Common use of Experimental and Investigational Services Clause in Contracts

Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam 10% - After deductible Not Covered Hearing diagnostic testing 10% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 10% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 10% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 10% - After deductible Not Covered Human leukocyte antigen testing 10% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 10% - After deductible Not Covered

Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam 100% - After deductible Not Covered Hearing diagnostic testing 100% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 2,000 per hearing aid. 1020% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 100% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 100% - After deductible Not Covered Human leukocyte antigen testing 100% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 100% - After deductible Not Covered

Experimental and Investigational Services. Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Coverage varies based on type of service. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Hearing exam 10% - After deductible $30 Not Covered Hearing diagnostic testing 100% - After deductible Not Covered Hearing aids - The benefit limit is $1,500 per hearing aid. 100% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 100% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 100% - After deductible Not Covered Human leukocyte antigen testing 100% - After deductible Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 1020% - After deductible Not Covered