- ine device (IUD), intrauterine device (IUD), and tubal ligation. Counseling and consulting (Including Physician office visits for diaphragm fitting fitting, injectable contraceptives, or injectable contra- ceptivesimplantable contraceptives) 35% Not covered You pay nothing Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation Elective abortion $100 per surgery Implantable contraceptives You pay nothing Not covered 13 Routine home care Infertility Services Diagnosis and treatment of cause of Infertility (in vitro fertili- zation and artificial insemination not covered) 50% Injectable contraceptives You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents Insertion and/or removal of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. intrauterine device (See Non-Preferred payment example belowIUD) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6Intrauterine device (IUD) You pay nothing Tubal ligation You pay nothing Vasectomy $75 per surgery

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3530% 3530% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3530% $100 per visit plus 3530% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35$250 per admission plus 30% 35$250 per admission plus 30% 10 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptivescontracep- tives) 3530% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3530% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3530% Not covered Vasectomy 3530% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Calen- dar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational oc- cupational therapist. 3530% Not covered 12 13 Medical supplies 3530% Not covered 12 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3530% Not covered 12 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Injectable Services Calendar Year visit limitation.) 3530% Not covered 12 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3530% Not covered 13 14 General Inpatient care 3530% Not covered 13 14 Inpatient Respite Care You pay nothing Not covered 13 14 Pre-hospice consultation You pay nothing Not covered 13 14 Routine home care You pay nothing Not covered 13 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35$250 per admission plus 30% 35$250 per admission plus 30% 14 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- pliessupplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Bar- iatric Surgery Benefits for Residents of Designated Counties in California sectionsec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices Services whether rendered in a Hospital or a free-standing Skilled Nursing Facili- tyFacility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3530% 50% Inpatient Services to treat acute medical complications of detoxification 35$250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory labor- atory services 3530% 50% of up to $500 per day 14 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3530% 50% of up to $300 per day 14 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3530% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3530% 50% of up to $300 per day Inpatient Hospital Services 35$250 per admission plus 30% 50% of up to $500 per day 14 15 Office location 35% $40 per visit 50% Outpatient department of a Hospital 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Pro- viders 18 Inpatient Hospital services 35$250 per admission plus 30% 50% of up to $500 per day 18 day18 Inpatient Professional services 35% You pay nothing 50% Residential care for Mental Health Condition 35$250 per admission plus 30% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 3530% 50% Behavioral Health Treatment in an office setting 3530% 50% Electroconvulsive Therapy (ECT) 18 3519 30% 50% Intensive Outpatient Program 18 3519 30% 50% Partial Hospitalization Program 19 3520 30% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3530% 50% Transcranial magnetic stimulation 3530% 50% Professional (Physician) office visits 35% $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics orthot- ics Services. Office visits 35% 50% $40 per visit Not covered Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 3530% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Emergency Room Benefits. Emergency room Room Physician Services services Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Outpatient Physician Services Benefit in the Professional Profes- sional (Physician) Benefits Benefits, “Outpatient Physician services, other than an office setting” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. 3520% 3520% Emergency room Services Room services not resulting in admission Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Hospital Bene- fits Benefits (Facility Services), “Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptives) 35% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemotherapy and necessary supplies neces- sary supplies” in this Summary of Benefits. $100 per visit plus 20% $100 per visit plus 20% Emergency Room services resulting in admission (See Non-Preferred payment example belowbilled as part of inpatient Hospital services) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50100 per admission plus 20% Subscriber contribution=Subscriber payment of up to $250 35100 per admission plus 20% 50% of up to $500 per day 14 Benefit Member Copayment 4 3 Services by Preferred, Participating, and Other Providers 5 4 Services by Non-Preferred Pre- ferred and Non-Participating Partici- pating Providers 6 Medical Treatment for the Teeth5 Family Planning Benefits1, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) 7 Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits Copayments listed in this section are for diagnosticoutpatient Physi- cian services only. If services are performed at a facility (Hospi- tal, non-preventive health Ser- vices. For Benefits for Preventive Health ServicesAmbulatory Surgery Center, see etc.), the Preventive Health Benefits section of this facility Copayment listed under the applicable facility benefit in the Summary of Benefits. For Benefits will also apply, except for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section insertion and/or removal of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting intrauterine device (Hospital or Outpatient FacilityIUD), an additional facility Coinsurance/Copayment may applyintrauterine device (IUD), and tubal ligation. 35% 50% Prenatal Counseling and postnatal consulting (Including Physician office visitsvisit for diaphragm fitting, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Papinjectable contraceptives or implantable contraceptives.) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6Diaphragm fitting procedure You pay nothing Not covered Implantable contraceptives You pay nothing Not covered Injectable contraceptives You pay nothing Not covered Insertion and/or removal of intrauterine device (IUD) You pay nothing Not covered Intrauterine device (IUD) You pay nothing Not covered Tubal ligation You pay nothing Not covered Vasectomy 20% Not covered

Emergency Room Benefits. Emergency room Room Physician Services services Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Outpatient Physician Services Benefit in the Professional Profes- sional (Physician) Benefits Benefits, “Outpatient Physician services, other than an office setting” in this Summary of Benefits and will be subject to any Calendar Year medical DeductibleBenefits. 3510% 3510% Emergency room Services Room services not resulting in admission admission1 Note: After Services services have been provided, Blue Shield may conduct con- duct a retro- spective retrospective review. If this review determines that Services ser- vices were provided for a medical condition that a person would not have reasonably believed was an emergency medical conditioncondi- tion, Benefits will be paid at the applicable Pre- ferred and Participating or Non-Preferred Participating Provider levels as specified under Hospital Bene- fits Benefits (Facility Services), “Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptives) 35% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemotherapy and necessary supplies neces- sary supplies” in this Summary of Benefits. $100 per visit plus 10% $100 per visit plus 10% Emergency Room services resulting in admission (See Non-Preferred payment example belowbilled as part of inpatient Hospital services) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50100 per admission plus 10% Subscriber contribution=Subscriber payment of up to $250 35100 per admission plus 10% 50% of up to $500 per day 14 Benefit Member Copayment 4 3 Services by Preferred, Participating, and Other Providers 5 4 Services by Non-Preferred Pre- ferred and Non-Participating Partici- pating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones 5 Family Planning Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Inpatient Hospital services 35% 50% of up $500 per day 18 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) 7 Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits Copayments listed in this section are for diagnosticoutpatient Physi- cian services only. If services are performed at a facility (Hospi- tal, non-preventive health Ser- vices. For Benefits for Preventive Health ServicesAmbulatory Surgery Center, see etc.), the Preventive Health Benefits section of this facility Copayment listed under the applicable facility benefit in the Summary of Benefits. For Benefits will also apply, except for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section insertion and/or removal of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting intrauterine device (Hospital or Outpatient FacilityIUD), an additional facility Coinsurance/Copayment may applyintrauterine device (IUD), and tubal ligation. 35% 50% Prenatal Counseling and postnatal consulting 1 (Including Physician office visitsvisit for diaphragm fitting, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Papinjectable contraceptives or implantable contraceptives.) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6Diaphragm fitting procedure 1 You pay nothing Not covered Implantable contraceptives 1 You pay nothing Not covered Injectable contraceptives 1 You pay nothing Not covered Insertion and/or removal of intrauterine device (IUD) 1 You pay nothing Not covered Intrauterine device (IUD) 1 You pay nothing Not covered Tubal ligation 1 You pay nothing Not covered Vasectomy 10% Not covered

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3530% 3530% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3530% $100 per visit plus 3530% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35$250 per admission plus 30% 35$250 per admission plus 30% 10 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptivescontracep- tives) 3530% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3530% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3530% Not covered Vasectomy 3530% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Calen- dar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational oc- cupational therapist. 3530% Not covered 12 13 Medical supplies 3530% Not covered 12 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3530% Not covered 12 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Injectable Services Calendar Year visit limitation.) 3530% Not covered 12 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3530% Not covered 13 14 General Inpatient care 3530% Not covered 13 14 Inpatient Respite Care You pay nothing Not covered 13 14 Pre-hospice consultation You pay nothing Not covered 13 14 Routine home care You pay nothing Not covered 13 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35$250 per admission plus 30% 35$250 per admission plus 30% 14 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- pliessupplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Bar- iatric Surgery Benefits for Residents of Designated Counties in California sectionsec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices Services whether rendered in a Hospital or a free-standing Skilled Nursing Facili- tyFacility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3530% 50% Inpatient Services to treat acute medical complications of detoxification 35$250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory labor- atory services 3530% 50% of up to $500 per day 14 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3530% 50% of up to $300 per day 14 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3530% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity deform- ity (Be sure to read the Principal Benefits and Coverages (Covered Services) section sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3530% 50% of up to $300 per day Inpatient Hospital Services 35$250 per admission plus 30% 50% of up to $500 per day 14 15 Office location 35% $45 per visit 50% Outpatient department of a Hospital 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 16 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Pro- viders 18 Inpatient Hospital services 35$250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services 35% You pay nothing 50% Residential care for Mental Health Condition 35$250 per admission plus 30% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 3530% 50% Behavioral Health Treatment in an office setting 3530% 50% Electroconvulsive Therapy (ECT) 18 3519 30% 50% Intensive Outpatient Program 18 3519 30% 50% Partial Hospitalization Program 19 3520 30% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3530% 50% Transcranial magnetic stimulation 3530% 50% Professional (Physician) office visits 35% $45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics orthot- ics Services. Office visits 35% $45 per visit 50% Orthotic equipment and devices 3530% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 64

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3530% 3530% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3530% $100 per visit plus 3530% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35$250 per admission plus 30% 35$250 per admission plus 30% 10 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptivescontracep- tives) 3530% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3530% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3530% Not covered Vasectomy 3530% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Calen- dar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational oc- cupational therapist. 3530% Not covered 12 13 Medical supplies 3530% Not covered 12 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3530% Not covered 12 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Injectable Services Calendar Year visit limitation.) 3530% Not covered 12 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3530% Not covered 13 14 General Inpatient care 3530% Not covered 13 14 Inpatient Respite Care You pay nothing Not covered 13 14 Pre-hospice consultation You pay nothing Not covered 13 14 Routine home care You pay nothing Not covered 13 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35$250 per admission plus 30% 35$250 per admission plus 30% 14 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- pliessupplies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Bar- iatric Surgery Benefits for Residents of Designated Counties in California sectionsec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices Services whether rendered in a Hospital or a free-standing Skilled Nursing Facili- tyFacility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3530% 50% Inpatient Services to treat acute medical complications of detoxification 35$250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory labor- atory services 3530% 50% of up to $500 per day 14 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3530% 50% of up to $300 per day 14 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3530% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3530% 50% of up to $300 per day Inpatient Hospital Services 35$250 per admission plus 30% 50% of up to $500 per day 14 15 Office location 35% $40 per visit 50% Outpatient department of a Hospital 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Pro- viders 18 Inpatient Hospital services 35$250 per admission plus 30% 50% of up $500 per day 18 Inpatient Professional services 35% You pay nothing 50% Residential care for Mental Health Condition 35$250 per admission plus 30% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 3530% 50% Behavioral Health Treatment in an office setting 3530% 50% Electroconvulsive Therapy (ECT) 18 3519 30% 50% Intensive Outpatient Program 18 3519 30% 50% Partial Hospitalization Program 19 3520 30% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic di- agnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35Benefits 30% 50% Transcranial magnetic stimulation 3530% 50% Professional (Physician) office visits 35% $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics orthot- ics Services. Office visits 35% 50% $40 per visit Not covered Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 3530% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 35% 35% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 35% $100 per visit plus 35% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35% 35% 10 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptives) 35% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 35% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 35% Not covered Vasectomy 35% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. 35% Not covered 12 Medical supplies 35% Not covered 12 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Year for all Home Health and Home Infusion/Home Injectable Ser- vices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 35% Not covered 12 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Services Calendar Year visit limitation.) 35% Not covered 12 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 35% Not covered 13 General Inpatient care 35% Not covered 13 Inpatient Respite Care You pay nothing Not covered 13 Pre-hospice consultation You pay nothing Not covered 13 Routine home care You pay nothing Not covered 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35% 35% 14 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- plies, including Subacute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Surgery Benefits for Residents of Designated Counties in California section. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices whether rendered in a Hospital or a free-standing Skilled Nursing Facili- ty. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 35% 50% Inpatient Services to treat acute medical complications of detoxification 35% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory services 35% 50% of up to $500 per day 14 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 35% 50% of up to $300 per day 14 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated stated, and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 35% 50% of up to $300 per day Inpatient Hospital Services 35% 50% of up to $500 per day 14 Office location 35% 50% Outpatient department of a Hospital 35% 50% of up to $500 per day 14 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers Pro- viders 16 Inpatient Hospital services 35% 50% of up to $500 per day 18 17 Inpatient Professional services 35% 50% Residential care for Mental Health Condition 35% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 35% 50% Behavioral Health Treatment in an office setting 35% 50% Electroconvulsive Therapy (ECT) 18 35% 50% Intensive Outpatient Program 18 35% 50% Partial Hospitalization Program 19 35% per episode 50% of up to $500 per day18 day, per episode Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 35% 50% Transcranial magnetic stimulation 35% 50% Professional (Physician) office visits 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics Services. Office visits 35% 50% Orthotic equipment and devices 35% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 64

Emergency Room Benefits. Emergency room Physician Services Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Outpatient Physician Services Benefit in the Professional (Physician) Benefits in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. 3530% 3530% Emergency room Services not resulting in admission Note: After Services have been provided, Blue Shield may conduct a retro- spective review. If this review determines that Services were provided for a medical condition that a person would not have reasonably believed was an emergency medical condition, Benefits will be paid at the applicable Pre- ferred and Non-Preferred Provider levels as specified under Hospital Bene- fits (Facility Services), Outpatient Services for treatment of illness or inju- ry, radiation therapy, chemotherapy and necessary supplies in this Summary of Benefits and will be subject to any Calendar Year medical Deductible. $100 per visit plus 3530% $100 per visit plus 3530% Emergency room Services resulting in admission (billed as part of Inpa- tient Hospital Services) 35$250 per admission plus 30% 35$250 per admission plus 30% 10 11 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Family Planning Benefits 11 12 Note: Copayments listed in this section are for Outpatient Physician Services only. If Services are performed at a facility (Hospital, Ambulatory Surgery Center, etc), the facility Copayment listed under the appropriate facility bene- fit benefit in the Summary of Benefits will also apply. Counseling and consulting (Including Physician office visits for diaphragm fitting or injectable contra- ceptivescontracep- tives) 3530% Not covered Diaphragm fitting procedure When administered in an office location, this is in addition to the Physician office visit Copayment. 3530% Not covered Injectable contraceptives When administered in an office location, this is in addition to the Physician office visit Copayment. $25 per injection Not covered Tubal ligation In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services for a delivery/abdominal surgery. 3530% Not covered Vasectomy 3530% Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Home Health Care Benefits Note: There is a combined Benefit maximum of 90 visits per Person per Cal- endar Calen- dar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Home health care agency Services, including home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational oc- cupational therapist. 3530% Not covered 12 13 Medical supplies 3530% Not covered 12 13 Home Infusion/Home Injectable Therapy Benefits Note: There is a combined Benefit maximum of 90 visits per Member per Calendar Cal- endar Year for all Home Health and Home Infusion/Home Injectable Ser- vicesServices. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. Hemophilia home infusion Services provided by a hemophilia infusion provider and prior authorized by the Plan. . Includes blood factor product. Home infusion/home intravenous injectable therapy provided by a Home In- fusion Infu- sion Agency Note: Home non-intravenous self-administered injectable drugs are covered under the Outpatient Prescription Drug Benefit. 3530% Not covered 12 13 Home visits by an infusion nurse (Home infusion agency nursing visits are not subject to the Home Health Care and Home Infusion/Home Health Inject- able Injectable Services Calendar Year visit limitation.) 3530% Not covered 12 13 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Hospice Program Benefits Covered Services for Members who have been accepted into an approved Hospice Program All Hospice Program Benefits must be prior authorized by the Plan and must be received from a Participating Hospice Agency. 24-hour Continuous Home Care 3530% Not covered 13 14 General Inpatient care 3530% Not covered 13 14 Inpatient Respite Care You pay nothing Not covered 13 14 Pre-hospice consultation You pay nothing Not covered 13 14 Routine home care You pay nothing Not covered 13 14 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Inpatient Emergency Facility Services 35$250 per admission plus 30% 35$250 per admission plus 30% 14 15 Inpatient non-Emergency Facility Services Semi-private room and board, and Medically Necessary Services and sup- pliessupplies, including Subacute Sub acute Care. For bariatric surgery Services for residents of designated counties, see the Bariatric Bar- iatric Surgery Benefits for Residents of Designated Counties in California sectionsec- tion. (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per admission plus 30% 50% of up to $500 per day Inpatient Medically Necessary skilled nursing Services including Subacute Sub acute Care Up to a Benefit maximum of 100 days per Member, per Calendar Year. These Services have a Calendar Year day maximum except when received through a Hospice Program provided by a Participating Hospice Agency. This day maximum is a combined Benefit maximum for all skilled nursing Ser- vices Services whether rendered in a Hospital or a free-standing Skilled Nursing Facili- tyFacility. If your Plan has a Calendar Year facility Deductible, the number of days start counting toward the maximum when the Services are first provided even if the Calendar Year medical Deductible has not been met. 3530% 50% Inpatient Services to treat acute medical complications of detoxification 35$250 per admission plus 30% 50% of up to $500 per day Outpatient diagnostic testing X-Ray, diagnostic examination and clinical la- boratory labor- atory services 3530% 50% of up to $500 per day 14 15 Outpatient dialysis Services (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $300 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $150 3530% 50% of up to $300 per day 14 15 Outpatient Services for surgery and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Outpatient Services for treatment of illness or injury, radiation therapy, chem- otherapy chemo- therapy and necessary supplies (See Non-Preferred payment example below) Example: 1 day in the Hospital, up to the $500 Allowable Amount times (x) 50% Subscriber contribution=Subscriber payment of up to $250 3530% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Medical Treatment for the Teeth, Gums, Jaw Joints, or Jaw Bones Benefits Treatment of gum tumors, damaged natural teeth resulting from Accidental Injury, TMJ as specifically stated and orthognathic surgery for skeletal de- formity (Be sure to read the Principal Benefits and Coverages (Covered Services) section sec- tion for a complete description.) Ambulatory Surgery Center Outpatient Surgery Facility Services 3530% 50% of up to $300 per day Inpatient Hospital Services 35$250 per admission plus 30% 50% of up to $500 per day 14 15 Office location 35% $35 per visit 50% Outpatient department of a Hospital 35$250 per surgery plus 30% 50% of up to $500 per day 14 15 Benefit Member Copayment 4 Mental Health Benefits (All Services provided through the Plan’s Mental Health Service Administrator (MHSA)) 15 16, 17 Services by MHSA Participating Providers Services by MHSA Non-Participating Providers 16 Pro- viders 18 Inpatient Hospital services 35$250 per admission plus 30% 50% of up to $500 per day 18 day18 Inpatient Professional services 35% You pay nothing 50% Residential care for Mental Health Condition 35$250 per admission plus 30% 50% of up to $500 per day Behavioral Health Treatment in home or other non-institutional setting 3530% 50% Behavioral Health Treatment in an office setting 3530% 50% Electroconvulsive Therapy (ECT) 18 3519 30% 50% Intensive Outpatient Program 18 3519 30% 50% Partial Hospitalization Program 19 3520 30% per episode 50% of up to $500 per day18 day Psychological testing to determine mental health diagnosis (outpatient diagnostic testing) Note: For diagnostic laboratory services, see the “Outpatient diagnostic laboratory services, including Papanicolaou test” section of this Summary of Benefits. And for diagnostic X-ray and imaging services, see the “Out- patient diagnostic X-ray and imaging services, including mammography” section of this Summary of Benefits. 3530% 50% Transcranial magnetic stimulation 3530% 50% Professional (Physician) office visits 35% $35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Orthotics Benefits Up to a Benefit maximum of $1,000 per Member, per Calendar Year for or- thotics orthot- ics Services. Office visits 35% $35 per visit 50% Orthotic equipment and devices 3530% 50% Benefit Member Copayment 4 Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 27 $45 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $60 or 50% of Blue Shield’s contracted rate 28 Not covered Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 27 $90 per prescription Not covered Non-Formulary Brand Name Drugs 27 The greater of $120 or 50% of Blue Shield’s contracted rate 29 Not covered Home Self-Administered Injectables 35% per prescription Not covered Oral Anticancer Medication 35% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 35% 9, 30 50% 9, 30 Benefit Member Copayment 4 PKU 35% Not covered Podiatric Services 35% 50% Benefit Member Copayment 4 Services by Preferred, Partici- pating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy 35% 50% of up to $500 per day 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facility), an additional facility Coinsurance/Copayment may apply. 35% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 35% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Annual Physical Examination including only the annual routine physical ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screen- ing test; and the human papillomavirus (HPV) screening test $35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $35 per visit Not covered Colorectal Cancer Screening Services 35% Not covered Osteoporosis Screening Services 35% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6%