Common use of Prevention and Early Detection Services Adult annual preventive Clause in Contracts

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan benefit year per member will be covered. 0% NO 2040% YES Well woman annual preventive visit One (1) routine gynecological examination per plan benefit year per female member will be covered. 0% NO 2040% YES Pediatric preventive office visit Well-Child Office Visits: 16 - 35 months: 11 visits; 36 months - 19 years: 1 per benefit year. 0% NO 40% YES Pediatric preventive clinic 0% NO 40% YES Diabetes education Individual and group sessions are covered. 0% NO 40% YES Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Adult Immunization 0% NO 2040% YES Pediatric Immunization 0% NO 2040% YES Travel Immunization 0% NO 2040% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 2040% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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:

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan benefit year per member will be covered. 0% NO 2040% YES Well woman annual preventive visit One (1) routine gynecological examination per plan benefit year per female member will be covered. 0% NO 2040% YES Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per benefit year. 0% 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 2040% YES Diabetes education Individual and group 0% NO 40% YES education sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan counseling benefit year when prescribed by a physician. 0% NO 2040% YES physician. Smoking cessation counseling For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 2040% YES Adult Immunization Pediatric 0% NO 2040% YES Pediatric Immunization Travel 0% NO 2040% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection injections only including administration. 0% YES 20% YES 40% YES Preventive Coverage includes, but screenings is not limited to, the following: mammograms, pap smear, PSA test, 0% NO 40% YES flexible sigmoidoscopy, colonoscopy, double contrast barium 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 2040% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 2040% YES Surgical services, including including, but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 2040% YES Manual breast pumps In conjunction with birth. 0% 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 020% YES 2040% YES Radiation Therapy/ Chemotherapy Services Outpatient 020% YES 2040% YES In a doctor’s office 020% YES 2040% YES Respiratory Therapy 020% YES 2040% YES Skilled Nursing Facility Care* Skilled or Sub- acute 020% YES 2040% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 040% YES Outpatient 20% YES 40% YES In a doctor’s office $15 0% NO 2040% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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-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 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) recommended for these diagnostic imaging services. 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. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 020% NO 20YES 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 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 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: Vision care services (continued) 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. $40 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 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. 0% NO Not Covered Not Covered The following lens 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: Vision Hardware for a member under the age of 19 treatments are covered: •  UV treatment; •  Tint ( (fashion, gradient, and glass- grey) •  Standard plastic scratch coating; •  Standard polycarbonate; •  Photocromatic/ transitions plastic Contact Lens 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. 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 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: Vision care services (continued) One supply Hardware for a member under the age 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 19 a 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 benefit year. 0% NO Not Covered Not Covered •  Conventional contact lens are covered limited to one per plan 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: Vision care services (continued) 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 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

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO 20YES 0% NO YES 50% YES YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 0% NO 20YES 0% NO YES 50% YES YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 2 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does themaximum out of pocket expense apply? Pediatric Well-Child preventive Office Visits: office visit Birth - 35 months: 11 visits; 0% NO 20YES 0% NO YES 50% YES Private Duty Nursing* Must be performed YES 36 months - 19 years: 1 per contract year. preventive 0% NO YES 0% NO YES 50% YES YES Diabetes Individual and education group sessions 0% NO YES 0% NO YES 50% YES YES are covered. Nutritional Unlimited counseling visits per contract year when 0% NO YES 0% NO YES 50% YES YES prescribed by a certified home health care agencyphysician. Immuniza- 0% NO YES 200% NO YES 50% YES Radiation Therapy/ Chemotherapy Services Outpatient YES Immuniza- 0% NO YES 200% NO YES 50% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 tions Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: 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 Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does themaximum out of pocket expense apply? Travel Immuniza- 0% NO YES 0% NO YES 50% YES YES Allergy 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. injections injection only including 0% YES 20YES 0% YES Diagnostic imaging and machine testsYES 50% YES YES administration Preventive Coverage screenings includes, other than but is not limited to, the diagnostic imaging services listed above. Copayment is per provider per day. following: mammograms, pap smear, PSA test, flexible 0% NO 20% YES Lab and pathology services. 0% NO 20YES 50% YES YES sigmoidos- copy, colonos- copy, double contrast barium enema, and fecal occult blood tests. Genetic Counseling for BRCA Must be performed by a certified genetic 0% NO YES 0% NO YES 50% YES YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: TestsYour copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does themaximum out of pocket expense apply? counselor. Contracep- tive and Sterilization Services for women Prescription drugs, Imaging*, dispensed and Labs administered by a licensed health care provider (includes machine tests and x-rays) 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 servicesother than a pharmacist). 0% NO 20% YES Lyme Disease- Diagnosis/ Treatment 0% NO 20YES 50% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition YES For prescription drugs purchased at a pharmacy, see the Summary of urgent care centerPharmacy Benefits. $50 Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% 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 YES 0% NO 20YES 50% YES Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: Vision care services (continued) Vision Hardware for a member under Your copayment Does the age deductible apply? Does the maximum out of 19 One pair pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of collection prescription frames per plan year. Non-collection prescription frames are NOT coveredpocket expense apply? Your copayment Does the deductible apply? Does themaximum out of pocket expense apply? Surgical services, including but not limited to, tubal ligation and insertion/ removal of IUD. 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 lensYES 0% NO YES 50% YES YES Manual breast pumps In conjunction with birth. 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 YES 0% NO Not Covered Not Covered YES 50% YES YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES YES 0% YES YES 50% YES YES Radiation Therapy/ Chemo- therapy Services Outpatient 0% YES YES 0% YES YES 50% YES YES In a doctor’s office 0% YES YES 0% YES YES 50% YES YES Respiratory Therapy 0% YES YES 0% YES YES 50% YES YES Skilled Nursing Facility Care Skilled or Sub-acute 0% YES YES 0% YES YES 50% YES YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: Vision care services Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Speech Therapy * ^ In a doctor’s/ therapist’s office* Limited to thirty (continued30) 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 visits per member per contract year. 0(combined with outpatient hospital service, see below). $25 NO YES Does not apply. Services rendered in this setting are Tier 1. 50% NO Not Covered Not Covered • Daily Wear Disposable are covered up YES YES Outpatient hospital * Limited to the benefit limit of a three thirty (330) month supply of daily disposable lenses in a plan visits per member per contract year. 0(combined with In a doctor’s/ therapist’s office, see above). Does not apply. Services rendered in this setting are Tier 2. $75 NO YES 50% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO Not Covered Not Covered YES YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: Vision care services (continued) One additional supply (as indicated above) Your copayment Does the deductible apply? Does the maximum out of contact lenses may be covered for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of improvement. Preauthorization recommended. pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Surgery Services Inpatient 0% YES YES 0% YES YES 50% YES YES Outpatient- hospital, ambulatory or independent surgical center 0% YES YES 0% YES YES 50% YES YES In a doctor’s office 0% NO YES 0% NO YES 50% YES YES Telemedicine When rendered by a designated provider. See Telemedicine Section 3.35 for details. $5 NO YES $5 NO YES Not Covered Not Covered Prescription drugs for which preauthorization is required Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) * Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Does not apply. Services rendered in this setting 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 drugTier 2 $600 NO YES 50% YES YES Service Service Type, 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 tiersProvider, or levels, for copayment purposesPlace of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 1 – generally low cost preferred generic drugs2 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? hospital, which require the lowest copaymentor certain designated free standing facilities Imaging. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higherPreauthor- ization is recommended. Copayment is applied per service.

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 2040% YES Well woman annual preventive visit One (1) routine annual gynecological preventive visit examination per plan year per female member 0% NO 40% YES will be covered. Pediatric Well-Child Office Visits: preventive Birth - 35 months: 11 office visit visits; 0% NO 2040% YES 36 months - 19 years: 1 per plan year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per plan counseling year when prescribed by 0% NO 40% YES a physician. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Adult Immunization 0% NO 2040% YES Pediatric Immunization 0% NO 2040% YES Travel Immunization 0% NO 2040% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 2040% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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:

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO YES 20% YES YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birthDoes the maximum out of pocket expense apply? Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per contract year. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient YES Pediatric preventive clinic 0% NO YES 20% YES In a doctor’s office YES Diabetes education Individual and group sessions are covered. 0% NO YES 20% YES Respiratory Therapy YES Nutritional counseling Unlimited visits per contract year when prescribed by a physician. 0% NO YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient Adult Immunization 0% NO YES 20% YES Outpatient YES Pediatric Immunization 0% NO YES 20% YES In a doctor’s office $15 YES Travel Immunization 0% NO YES 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Allergy injections Applies to injection only including administration. 0% NO YES 20% YES YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. See the Summary of Pharmacy Benefits. 0% NO YES 20% YES YES Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO YES 20% YES YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs 0% NO YES 20% YES YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? purchased at a pharmacy, see the Summary of Pharmacy Benefits. Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO YES 20% YES YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO YES 20% YES YES Manual breast pumps In conjunction with birth. 0% NO YES 20% YES YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES YES 20% YES YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES YES 20% YES YES In a doctor’s office 0% YES YES 20% YES YES Respiratory Therapy 0% YES YES 20% YES YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES YES 20% YES YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Limited to thirty (30) visits per member per contract year. $30 NO YES 20% YES YES Surgery Services Inpatient 0% YES YES 20% YES YES Outpatient 0% YES YES 20% YES YES In a doctor’s office 0% NO YES 20% YES YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.36 for details. $20 NO YES Not Covered 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; • and  Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% YES 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 Subscriber Agreement 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: TestsYour copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? imaging services. Diagnostic imaging and machine tests, Imaging*, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO YES 20% YES YES Lab and Labs (includes machine tests and x-rays) pathology services. 0% NO YES 20% YES YES Sleep Studies Preauthorization is recommended for facility based sleep studies. 0% YES YES 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 YES YES 20% YES YES Lyme Disease- Diagnosis/ Treatment 0% NO YES YES 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 Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $50 NO YES The level of coverage is the same as network provider. Vision care services (continued) Vision Hardware for In a member under the age of 19 doctor’s office One pair of collection prescription frames routine eye exam per plan contract year. Non-collection prescription frames are NOT covered. 0$30 NO YES 20% 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: Vision care services (continued) 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: Vision care services (continued) 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 Prescription drugs for which preauthorization is required are marked with the symbol (+) in YES YES See the Summary of Pharmacy Benefits. Preauthorization is required Benefits 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 higherSUMMARY OF MEDICAL BENEFITS i

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 2040% YES Well woman annual preventive visit One (1) routine annual gynecological preventive visit examination per plan year per female member 0% NO 40% YES will be covered. Pediatric Well-Child Office Visits: preventive Birth - 35 months: 11 office visit visits; 0% NO 2040% YES 36 months - 19 years: 1 per plan year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per plan counseling year when prescribed by 0% NO 40% YES a physician. 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? Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Adult Immunization 0% NO 2040% YES Pediatric Immunization 0% NO 2040% YES Travel Immunization 0% NO 2040% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 2040% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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?

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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 higherYES

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 0% NO 2060% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: Prevention Well woman One (1) routine and Early annual gynecological Detection Services (continued) preventive visit examination per contract year per 0% NO 0% NO 60% YES female member will be covered. Pediatric preventive office visit Well-Child Office preventive Visits: office visit Birth - 35 -35 months: 11 visits; 0% NO 0% NO 60% YES 36 months - 19 years: 1 per plan contract year. Pediatric preventive 0% NO 20% YES Pediatric preventive clinic 0% NO 2060% YES clinic Diabetes education Individual and education group sessions are covered. 0% NO 200% NO 60% YES covered. Nutritional counseling Unlimited visits per plan counseling contract year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 2060% YES physician. Smoking Cessation counseling 0% NO 0% NO 60% YES Adult Immunization Immuniza- 0% NO 20% YES Pediatric Immunization 0% NO 2060% YES Travel Immunization tions Pediatric Immuniza- tions 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 20NO 60% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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: Prevention and Early Detection Immuniza- 0% NO 0% NO 60% YES Services (continued) Allergy Applies to injection injections only including 20% YES 20% YES 60% YES administration. Preventive screenings Coverage includes, screenings but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopysigmoidos- 0% NO 0% NO 60% YES copy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Must be performed Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 200% NO 60% YES Contraceptive and Sterilization Services for women Contra- Prescription drugs, ceptive and dispensed and Sterilization administered by a Services for licensed health women care provider (other than a pharmacist). 0% NO 0% NO 60% YES For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted 0% NO 0% NO 60% YES and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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:

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO YES 20% YES YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birthDoes the maximum out of pocket expense apply? Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per contract year. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient YES Pediatric preventive clinic 0% NO YES 20% YES In a doctor’s office YES Diabetes education Individual and group sessions are covered. 0% NO YES 20% YES Respiratory Therapy YES Nutritional counseling Unlimited visits per contract year when prescribed by a physician. 0% NO YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient Adult Immunizations 0% NO YES 20% YES Outpatient YES Pediatric Immunizations 0% NO YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 Subscriber Agreement 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: 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 Your copayment Does 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. deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Travel Immunizations 0% NO YES 20% YES Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per dayYES Allergy injections Applies to injection only including administration. 0% NO YES 20% YES Lab YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, fecal occult blood tests, screening for gestational diabetes, and pathology serviceshuman papillomavirus. 0% NO YES 20% YES YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO YES 20% YES YES Subscriber Agreement 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: TestsYour copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Contraceptive and Sterilization Services for women Prescription drugs, Imaging*dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO YES 20% YES YES Barrier method (cervical cap or diaphragm) fitted and Labs (includes machine tests and x-rays) Diagnostic colorectal services Includingsupplied during an office visit. 0% NO YES 20% YES YES Surgical services, including but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, tubal ligation and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal servicesinsertion/removal of IUD. 0% NO YES 20% YES Lyme Disease- Diagnosis/ Treatment YES Manual breast pumps In conjunction with birth. 0% NO YES 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 Subscriber Agreement 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: Vision Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Private Duty Nursing* Must be performed by a certified home health 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 coveredagency. 0% NO YES 20% YES YES Radiation Therapy/ Chemotherapy Services Outpatient 0% NO YES 20% YES YES In a doctor’s office 0% NO YES 20% YES YES Respiratory Therapy 0% NO YES 20% YES YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% NO YES 20% YES YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Limited to thirty (30) visits per member per contract year. 20% NO YES 20% YES YES Surgery Services Inpatient 0% NO YES 20% YES YES Outpatient 0% NO YES 20% YES YES In a doctor’s office 0% NO YES 20% YES YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.36 for details. $15 NO YES 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 Subscriber Agreement 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: Vision care services Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Tests, Imaging*, and Labs (continuedincludes machine tests and x-rays) 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. Outpatient Hospital Facility/ Outpatient Non-collection contact lenses are NOT covered. • Extended Wear Disposables are covered up Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a plan yearfollowing diagnostic imaging services:  MRI;  MRA;  CAT scans;  CTA scans;  PET scans;  Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 0% NO Not Covered Not Covered • Daily Wear Disposable are covered up to YES 20% YES YES For tests, imaging and lab, other than the benefit limit of a three (3) month supply of daily disposable lenses in a plan yeardiagnostic imaging services listed above. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan yearYES 20% YES YES Sleep Studies Preauthorization is recommended for facility based sleep studies. 0% NO Not Covered Not Covered YES 20% YES YES Subscriber Agreement 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: Vision care Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Diagnostic colorectal services (continued) One additional supply (as indicated above) of contact lenses may be covered Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for certain conditions: · Anisometropia · High Ametropia · Keratoconus · Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommendedpreventive colorectal services. 0% NO Not Covered Not Covered Prescription drugs for which preauthorization YES 20% YES YES Lyme Disease- Diagnosis/ Treatment 0% NO YES 20% YES YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. $15 NO YES The level of coverage is required are marked with the symbol (+) in same as network provider. Vision care services In a doctor’s office One routine eye exam per contract year. $15 NO YES 20% YES YES Subscriber Agreement See the Summary of Pharmacy Benefits. Preauthorization is required Benefits 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 higher1.0 INTRODUCTION 1

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan benefit year per member will be covered. 0% NO 20% YES Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per plan benefit year per female member will be covered. 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: Prevention and Early Detection Services (continued) Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan benefit year. 0% NO 20% YES Not Covered Not Covered Pediatric preventive clinic 0% NO 20% YES Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES 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? Manual breast pumps In conjunction with birthPrevention and Early Detection Services (continued) Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 yearSmoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. $20 0% 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: 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 Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections 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 studiesinjection only including administration. 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: Vision care services Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) Vision Hardware Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for a member under the age of 19 One pair of collection prescription frames per plan year. Non-collection prescription frames are NOT coveredgestational diabetes, and human papillomavirus. 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 lensGenetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint ( fashionContraceptive and Sterilization Services for women Prescription drugs, gradient, dispensed 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 administered by a covered heath care service you pay: Non-network provider For a covered licensed health care service you pay provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the difference between the charge amount and the allowance plus: Vision care services (continued) One supply Summary 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 yearPharmacy Benefits. 0% NO Not Covered Not Covered • Daily Wear Disposable are covered up to the benefit limit of a three Barrier method (3cervical cap or diaphragm) month supply of daily disposable lenses in a plan year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan yearfitted and supplied during an office visit. 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: Vision care services Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prevention and Early Detection Services (continued) One additional supply Contraceptive and Sterilization Services for women (as indicated abovecontinued) Surgical services, including but not limited to, tubal ligation and insertion/removal 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 recommendedIUD. 0% NO Not Covered Not Covered Prescription drugs Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES 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? Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 for which preauthorization is required are marked with details. $30 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 symbol (+) in the Summary of Pharmacy Benefitsfollowing diagnostic imaging services:  MRI;  MRA;  CAT scans;  CTA scans;  PET scans;  Nuclear Cardiac Imaging; and  Sleep Studies. Preauthorization is required recommended for certain brand name prescription drugs these diagnostic services and certain specialty Prescription Drugsfor facility based sleep studies. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For details on how to obtain prescription drug preauthorization 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) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory (continued) For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered 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 Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES 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? Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES 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, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered 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 drugframes per benefit year. Non-collection prescription frames are NOT covered. 0% YES Not Covered Not Covered One pair of glass or plastic lenses per benefit year. 0% YES Not Covered Not Covered Service Service Type, 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 tiersProvider, or levelsPlace 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 Hardware for a member under the age of 19 (continued) Prescription glasses – Frames (continued) This includes single vision, for 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 Contact Lens 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. 0% YES 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 purposes: Tier 1 – generally low cost preferred generic drugs, which require Does the lowest copayment. Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, which require a higherdeductible apply? Your copayment Does the deductible apply?

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan benefit year per member will be 0% NO 20% YES covered. Well woman One (1) routine annual gynecological preventive visit examination per benefit year per female 0% NO 20% YES member will be covered. Pediatric Well-Child Office preventive Visits:Birth - 35 months: office visit 11 visits; 0% NO 20% YES 36 months - 19 years: 1 per benefit year. Pediatric preventive 0% NO 20% YES clinic Diabetes Individual and group 0% NO 20% YES education sessions are 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: Prevention and Early Detection Services Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO 20% YES Well woman annual preventive visit One Smoking For nicotine cessation replacement therapy counseling (1NRT) routine gynecological examination per plan year per female member will be covered. and smoking cessation prescription 0% NO 20% YES drugs, see Summary of Pharmacy Benefits. Adult 0% NO 20% YES Immunization Pediatric 0% NO 20% YES Immunization Travel 0% NO 20% YES Immunization Allergy Applies to injection only injections including 0% YES 20% YES administration. Preventive Coverage includes, but screenings is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double 0% NO 20% YES contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Contraceptive and Sterilization Services for women (continued) Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Manual breast pumps In conjunction with birth. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. Nursing 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% $200 Copay per admission YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. $40 YES 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 0% YES 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 NO 40 YES 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: 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 Outpatient Hospital Facility/ Outpatient Non-Hospital facility including in a Doctor’s office, urgent care center, or free-standing laboratory (continued) Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and • Sleep Studies. Studies Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 0% $150 YES 20% YES Diagnostic 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 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: 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% NO 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 NO 75 YES The level of coverage is the same as network provider. 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: Vision care services Eye Exam In a doctor’s office One routine eye exam per plan year benefit year, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. $50 YES 20% YES 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 (continued) One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% YES Not Covered Not Covered One pair of glass or plastic lenses per benefit year. 0% YES 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: 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. (continued) 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 Contact Lens 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. 0% NO YES 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: Vision care services Hardware for a member under the age of 19 (continued) One supply of collection contact lenses Contact Lens (Extended Wear OR Daily Wear OR Conventionalcontinued) covered in lieu of Prescription Glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are 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. 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 benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered • Conventional contact lens are covered one per plan year. 0% NO YES 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: Vision care services Hardware for a member under the age of 19 (continued) Contact Lens (continued) 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 YES Not Covered Not Covered 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

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 20 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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 higherYES

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO 20YES 40% YES YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 0% NO 20YES 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birthDoes the maximum out of pocket expense apply? Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per contract year. 0% NO 20YES 40% YES Private Duty Nursing* Must be performed YES Pediatric preventive clinic 0% NO YES 40% YES YES Diabetes education Individual and group sessions are covered. 0% NO YES 40% YES YES Nutritional counseling Unlimited visits per contract year when prescribed by a certified home health care agencyphysician. 0% NO YES 40% YES YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO YES 40% YES YES Adult Immunization 0% NO YES 40% YES YES Pediatric Immunization 0% NO YES 40% YES YES Travel Immunization 0% NO YES 40% YES YES Allergy injections Applies to injection only including administration. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. See the Summary of Pharmacy Benefits. 0% NO YES 40% YES YES Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor 0% NO YES 40% YES YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO YES 40% YES YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO YES 40% YES YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO YES 40% YES YES Manual breast pumps In conjunction with birth. 0% NO YES 40% YES YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES YES 40% YES YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES YES 40% YES YES In a doctor’s office 0% YES YES 40% YES YES Respiratory Therapy 0% YES YES 40% YES YES Skilled Nursing Facility Care* Skilled or Sub-acute 0% YES YES 40% YES YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Limited to thirty (30) visits per member per contract year. 0% YES YES 40% YES YES Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Surgery Services Inpatient 0% YES YES 40% YES YES Outpatient 0% YES YES 40% YES YES In a doctor’s office 0% YES YES 40% YES YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.36 for details. 0% YES YES Not Covered 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; • and  Nuclear Cardiac Imaging; and • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studiesimaging services. 0% YES 20YES 40% 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 Subscriber Agreement 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: TestsYour copayment Does the deductible apply? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Diagnostic imaging and machine tests, Imaging*, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% YES YES 40% YES YES Sleep Studies Preauthorization is recommended for facility based sleep studies. 0% YES YES 40% YES YES Lab and Labs (includes machine tests and x-rays) pathology services 0% YES YES 40% 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 20YES YES 40% YES YES Lyme Disease- Diagnosis/ Treatment 0% NO 20YES YES 40% 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 Subscriber Agreement 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? Does the maximum out of pocket expense apply? Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES YES The level of coverage is the same as network provider. Vision care services (continued) Vision Hardware for In a member under the age of 19 doctor’s office One pair of collection prescription frames routine eye exam 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: Vision care services (continued) 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 contract 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. 0YES YES 40% 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: Vision care services (continued) 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 Prescription drugs for which preauthorization is required are marked with the symbol (+) in YES YES See the Summary of Pharmacy Benefits. Preauthorization is required Benefits 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 higherSUMMARY OF MEDICAL BENEFITS iii

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization 0% NO 20% YES Pediatric Immunization 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 20% YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES Manual breast pumps In conjunction with birth. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 4020% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 0% NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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; • 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 For tests, imaging and machine testslab, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO YES 20% YES Lab Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and pathology barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% NO YES 20% YES Lyme Disease- Diagnosis/ Treatment 0% YES 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 30 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: 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 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: Vision care services Vision Hardware for a member under the age of 19 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 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: Vision care services (continued) One supply Vision Hardware for a member under the age 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 19 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: Vision care services (continued) 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 Preauthorization recommended. 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

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan benefit year per member will be covered. 0% NO 2030% YES covered. Well woman annual preventive visit One (1) routine annual gynecological preventive visit examination per plan benefit year per female 0% NO 30% YES member will be covered. Pediatric Well-Child Office preventive Visits: office visit Birth - 35 months: 11 visits; 0% NO 2030% YES 36 months - 19 years: 1 per benefit year. Pediatric preventive 0% NO 30% YES clinic Diabetes Individual and group 0% NO 30% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 30% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 30% YES Summary of Pharmacy Benefits. Adult 0% NO 30% YES Immunization 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office VisitsImmunization 0% NO 30% YES Travel Immunization 0% NO 30% YES Allergy Applies to injection injections only including administration. 10% YES 30% YES Preventive Coverage includes, but screenings is not limited to, the following: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan yearmammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium 0% NO 30% YES enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. Genetic Must be performed by Counseling for BRCA a certified genetic counselor. 0% NO 2030% YES Pediatric preventive clinic Contraceptive Prescription drugs, and dispensed and Sterilization administered by a Services for licensed health care women provider (other than a pharmacist). For 0% NO 2030% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan year when prescribed by prescription drugs purchased at a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugspharmacy, see the Summary of Pharmacy Benefits. 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: Early Detection Services (continued) Barrier method (cervical cap or diaphragm) fitted and 0% NO 2030% YES Adult Immunization supplied during an office visit. Surgical services, including, but not limited to, tubal ligation and insertion/removal 0% NO 2030% YES Pediatric Immunization of IUD. Manual breast In conjunction with pumps birth. 0% NO 2030% YES Travel Immunization 0% NO 20Private Duty Nursing* Must be performed by a certified home health care agency. 10% YES Allergy injections Applies to injection only including administration. 0% YES 2030% 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 20% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 010% YES 2030% YES In a doctor’s office 010% YES 2030% YES Respiratory Therapy 010% YES 2030% YES Skilled Nursing Facility Care* Skilled or Sub- acute 010% YES 2030% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 2010% YES 4030% YES Surgery Services Inpatient 010% YES 2030% YES Outpatient 010% YES 2030% YES In a doctor’s office $15 25 NO 2030% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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 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: 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-free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; • Nuclear Cardiac Imaging; and And • Sleep Studies. Preauthorization is recommended for these diagnostic services and for facility based sleep studies. 010% YES 2030% YES Diagnostic For tests, imaging and machine testslab, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% NO 2010% YES Lab 30% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and pathology barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 010% NO 20YES 30% 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 Your copayment Does the deductible apply? Your copayment Does the deductible apply? Lyme Disease- Diagnosis/ Treatment 010% NO 20YES 30% 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 Eye Exam In a doctor’s office One routine eye exam per plan year 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 60 NO 2030% YES NO 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: Vision care services (continued) 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 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: Vision care services (continued) 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: Vision care services Hardware for a member under the age of 19 (continued) Prescription glasses – Frames (continued) 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 Contact Lens 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. 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: Vision Hardware for a member under the age of 19 (continued) Contact Lens (continued) 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 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 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 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? Preauthorization is recommended. 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

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan year per member will be covered. 0% NO 2040% YES Well woman annual preventive visit One (1) routine gynecological examination per plan year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan year. 0% NO 2040% YES Pediatric preventive clinic 0% NO 2040% YES Diabetes education Individual and group sessions are covered. 0% NO 2040% YES Nutritional counseling Unlimited visits per plan year when prescribed by a physician. 0% NO 2040% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Adult Immunization 0% NO 2040% YES Pediatric Immunization 0% NO 2040% YES Travel Immunization 0% NO 2040% YES Allergy injections Applies to injection only including administration. 020% YES 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: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 2040% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 2040% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 2040% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 2040% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 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? Manual breast pumps In conjunction with birth. 0% NO 2040% YES Private Duty Nursing* Must be performed by a certified home health care agency. 020% YES 2040% YES Radiation Therapy/ Chemotherapy Services Outpatient 020% YES 2040% YES In a doctor’s office 020% YES 2040% YES Respiratory Therapy 020% YES 2040% YES Skilled Nursing Facility Care* Skilled or Sub- acute 020% YES 2040% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 040% YES Outpatient 20% YES 40% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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. 040% 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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 higherYES

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO 20% YES YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 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 Your copayment Does the difference between deductible apply? Does the charge amount and the allowance plus: Prevention and Early Detection Services (continued) maximum out of pocket expense apply? Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 11 3 visits; 36 months - 19 years: 1 per plan contract year. 0% NO 20% YES YES Pediatric preventive clinic 0% NO 20% YES YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES YES Nutritional counseling Unlimited visits per plan contract year when prescribed by a physician. 0% NO 20% YES YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES YES Adult Immunization 0% NO Immunizations 20% YES YES Pediatric Immunization 0% NO Immunizations 20% YES YES Travel Immunization 0% NO Immunizations 20% YES YES Allergy injections Applies to injection only including administration. 0% YES 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: Prevention and Early Detection Services (continued) YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO See the Summary of Pharmacy Benefits. 20% YES YES Service Service Type, Provider, or Place of Service Benefit Limit Flex plan you pay: Your copayment Does the deductible apply? Does the maximum out of pocket expense apply? Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20% YES YES Manual breast pumps In conjunction with birth. 20% YES YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES YES In a doctor’s office 20% YES YES Respiratory Therapy 20% YES YES Skilled Nursing Facility Care* Skilled or Sub- acute 20% YES YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Limited to thirty (30) visits per member per contract year. 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? Manual breast pumps In conjunction with birth. 0% NO Surgery Services Inpatient 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES Outpatient 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 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: 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 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: Tests, Imaging*, and Labs (includes machine tests and x-rays) 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 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 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: 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: Vision care services (continued) 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: Vision care services (continued) 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 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 higherYES

Prevention and Early Detection Services Adult annual preventive. visit One (1) routine adult physical examination per plan contract year per member will be covered. 0% NO 20% YES Well woman annual preventive visit One (1) routine gynecological examination per plan contract year per female member will be covered. 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: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per plan contract year. 0% NO 20% YES Pediatric preventive clinic 0% NO 20% YES Diabetes education Individual and group sessions are covered. 0% NO 20% YES Nutritional counseling Unlimited visits per plan contract year when prescribed by a physician. 0% NO 20% YES Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO 20% YES Adult Immunization Immunizations 0% NO 20% YES Pediatric Immunization Immunizations 0% NO 20% YES Travel Immunization 0% NO 20% YES Allergy injections Applies to injection only including administration. 0% YES 20% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: NonCare Coordinated by Your Primary Care Physician and Permitted Self-network provider For a covered health care service you pay Referrals Your copayment Does the difference between Deductible apply? Does the charge amount and the allowance plus: Prevention and Early Detection Services (continued) maximum out of pocket expense apply? Travel Immunizations 0% NO YES Allergy injections Applies to injection only including administration. 0% NO YES Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. See the Summary of Pharmacy Benefits. 0% NO 20% YES Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 20% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and and Sterilization administered by a licensed health care Services for provider (other than a pharmacist). For women prescription drugs purchased at a 0% NO YES pharmacy, see the Summary of Pharmacy Benefits. 0% NO 20% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 20% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 20YES Manual breast In conjunction with birth. 0% NO YES pumps Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: NonCare Coordinated by Your Primary Care Physician and Permitted Self-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Referrals Your copayment Does the deductible Deductible apply? Your copayment Does the deductible maximum out of pocket expense apply? Manual breast pumps In conjunction with birth. 0% NO 20% YES Private Duty Nursing* Must be performed by a certified home health care agency. 0% YES 20% YES Radiation Therapy/ Chemotherapy Services Outpatient 0% YES 20% YES In a doctor’s office 0% YES YES Respiratory Therapy 20% YES Respiratory Therapy 0% YES 20% YES Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES 20% YES Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative servicesLimited to thirty (30) visits per member per contract year. 200% YES 40% YES Surgery Services Inpatient 0% YES 20% YES Outpatient 0% YES 20% YES In a doctor’s office $15 0% NO 20% YES Telemedicine When rendered by a designated provider. See Telemedicine – Section 3.35 3.36 for details. First telemedicine visit in a plan year. Benefit applies per member, per plan year. $0 25 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: YES 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 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 Service Service Type, Provider, or Place of Service Benefit Limit Network provider Care Coordinated by Your Primary Care Physician and Permitted Self-Referrals Your copayment Does the Deductible apply? Does the maximum out of pocket expense apply? laboratory Preauthorization is recommended for these diagnostic imaging services. For a covered heath care service you pay: Non-network provider For a covered health care service you pay tests, imaging and lab, other than the difference between the charge amount and the allowance plus: Tests, Imaging*, and Labs (includes machine tests and x-rays) diagnostic imaging services listed above. 0% NO YES Sleep Studies Preauthorization is recommended for facility based sleep studies 0% 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 Lyme Disease- Diagnosis/ Treatment 0% NO 20% YES 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. YES 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 coveredcontract year. $50 40 NO 20% YES Vision Hardware Using your Flex Plan, you may seek care 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: Nonmany services from non-network provider For providers or from network providers without a referral from your primary care physician. Once you use the Flex Plan option to receive covered health care service you pay the difference between the charge amount and the allowance plus: 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 visionservices, 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 all covered health care service you pay services associated with the difference between the charge amount and the allowance plus: Vision episode of care services (continuede.g., lab, x-ray, hospitalization) 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 subject to the benefit limit terms of a six (6) month supply of monthly or two (2) week disposables in a plan yearthis Rider. 0% NO Not Covered Not Covered • Daily Wear Disposable Services which are not covered up to under 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 Flex Plan 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: Vision care services (continued) 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 Prescription drugs for which preauthorization is required are marked with the symbol (+) noted in the Summary of Pharmacy Flex Plan 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.