Common use of Other than Preventive Care Services Clause in Contracts

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 Hospital based clinic visits $40 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 Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $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. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible

Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies to injection injection-sapplies toinjection only, including administration. 0% 20% - After deductible Hospital based clinic 20%- Afterdeductible Diabetic office visits Podiatrist service-s first routine visit inpalan year $40 20% - After deductible 0 20%- Afterdeductible Vision care service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 20%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Pediatric Hospitalbased clinic visit visits $30 20%- Afterdeductible PCP practices with PCMH model of care visits- including behavioral hea.ltVhisits includPeCP office visits anPdCP house calls andpediatric clinic vis.its $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible 20%- Afterdeductible Retail clinics $30 20% - After deductible Specialists Office 20 20%- Afterdeductible Specialists- office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to behavioral health, allergists, dermatologists and podiatrists. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. podiatr $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible 20%- Afterdeductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Physical/Occupational Therapy Outpatient hospital/in hospitainl/ a physician’s/therapist’s office. 20% - After deductible S K \ WV KL XX XX DD 20%- Afterdeductible 40% - After deductibleAftedr eductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), and notpurchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0%- Afterdeductible 20%- Afterdeductible Infuseddrugs* 0%- Afterdeductible 20%- Afterdeductible Medications other than injected and infused drugs* Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered.

Other than Preventive Care Services. See Prevention and Early Detection Services for Servicesfor coverage of annual preventive office visits.) Allergy injections - Applies injection-sApplies to injection only, including administration. 0% 20% - After deductible Hospital based 0%- Afterdeductible 40%- Afterdeductible Hospitalbased clinic visits $40 20% - After deductible 0%- Afterdeductible 40%- Afterdeductible Pediatric clinic visit PCP practices withPCMHmodel of care 0%- Afterdeductible 40%- Afterdeductible PCP does notpractice withPCMHmodel of care 0%- Afterdeductible 40%- Afterdeductible PCP visits- includingbehavioral healthV. isits includPeCP office visits anPdCP house calls. PCP practices withPCMHmodel of care 0%- Afterdeductible 40%- Afterdeductible PCP does notpractice withPCMHmodel of care 0%- Afterdeductible 40%- Afterdeductible Retail clinics 0%- Afterdeductible 40%- Afterdeductible Specialists Office visits and house calls rendered by a specialis Specialist includes but is not limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. 0%- Afterdeductible 40%- Afterdeductible Office visits and house calls rendered by a behavior health specialist. 0%- Afterdeductible 40%- Afterdeductible Organ Transplants Organ transplant services 0%- Afterdeductible 40%- Afterdeductible Physical/Occupational Therapy 2 X W S D W L H WQ KW X X XX R 0%- Afterdeductible 40%- Afterdeductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0%- Afterdeductible 40%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic Equipment and Supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 0%- Afterdeductible 40%- Afterdeductible Infuseddrugs* 0%- Afterdeductible 40%- Afterdeductible Medications other than injected and infused *rugs Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits - 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 Pediatric clinic visit PCP practices with PCMH model of Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 40%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care $20 20% - After deductible PCP does not practice with PCMH model of agen 0%- Afterdeductible 40%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Respiratory Therapy Inpatient 0%- Afterdeductible 40%- Afterdeductible Outpatient 0%- Afterdeductible 40%- Afterdeductible Skilled Care in a Nursing Facilit*y Skilled or su-bacute care $30 20% - After deductible PCP visits - including behavioral health0%- Afterdeductible 40%- Afterdeductible Speech Therapy 2 X W S D W L H WQ KW X X XX R 0%- Afterdeductible 40%- Afterdeductible Surgery Services* Inpatient physiciasnervices 0%- Afterdeductible 40%- Afterdeductible Outpatientservices- includesphysicianservices and outpatient hospitaolr ambulatorysurgical centerfacility services. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible Specialists Office visits and house calls 0%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Telemedicine Services When rendered by a specialist (designatepdrovider. 0%- Afterdeductible Not Covered When rendered by anetworkprovider. 0%- Afterdeductible Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans, PE scans, nuclear medicine and cardiac imaging. 0%- Afterdeductible 40%- Afterdeductible Sleep studies*. 0%- Afterdeductible 40%- Afterdeductible Diagnostic imaging and tests, other than a behavioral health specialist)major diagnostic imaging and testing services noted above 0%- Afterdeductible 40%- Afterdeductible Lab and pathology services. Specialist includes 0%- Afterdeductible 40%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but is not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. S Prevention and Early Detection Services for preven colorectal services.) 0%- Afterdeductible 40%- Afterdeductible Lyme diseasediagnosis and treatment 0%- Afterdeductible 40%- Afterdeductible Urgent Care Urgent care services 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Vision Care Services Vision exam- One routine eye exam pemr emberper plan year. 0%- Afterdeductible 40%- Afterdeductible Non-routine eye exam 0%- Afterdeductible 40%- Afterdeductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and detail These services only apply to allergistsan enrolled member under t age of 19: Prescription glasses- Frame and lenses 0%- Afterdeductible Not Covered Contact lens (in lieu of prescription glasses) 0%- Afterdeductible Not Covered Vision hardware for enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, dermatologists and podiatrists. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologicmail order, or peripheral vascular disease. $0 20% - After deductible Organ Transplants Organ transplant services 0% - After deductible 20% - After deductible Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductiblespecialty, pharmacy.

Other than Preventive Care Services. See Prevention and Early Detection Services DetectionServices for coverage of annual preventive office visits.) Allergy injections - Applies injection-sApplies to injection only, including administration. 0% 20% - After deductible Hospital based $0 20%- Afterdeductible Diabetic Office Visits Podiatrist Service-sFirst routine visit inpalan year $0 20%- Afterdeductible Vision Care Service-sfirst routine eye exam inpalan yearthat includes a retinal eye exam. $0 20%- Afterdeductible Hospitalbased clinic visits $40 2050 20%- Afterdeductible PCP visits- includingbehavioral healthV. isits includPeCP office visits anPdCP house calls and pediatric clinic visits $30 20%- Afterdeductible Retail clinics $30 20%- Afterdeductible Specialists Office visits and house calls rendered by a specialis Specialist includes but nisot limited to allergists, dermatologists and podiatrists. See below for behavioral health specialist. $50 20%- Afterdeductible Office visits and house calls rendered by a behavior health specialist. $30 20%- Afterdeductible Organ Transplants Organ transplant services 0% - After deductible Afterdeductible 20%- Afterdeductible Physical/Occupational Therapy 2 X W S D W L H WQ KW X X XX R 20%- Afterdeductible 40% Aftedr eductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0% - Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic Equipment and Supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 0% - Afterdeductible 20%- Afterdeductible Infuseddrugs* 0% - Afterdeductible 20%- Afterdeductible Medications other than injected and infused *rugs Are included in thaellowance for the medical service bein rendered. Are included in thaellowance for the medical service being rendered. Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and detailsanddetails. 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 Pediatric clinic visit PCP practices with PCMH model of Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care $20 agen 0% - Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% - Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% - Afterdeductible 20%- Afterdeductible Respiratory Therapy Inpatient 0% - Afterdeductible 20%- Afterdeductible Outpatient 0% - Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facilit*y Skilled or su-bacute care 0% - Afterdeductible 20%- Afterdeductible Speech Therapy Outpatient K R V S L WW DK OH U LD 20% - After deductible PCP does not practice with PCMH model of care $30 20Afterdeductible 40%- Afterdeductible Surgery Services* Inpatient physiciasnervices 0% - After deductible PCP visits - including behavioral healthAfterdeductible 20%- Afterdeductible Outpatientservices- includesphysicianservices and outpatient hospitaolr ambulatory surgical centfearcility services. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 200% - After deductible PCP does not practice with PCMH model of care $30 20Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% - After deductible Retail clinics $30 20% - After deductible Specialists Office visits and house calls 20%- Afterdeductible Telemedicine Services When rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialistdesignatepdrovider. $30 20% Not Covered When rendered by anetworkprovider. $30 Not Covered Tests, Labs, Imaging and X-rays - After deductible Podiatrist Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans, PE scans, nuclear medicine and cardiac imaging. 0%- Afterdeductible 20%- Afterdeductible Sleep studies*. 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above $75 20%- Afterdeductible Lab and pathology services. $25 20%- Afterdeductible Diagnostic colorectal servic-e(sIncluding, but not limited to, feclaoccult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. S Prevention and Early Detection Services - one foot evaluation in a for preven colorectal services.) 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $25 20%- Afterdeductible Urgent Care Urgent care services $100 The level of coverage is the same as network xxxxxx.xx Vision Care Services Vision exam- One routine eye exam pemr emberper plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular diseaseyear. $0 20% - After deductible Organ Transplants Organ transplant 20%- Afterdeductible Non-routineeye exam $0 20%- Afterdeductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and detail These services only apply to an enrolled member under age of 19: Prescription glasses- Frameand lenses 0% - After deductible 20Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Physical/Occupational Therapy Outpatient hospital/in Not Covered Vision hardware for enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a physician’s/therapist’s office. 20% - After deductible 40% - After deductibleretail, mail order, or specialty, pharmacy.

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% 2010% - After deductible Not Covered Hospital based clinic visits $40 20% 60 Not Covered PCP visits - After deductible including behavioral health. Visits include PCP office visits and PCP house calls and pediatric clinic visits. PCP practices with PCMH model of care $20 Not Covered PCP does not practice with PCMH model of care $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and additionalbenefit limitsand details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible Retail clinics $30 20% - After deductible 50 Not Covered 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. $40 20% - After deductible 60 Not Covered Office visits and house calls rendered by a behavioral health specialist. $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible Not Covered Organ Transplants Organ transplant services 010% - After deductible 20% - After deductible Not Covered Physical/Occupational Therapy Outpatient hospital/in a physician’s/therapist’s office. 2010% - After deductible 40Not Covered Pregnancyand Maternity Services Pre-natal, delivery, and postpartum services. 10% - After deductibledeductible Not Covered Prescription Drugsand Diabetic Equipment and Supplies Prescription drugs and diabetic equipmentand supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of Pharmacy Benefits Medical prescription drugs requiringadministration by a licensed health care provider* : Medical prescription drugs other than infused drugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medications. 10% - After deductible Not Covered Infused drugs 10% - After deductible Not Covered Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 10% - After deductible Not Covered

Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive office visits.) Allergy injections - Applies injection-sapplies to injection only, including administration. 0% 200% - After deductible Hospital based clinic visits $40 2050%- Afterdeductible Diabetic office visits: Podiatrist service-s first routine visit inpalan year 0% - After deductible 0% 50%- Afterdeductible Vision care service-sfirst routine eye exam in aplan yearthat includes a retinal eye exam. 0% 0% 50%- Afterdeductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Tier 1 Network Providers Tier 2 Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay You Pay Hospitalbased clinic visits $30 $60 50%- Afterdeductible Pediatric clinic visit PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care visits $30 20% - After deductible $60 50%- Afterdeductible PCP visits - visits- including behavioral health. Visits include PCP healtVhi.sits includePCP office visits and PCP anPdCP house calls. PCP practices with PCMH model of care $20 20% - After deductible PCP does not practice with PCMH model of care $30 20% - After deductible 50 50%- Afterdeductible Retail clinics $30 20% - After deductible Specialists Office 20 $50 50%- Afterdeductible Specialists- office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but b is not limited to allergiststboehavioral healt,hallergists, dermatologists and podiatrists. $40 20% - After deductible Office visits and house calls rendered by a behavioral health specialist. 30 $30 20% - After deductible Podiatrist Services - one foot evaluation in a plan year when performed to treat members with a systemic condition such as metabolic, neurologic, or peripheral vascular disease. $0 20% - After deductible 60 50%- Afterdeductible Organ Transplants Organ transplant services 0% - transplanstervices $150 per admission- After deductible 20% - $1000 per admission- After deductible 50%- Afterdeductible Physical/Occupational Therapy Outpatient hospital/in hospitainl/ a physician’s/therapist’s S K \ WV KL FH office. 20$30 $60 50%- Afterdeductible Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. $30 $60 50%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment an supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescripti drugs purchased at a retail, specialty, or mail orderpharmacy. Prescription drugs dispensed and administere by a licensed health carperovider(other than a pharmacist), andnotpurchased from a retail, specialty or mail ordeprharmacy: Injectable drugs* 0% - After deductible 400% - After deductible50%- Afterdeductible Infused drugs* 0% 0% 50%- Afterdeductible Medications other than injected and infuse rugs* Are included in the allowancefor the medical service being rendered. Are included in the allowancefor the medical service being rendered. Are included in the allowancefor the medical service being rendered.