Common use of Hair Prosthetics Clause in Contracts

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,000

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,000Not Applicable

Hair Prosthetics. (Wigs)*;  • Hearing Aids*;  • Obstetricians and Gynecologists;  • Oncologists - Office Visits (consultation or second opinion; all other services require a  • Optometrists and Ophthalmologists;  • Oral Surgery;  • Pediatric Dental Services; • Pediatric Vision Services; • Retail Clinics; and  • Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The Deductible; Maximum Ou-otf-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible-The amount you must pay each plan year before eacphlan yearbefore we begin to pay for certain covered certacinovered healthcare servicesservice. See sSee Glossary section for further details. The deductible applies Tdheeductibleapplies to network and networkand non-network services networkservices separately. Services that apply the deductible are thedeductibleare indicated as "After Deductible" in AfteDreductible"in the Summary of Medical Benefits and the Summary of Pharmacy Pharma Benefits. Deductible for an Individual Plan: $2,000 $4,000 Deductible for a Family Plan: Pla:n The Family plan deductible is deductibleis met by adding the amount of covered healthcare expenses coofvered healthcareexpenses applied to the deductible for thedeductiblefor all family members; however members;however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Maximum OutOu-oftof-Pocket Expense - The total combined combnied amount of your deductible and copayments you youdreductibleand copaymentsyou must pay each plan year for certain covered yearfor certaincovered healthcare servicesservice. See sSee Glossary section for further details. The maximum outTmheaximum ou-of- ot f-pocket expense limit accumulates separately for network and fnoertworkand non-network services. The deductible and copayments (including.Thedeductibleand copayments(including, but not limited to, office visits copayments and viscitospaymentsand prescription drug copayments) apply copayments)apply to the maximum out- ofthemaximum ou-ot f-pocket expense. Maximum OutOu-oftof-Pocket Expense for an Individual Plan: $6,000 $12,00012,000 MaximumOut-of-Pocket Expense for a Family Plan: The familymaximum ou-ot f-pocket expenselimit is met by adding the amount ocfovered healthcare expenses applied to themaximum ou-ot f-pocket expenselimit for all familymembers, however no one (1)membercan contribute more than the amount shown in the Maximu Out-of-Pocket Expense for an Individual Plan. $12,000 $24,000

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Pediatric Dental Services;  Pediatric Vision Services;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible; Maximum Out-of-Pocket Expense Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both network and non-network services separatelycombined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 4,800 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 9,600 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- of-pocket expense limit accumulates separately applies for both network and non-network servicesservices combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,0005,800 Not Applicable

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 3,000 $4,000 6,000 Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 6,000 $8,000 12,000 Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 6,850 $12,00013,700

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The Deductible-The amount you must pay each plan eacphlan year before we begin to pay for certain covered certacionvered healthcare services. See Glossary section for further details. The deductible applies to network and detaTilhs.e deductibleapplies tonetworkand non-network services networkservices separately. Services that apply the deductible are thdeductibleare indicated as "After Deductible" in the Summary AfterDeductible"in theSummary of Medical Benefits and the Summary of Pharmacy Benefits. Xxxxxx.xx Deductible for an Individual Plan: $2,000 $4,000 Deductible for a Family Plan: Pla:n The Family plan deductible is deductibleis met by adding the amount of covered healthcare expenses coofvered healthcareexpenses applied to the deductible for thedeductiblefor all family members; however familymembers;however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Maximum OutOu-oftof-Pocket Expense - The total combined amount of your deductible and copayments you youdreductibleand copaymentsyou must pay each plan year for certain covered yearfor certaincovered healthcare servicesservice. See sSee Glossary section for further detailsfurthdeertails. The maximum outThemaximum ou-of- ot f- pocket expense limit expenselimit accumulates separately for network fnoertwork and non-network servicesnetworkservices. The deductible and Thedeductibleand copayments (including, but not limited to, office visits copayments and vciospitasymentsand prescription drug copayments) apply drucgopayments)apply to the maximum out- themaximum ou-t of-pocket expense. Maximum OutOu-oftof-Pocket Expense for an Individual Plan: $6,000 $12,00012,000 Maximum Ou-tof-Pocket Expense for a Family Plan: The familymaximum ou-ot f-pocket expense limit is met by adding the amounct oovfered healthcare expensesapplied to themaximum ou-ot f- pocket expenselimit for all fammilyembers, however no one (1) familmy embercan contribute more than the amount shown in the Individual Pmlaanximum out-of-pocket expenseamount. $12,000 $24,000 Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as networkprovide.r Air/water* $50 The level of coverage is the same as network xxxxxx.xx Applied behavioral analysis* 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- Outpatient Hospital 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- In aprovider’soffice 0%- Afterdeductible 20%- Afterdeductible

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Pediatric Dental Services;  Pediatric Vision Services;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- of-pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,000

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Retail Clinics; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 6,000 $4,000 10,000 Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 12,000 $8,000 20,000 Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 6,850 $12,00013,700

Hair Prosthetics. (Wigs)*;  Hearing Aids*;  Obstetricians and Gynecologists;  Oncologists - Office Visits (consultation or second opinion; all other services require a  Optometrists and Ophthalmologists;  Oral Surgery;  Pediatric Dental Services;  Pediatric Vision Services;  Retail Clinics; and  Speech Therapy; and  Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible; Maximum Out-of-Pocket Expense Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both network and non-network services separatelycombined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 4,650 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 9,300 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of- of-pocket expense limit accumulates separately applies for both network and non-network servicesservices combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out- out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,0005,650 Not Applicable

Hair Prosthetics. (Wigs)*;  • Hearing Aids*;  • Obstetricians and Gynecologists;  • Hematology Oncologists - Office Visits (consultation or second opinion; all other services require a  referral); • Optometrists and Ophthalmologists;  • Oral Surgery;  • Pediatric Dental Services; • Retail Clinics; and  • Telemedicine Services when rendered by a designated provider. * You may self-refer to an out-of-network provider or a non-network participating provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible -The Deductible; Maximum Ou-otf-Pocket Expense Network Providers Tier 1 Network Providers Tier 2 Non-network Providers You Pay You Pay You Pay Deductible-The amount you must pay each plan year before eacphlan yearbefore we begin to pay for certain covered certacionvered healthcare services. See service.sSee Glossary section for further details. The deductible applies to network Thdeeductibleapplies tonetwork and non-network services networkservices separately. Services that apply the deductible are thedeductibleare indicated as "After Deductible" in the Summary Deductible"in theSummary of Medical Benefits and the Summary of Pharmacy Benefits. Note: Aldl eductible amounts enrolled members pay towards the Tier 1deductible are also applied toward the Tier 2deductible. Deductible for an Individual Plan: $1,000 $2,000 $4,000 6,600 Deductible for a Family Plan: Pla:n The Family plan deductible is plandeductibleis met by adding the amount of covered healthcare expenses ofcovered healthcareexpenses applied to the deductible for deductiblefor all family membersfamilmy embers; however no one (1) member can contribute contribut more than the amount shown above for "Deductible Deductbile for an Individual Plan". $2,000 $4,000 $8,000 13,200 Maximum OutOu-oftof-Pocket Expense - The total combined amount of your deductible and copayments you yoduer ductibleand copaymentsyou must pay each plan year for certain covered eachplan yearfor certaincovered healthcare servicesservice. See sSee Glossary section for further details. The maximum outTmheaximum ou-of- ot f- pocket expense limit expenselimit accumulates separately for network and networkand non-network servicesnetworkservices. The deductible Thedeductible and copayments (includingcopayments(including, but not limited to, office visits copayments and visitcsopaymentsand prescription drug copayments) apply copayments)apply to the maximum out- ofthemaximum ou-ot f-pocket expense. The Network Provider maximum ou-ot f-pocket expenselimit for Tier and Tier 2 are combined. The Network Provider maximum ou-ot f-pocket expenselimit for Tier and Tier 2 are combined. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 6,800 See Tier 1 $12,00020,400 Maximum Ou-tof-Pocket Expense for a Family Plan: The familymaximum ou-ot f- pocket expenselimit is met by adding the amount ofcovered healthcare expenses applied to themaximumout-of-pocket expenselimit for all fammilyembers, however no one (1)membercan contribute more than the amount shown in the Maximum O-uotf-Pocket Expense for an Individual Plan. $13,600 See Tier 1 $40,800