Common use of Hospice Care Clause in Contracts

Hospice Care. Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% 20% - After deductible 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. 20% - After deductible 40% - After deductible Outpatient - facility 0% - After deductible 20% - After deductible In the physician’s office/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% 20% - After deductible In a hospital or other health care facility 0% - After deductible 20% - After deductible

Hospice Care. Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% 20% - After deductible 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. 20% - After deductible 40% - After deductible Outpatient - facility 0% - After deductible 20% - After deductible In the physician’s office/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications, such as physical or occupational therapy. 0% 20% - After deductible In a hospital or other health care facility facility. 0% - After deductible 20% - After deductible

Hospice Care. Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% 20% - After deductible 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. 20% - After deductible 4020% - After deductible Outpatient - facility hospital 0% - After deductible 20% - After deductible In the physician’s office/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% 20% - After deductible In a hospital or other health care facility 0% - After deductible 20% - After deductible

Hospice Care. Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% 20% - After deductible 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. 20% - After deductible 40% - After deductible Outpatient - facility 0% - After deductible 20% - After deductible In the physician’s office/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications, such as physical or occupational therapy. 0% 20% - After deductible In a hospital or other health care facility facility. 0% - After deductible 20% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 20% - After deductible Hospital based clinic visits $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $20 20% - After deductible Retail clinics $20 20% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $30 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $20 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - After deductible

Hospice Care. Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% 20% - After deductible 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. 20% - After deductible 40% - After deductible Outpatient - facility 0% - After deductible 20% - After deductible In the physician’s office/in your home 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay General hospital or specialty hospital services* - Unlimited Days unlimited days 0% - After deductible 20% - After deductible Rehabilitation facility services* - Limited limited to 45 days per plan year. 0% - After deductible 20% - After deductible Physician hospital visits 0% - After deductible 20% - After deductible Inpatient - see Mastectomy Services in Section 3 for details. 0% 20% - After deductible Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% 20% - After deductible Mastectomy-related treatment - includes prostheses and treatment for physical complications, such as physical or occupational therapy. 0% 20% - After deductible In a hospital or other health care facility facility. 0% - After deductible 20% - After deductible Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - applies to injection only, including administration. 0% 20% - After deductible Diabetic office visits Podiatrist services - first routine visit in a plan year $0 20% - After deductible Vision care services - first routine eye exam in a plan year that includes a retinal eye exam. $0 20% - After deductible Hospital based clinic visits $50 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. $30 20% - After deductible Retail clinics $30 20% - After deductible Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $50 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Organ transplant services 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% After deductible