Common use of Hair Prosthetics Clause in Contracts

Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 20% - After deductible Hospital emergency room $200 The level of coverage is the same as network provider.

Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 20- After deductible 40% - After deductible Hospital emergency room $200 0% - After deductible The level of coverage is the same as network provider.

Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible 4020% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - After deductible 4020% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 200% - After deductible 4020% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible 4020% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible 4020% - After deductible Enteral formula or food taken orally * 200% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 200% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 20% - After deductible Hospital emergency room $200 300 The level of coverage is the same as network provider.

Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 2040% - After deductible Hospital emergency room $200 250 The level of coverage is the same as network provider.

Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 2030% - After deductible 4050% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 2030% - After deductible 4050% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 2030% - After deductible 4050% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 2030% - After deductible 4050% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 2030% - After deductible 4050% - After deductible Enteral formula or food taken orally * 2030% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 2030% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 2050% - After deductible Hospital emergency room $200 250 The level of coverage is the same as network provider.