Common use of for details Clause in Contracts

for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan year. $20 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 20% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO 20% YES Lab and pathology services. 0% NO 20% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Lyme Disease- Diagnosis/ Treatment 0% NO 20% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan year. $20 25 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 2040% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% $50 NO 2040% YES Lab and pathology services. 0% $20 NO 20% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO 2040% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) (continued) Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES 40% YES Lyme Disease- Diagnosis/ Treatment 0% NO 20YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 75 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 NO 2040% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% NO Not Covered Not Covered • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan year. $20 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Non- Hospital facility including in a Doctor’s office, urgent care center, or free-free- standing laboratory Applies to the following diagnostic imaging services: •  MRI; •  MRA; •  CAT scans; •  CTA scans; •  PET scans; • and  Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studiesimaging services. 0% YES 20% YES Diagnostic YES For tests, imaging and machine testslab, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO 20% YES Lab and pathology services. 0% NO YES Sleep Studies Preauthorization is recommended for facility based sleep studies 20% YES YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO 20% YES YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service Flex plan you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible maximum out of pocket expense apply? Lyme Disease- Diagnosis/ Treatment 0% NO 20% YES YES Urgent care facility Urgent care facility/facility/ walk-in See Section 8.0 - definition of urgent care center. $50 NO See Summary of Medical benefits. The level of coverage is the same as network providercare coordinated by your primary care physician and permitted self-referrals. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19contract year. Medically necessary eye exams are covered. $50 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to YES See the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name coverage information about prescription drugs and certain specialty Prescription Drugsdiabetic equipment/supplies purchased from a pharmacy. For details on how Refer to obtain prescription drug preauthorization the Table of Contents for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorizationthe page number where you can find the information in this agreement. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS iv FLEX PLAN xix

for details. First telemedicine visit in a plan calendar year. Benefit applies per member, per plan calendar year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan calendar year. $20 50 NO Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies Preauthorization is recommended for these diagnostic services. 20% YES 40% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 20% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO 20% YES Lab and pathology services. 0% NO 20% YES (continued) Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO 20% YES 40% YES Lyme Disease- Diagnosis/ Treatment 20% YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $75 NO The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. $65 NO 40% YES Medically necessary eye exams are covered. Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Lyme Disease- Diagnosis/ Treatment 0% NO 20% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per plan benefit year. 0% NO Not Covered Not Covered Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Hardware for a member under the age of 19 (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glassesglasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Hardware for a member under the age of 19 (continued) • Daily Wear Disposable are covered up to the benefit limit of a three Contact Lens (3continued) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · • Anisometropia · • High Ametropia · • Keratoconus · • Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

for details. First telemedicine visit in a plan calendar year. Benefit applies per member, per plan calendar year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan calendar year. $20 40 NO Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; And • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 20% YES 40% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 20% YES 40% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 20% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO 20% YES Lab and pathology services. 0% NO 20% YES (continued) Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. (continued) See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0Lyme Disease- Diagnosis/ Treatment 20% YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $75 NO 20The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Lyme Disease- Diagnosis/ Treatment 0% NO 20% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per plan benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Hardware for a member under the age of 19 (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glassesglasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan benefit year. • Daily Wear Disposable are covered up to the benefit limit a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services Hardware for a member under the age of 19 (continued) • Daily Wear Disposable are covered up to the benefit limit of a three Contact Lens (3continued) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · • Anisometropia · • High Ametropia · • Keratoconus · • Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan year. $20 40 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 020% YES 2040% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% $75 NO 2040% YES Lab and pathology services. 0% $25 NO 20% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO 2040% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) (continued) Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 20% YES 40% YES Lyme Disease- Diagnosis/ Treatment 020% NO 20YES 40% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 125 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 55 NO 2040% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic $0 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. year 0% NO Not Covered Not Covered • Daily Wear Disposable are covered up to the benefit limit a three (3) month supply of daily disposable lenses in a plan year 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year • 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.

for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO Not Covered Not Covered Subsequent telemedicine visits in a plan year. $20 40 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 20% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% $75 NO 20% YES Lab and pathology services. 0% NO 20% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% $25 NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) (continued) Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES 20% YES Lyme Disease- Diagnosis/ Treatment 0% NO YES 20% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 125 NO The level of coverage is the same as network provider. Vision care services In a doctor’s office One routine eye exam per plan year without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. $50 55 NO 20% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) Vision Hardware for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per plan year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) The following lens treatments are covered: • UV treatment; • Tint ( fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan year. 0% NO Not Covered Not Covered • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Vision care services (continued) • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS Only applies to the Summary of Pharmacy Benefits Required Preauthorization Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs in our formulary are placed into the following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higher copayment than Tier 1.