Common use of Prevention and Early Detection Services Clause in Contracts

Prevention and Early Detection Services. Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 0% NO 70% YES Contracep- tive 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 0% NO 70% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 0% NO 70% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 0% NO 70% YES Manual breast pumps In conjunction with birth. 0% NO 0% NO 70% 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? Your copayment Does the deductible apply? Private Duty Nursing* Must be performed by a certified home health care agency. 30% YES 30% YES 70% YES Radiation Therapy/ Chemo-therapy Services Outpatient 30% YES 30% YES 70% YES In a doctor’s office 30% YES 30% YES 70% YES Respiratory Therapy 30% YES 30% YES 70% YES Skilled Nursing Facility Care Skilled or Sub-acute 30% YES 30% YES 70% YES Speech Therapy * ^ In a doctor’s/ therapist’s office* Covered health care services include rehabilitative and habilitative services. $25 NO $25 NO 70% YES Outpatient hospital * Covered health care services include rehabilitative and habilitative services. $75 NO $75 NO 70% YES Surgery Services Inpatient Facility See Inpatient Hospital Services Inpatient Doctor 30% YES 30% YES 70% 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? Your copayment Does the deductible apply? Surgery Services Outpatient- hospital , ambulatory or independent surgical center 30% YES 30% YES 70% YES In a doctor’s office 0% NO 0% NO 70% YES Tests, Imaging*, and Labs (includes machine tests and x-rays) * Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended. Copayment is applied per service. $600 NO $600 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear $200 NO $600. NO 70% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * urgent care center, or certain designated free- standing outpatient facilities Cardiac Imaging. Preauthorization is recommended. Copayment is applied per service. Outpatient Hospital facility, free standing facilities owned and /or affiliated with a hospital , or certain designated free standing facilities Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 NO $150 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 NO $150 NO 70% 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? Your copayment Does the deductible apply? Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities Lab and pathology services. $75 NO $75 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated free- standing outpatient facilities Lab and pathology services. $25 NO $75 NO 70% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * Outpatient Hospital facility Sleep studies $600 NO $600 NO 70% YES Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing outpatient facility, or other non- hospital setting Sleep studies $200 NO $600. NO 70% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidos-copy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive 30% YES 30% YES 70% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * Screening for preventive colorectal services. Lyme Disease- Diagnosis/ Treatment 30% YES 30% YES 70% YES Urgent care facility Urgent care facility/ walk-in See Section 8.0 - definition of urgent care center. $125 NO The level of coverage is the same as Tier 1. The level of coverage is the same as Tier 1. 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. Medically necessary eye exams are covered. $65 NO $85 NO 70% 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? Your copayment Does the deductible apply? Vision Hardware for a member aged 19 and older Not Covered Not Covered 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 benefit year. Non-collection prescription frames are NOT covered. 0% NO 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. 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 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 coating; • Standard polycarbonate; • Photocro- matic/ 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 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 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 of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. 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. Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 0% NO 70% YES Contracep- tive 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 0% NO 70% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 0% NO 70% YES visit Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 0% NO 7060% YES Manual breast pumps In conjunction with birth. birth 0% NO 0% NO 7060% YES Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 20% YES 60% YES Radiation Therapy/ Chemo- therapy Services Outpatient 20% YES 20% YES 60% YES In a doctor’s office 20% YES 20% YES 60% YES Respiratory Therapy 20% YES 20% YES 60% YES Skilled Nursing Facility Care Skilled or Sub-acute 20% YES 20% YES 60% YES Speech Therapy * ^ In a doctor’s/ therapist’s office* $25 NO $25 NO 60% YES Outpatient hospital * $75 NO $75 NO 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Private Duty Nursing* Must be performed by a certified home health care agency. 30% YES 30% YES 70% YES Radiation Therapy/ Chemo-therapy Services Outpatient 30% YES 30% YES 70% YES In a doctor’s office 30% YES 30% YES 70% YES Respiratory Therapy 30% YES 30% YES 70% YES Skilled Nursing Facility Care Skilled or Sub-acute 30% YES 30% YES 70% YES Speech Therapy * ^ In a doctor’s/ therapist’s office* Covered health care services include rehabilitative and habilitative services. $25 NO $25 NO 70% YES Outpatient hospital * Covered health care services include rehabilitative and habilitative services. $75 NO $75 NO 70% YES Surgery Services Inpatient Facility See Inpatient Hospital Services Inpatient Doctor 3020% YES 3020% YES 7060% YES Outpatient- hospital , ambulatory or independent surgical center 20% YES 20% YES 60% YES In a doctor’s office 0% NO 0% NO 60% YES Tests, Imaging*, and Labs (includes machine tests and x- rays) * Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended Copayment is applied per service. $600 NO $600 NO 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Surgery Services Outpatient- hospital , ambulatory or independent surgical center 30% YES 30% YES 70% YES In a doctor’s office 0% NO 0% NO 70% YES Tests, Imaging*, and Labs (includes machine tests and x-x- rays) * Outpatient Non- Hospital facilityfacilities: including; in a Doctor’s office, free standing facilities owned and/ or affiliated with a hospitalurgent care center, or certain designated free free- standing outpatient facilities • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended. Copayment is applied per service. $600 200 NO $600 NO 7060% YES Outpatient Non- Hospital facilities: including; in facility, free standing facilities owned and /or affiliated with a Doctor’s officehospital, • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; or certain designated free standing facilities Diagnostic imaging and • Nuclear machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $200 150 NO $600. 150 NO 7060% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-x- rays) * urgent care center, or certain designated free- standing outpatient facilities Cardiac Imaging. Preauthorization is recommended. Copayment is applied per service. Outpatient Hospital facility, free standing facilities owned and /or affiliated with a hospital , or certain designated free standing facilities Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 NO $150 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated free- standing outpatient facilities Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 NO $150 NO 7060% YES Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities Lab and pathology services $75 NO $75 NO 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Outpatient Hospital facilityTests, free standing facilities owned and/ or affiliated with a hospitalImaging*, or certain designated free standing facilities Lab and pathology services. $75 NO $75 NO 70% YES Labs (includes machine tests and x- rays) * Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated free- standing outpatient facilities Lab and pathology services. services $25 NO $75 NO 7060% YES Outpatient Hospital facility Sleep studies $600 NO $600 NO 60% YES Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing outpatient facility, or non-hosp- ital setting Sleep studies $200 NO $600 NO 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-x- rays) * Outpatient Hospital facility Sleep studies $600 NO $600 NO 70% YES Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing outpatient facility, or other non- hospital setting Sleep studies $200 NO $600. NO 70% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidos-copy, colonoscopy, and barium enema. 20% YES 20% YES 60% YES See Prevention and Early Detection Services - Preventive 30Screening for preventive colorectal services. Lyme Disease- Diagnosis/ Treatment 20% YES 3020% YES 7060% YES Urgent care facility Urgent care facility/ walk-in See Section 8.0 - definition of urgent care center. $75 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider 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. $30 NO $50 NO 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: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * Screening for preventive colorectal services. Lyme Disease- Diagnosis/ Treatment 30% YES 30% YES 70% YES Urgent care facility Urgent care facility/ walk-in See Section 8.0 - definition of urgent care center. $125 NO The level of coverage is the same as Tier 1. The level of coverage is the same as Tier 1. 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. Medically necessary eye exams are covered. $65 Vision Hardware for a member aged 19 and older Not Covered Not Covered 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 benefit year. 0% NO $85 0% NO 70Not Covered Not Covered Non-collection prescription frames are NOT covered. One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. 0% YES NO 0% NO Not Covered Not Covered The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass-grey) • Standard plastic scratch coating; 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? Your copayment Does the deductible apply? Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames • Standard polycarbonate; • Photocro-matic/ transitions plastic Contact Lens One pair supply of collection prescription frames per benefit yearcontact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. NonIncludes evaluation, fitting or follow-collection prescription frames are NOT coveredup care relating to contact lenses. 0% NO 0% NO Not Covered Not Covered One pair of glass or plastic Non-collection contact lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lensare NOT covered. The following lens treatments contact lenses are covered: • UV treatment; • Tint Extended Wear Disposables are covered up to the benefit limit of a six (fashion, gradient, and glass-grey6) • Standard plastic scratch month supply of monthly or two (2) week disposables in a benefit year. 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 coating; • Standard polycarbonate; • Photocro- matic/ 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 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 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 of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. Preauthorization recommended. 0% NO 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. Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 0% NO 7075% YES Contracep- tive 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 0% NO 7075% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 0% NO 7075% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 0% NO 7075% YES Manual breast pumps In conjunction with birth. 0% NO 075% NO 70YES Private Duty Nursing 50% YES 75% YES Radiation Therapy/ Chemotherapy Services Outpatient 50% YES 75% YES In a doctor’s office 50% YES 75% YES Respiratory Therapy 50% YES 75% 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? Your copayment Does the deductible apply? Private Duty Nursing* Must be performed by a certified home health care agency. 30% YES 30% YES 70% YES Radiation Therapy/ Chemo-therapy Services Outpatient 30% YES 30% YES 70% YES In a doctor’s office 30% YES 30% YES 70% YES Respiratory Therapy 30% YES 30% YES 70% YES Skilled Nursing Facility Care Care* Skilled or Sub-Sub- acute 3050% YES 30% YES 7075% YES Speech Therapy Therapy* ^ In Outpatient/in a doctor’s/ therapist’s office* office Covered health care services include rehabilitative and habilitative services. $25 NO $25 NO 7050% YES Outpatient hospital * Covered health care services include rehabilitative and habilitative services. $75 NO $75 NO 7075% YES Surgery Services Inpatient Facility See Inpatient Hospital Services Inpatient Doctor 3050% YES 3075% YES 70Outpatient 50% YES 75% YES In a doctor’s office 50% YES 75% YES 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. Preauthorization is recommended for these diagnostic imaging services. 50% YES 75% YES For tests, imaging and lab, other than the diagnostic imaging services listed above. 50% YES 75% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. 50% YES 75% 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? Your copayment Does the deductible apply? Surgery Services Outpatient- hospital , ambulatory or independent surgical center 30% YES 30% YES 70% YES In a doctor’s office 0% NO 0% NO 70% YES Tests, Imaging*, See Prevention and and Labs Early Detection (includes machine Services - Preventive tests and x-rays) * Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac ImagingScreening for preventive colorectal services. Preauthorization is recommended. Copayment is applied per service. $600 NO $600 NO 70Lyme Disease- Diagnosis/ Treatment 50% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear $200 NO $600. NO 7075% YES Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 50% 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, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. 50% YES 75% 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 benefit year. 50% YES Not Covered Not Covered Non-collection prescription frames are NOT covered. One pair of glass or plastic lenses per benefit year. 50% YES Not Covered Not Covered 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * urgent care center, or certain designated free- standing outpatient facilities Cardiac Imaging. Preauthorization is recommended. Copayment is applied per service. Outpatient Hospital facility, free standing facilities owned and /or affiliated with a hospital , or certain designated free standing facilities Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $150 NO $150 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. $50 NO $150 NO 70% 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? Your copayment Does the deductible apply? Outpatient Hospital facility, free standing facilities owned and/ or affiliated with a hospital, or certain designated free standing facilities Lab and pathology services. $75 NO $75 NO 70% YES Outpatient Non- Hospital facilities: including; in a Doctor’s office, urgent care center, or certain designated free- standing outpatient facilities Lab and pathology services. $25 NO $75 NO 70% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * Outpatient Hospital facility Sleep studies $600 NO $600 NO 70% YES Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing outpatient facility, or other non- hospital setting Sleep studies $200 NO $600. NO 70% YES Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidos-copy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive 30% YES 30% YES 70% 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? Your copayment Does the deductible apply? Tests, Imaging*, and Labs (includes machine tests and x-rays) * Screening for preventive colorectal services. Lyme Disease- Diagnosis/ Treatment 30% YES 30% YES 70% YES Urgent care facility Urgent care facility/ walk-in See Section 8.0 - definition of urgent care center. $125 NO The level of coverage is the same as Tier 1. The level of coverage is the same as Tier 1. 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. Medically necessary eye exams are covered. $65 NO $85 NO 70% 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? Your copayment Does the deductible apply? Vision Hardware for a member aged 19 and older Not Covered Not Covered 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 benefit year. Non-collection prescription frames are NOT covered. 0% NO 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass-glass- grey) • Standard plastic scratch 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 coating; • Standard polycarbonate; • Photocro- matic/ 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. 50% YES Not Covered Not Covered Non-collection contact lenses are NOT covered. 0% NO 0% NO Not Covered Not Covered The following contact lenses are covered: • Extended Wear Disposables are covered up to the 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 Contact Lens 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 of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 50% YES Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia 0% NO 0% NO Not Covered Not Covered 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? Your copayment Does the deductible apply? Vision Hardware for a member under the age of 19 • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. 50% YES 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