Common use of Prevention Care Services and Early Detection Services Clause in Contracts

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.pay

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $20 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.pay

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 400% - After deductible 50%- Afterdeductible Private Duty Nursing Services* Must be performed by a certified home certifiheodme health care agency. $30 $60 50%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 400% - After deductible 50%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ 0% 0% 50%- Afterdeductible Respiratory Therapy Inpatient 0% 0% 50%- Afterdeductible Outpatient 0% 0% 50%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care $500 per admission- Afterdeductible $1000 per admission- Afterdeductible 50%- Afterdeductible Speech Therapy Outpatient hospitainl/ a S K \ WV KL FH office. $30 $60 50%- Afterdeductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Tier 1 Network Providers Tier 2 Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy You Pay Surgery Services Inpatient physiciasnervices $0 - Afterdeductible $0 - Afterdeductible 50%- Afterdeductible Tier 1 benefits apply if admitted through the emergency room. Outpatient 0% - After deductible 40% - After deductible physiciasnervices $0 $0 50%- Afterdeductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled S K o\ ffiVce L F L D Q ¶ $0 $0 50%- Afterdeductible Outpatienthospita,l ambulatory or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician independent surgical center- facility services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible $150- Afterdeductible $1000- Afterdeductible 50%- Afterdeductible Telemedicine Services When rendered by our designated telemedicine providera designatepdrovider. 0% - After deductible $20 $20 Not Covered When rendered by a network provider other than our designated telemedicine provideranetworkprovider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $20 $20 NotCovered Tests, Labs, Imaging and X-rays - Diagnostic OutpatientOutpatient hospitaflacility, in free standing facilities owned and/ or affiliated with a physician’s office, urgent care center hosp or free-certain designated free standing laboratory: Major diagnostic imaging and testing* including but not limited tofacilities: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine and cardiac imagingmedicine*. 0% - After deductible 40% - After deductible $200- Afterdeductible $600- Afterdeductible 50%- Afterdeductible Sleep studies.* 0% $200- Afterdeductible $600- Afterdeductible 50%- Afterdeductible Diagnostic imaging and machine tests, oth than the diagnostic imaging services listed above. $0 $75 - After deductible 40% Afterdeductible 50%- Afterdeductible Lab and pathology services. $0 $25 - After deductible Afterdeductible 50%- Afterdeductible Outpatientnon-Hospitalfacilities: including; in physician’soffice,urgent care cente,ror certain designated free-standingoutpatientfacilities. MRI*, MRA*, CAT scans*, CTA scans*, scans*, and nuclear medicine*. $200- Afterdeductible $600- Afterdeductible 50%- Afterdeductible Sleep studies.* $200- Afterdeductible $600- Afterdeductible 50%- Afterdeductible Diagnostic imaging and tests, other than major th diagnostic imaging and testing services noted listed above. 0% $0 $75 - After deductible 40% - After deductible Afterdeductible 50%- Afterdeductible Lab and pathology services. 0% $0 $25 - After deductible 40% - After deductible Afterdeductible 50%- Afterdeductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but bu not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Preventioannd Early Detection Services for preventive colorectal colorecta services.) 0% $0 $0 - After deductible 40% - After deductible Afterdeductible 50%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible $0 $0 50%- Afterdeductible Urgent Care Urgent care services 0% - After deductible $75 The level of coverage is i the same as a Tier 1 network provider. xxxxxx.xx The level of coverage i the same as a Tier 1 network xxxxxx.xx Vision Care Services Vision exam - One exam- one routine eye exam per member per memberper plan year. 0% - After deductible 40% - After deductible $45 $60 50%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible $30 $60 50%- Afterdeductible Pediatric Vision Care for members under vision care fomrembersunder age 19: See Vision Care Services in Section 3 for benefit limits and limitasnd details. These services only Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Tier 1 Network Providers Tier 2 Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay You Pay apply to an enrolled member under enrollemd emberunder the age of 19: :. Prescription glasses - Frame glasses- frame and lenses 0% - After deductible The level of coverage i the same as a Tier 1 networkprovider. Not Covered Contact lens (in lieu of prescription glasses) glasses 0% - After deductible The level of coverage i the same as a Tier 1 networkprovider. Not Covered Vision hardware for enrolled members aged enrollmedembersaged 19 and older. Not Covered Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Departmentpharmacy.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services Inpatient physician services 0% - After deductible 20% - After deductible Outpatient physician services 0% - After deductible 20% - After deductible In a physician’s office 0% 20% - After deductible Telemedicine Services When rendered by a designated provider. $20 Not Covered When rendered by a network provider. $20 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 40$50 20% - After deductible Lab and pathology services. 0% - After deductible 40$20 20% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40$20 20% - After deductible Urgent Care Urgent care services 0% - After deductible $75 The level of coverage is the same as network provider. Vision Care Services Vision exam - One one routine eye exam per member per plan year. 0% - After deductible 40$0 20% - After deductible Non-routine eye exam 0$0 20% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 20% - After deductible Surgery Services Inpatient physician services 0% - After deductible 20% - After deductible Outpatient physician services 0% - After deductible 20% - After deductible In a physician’s office 0% 20% - After deductible Telemedicine Services When rendered by a designated provider. $30 Not Covered When rendered by a network provider. $30 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine*. 0% - After deductible 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 4020% - After deductible Urgent Care Urgent care services 0% - After deductible $50 The level of coverage is the same as network provider. Vision Care Services Vision exam - One one routine eye exam per member per plan year. 0% - After deductible 40$0 20% - After deductible Non-routine eye exam 0$0 20% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% $30 - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $30 - After deductible Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% $50 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% $50 - After deductible 40% - After deductible Non-routine eye exam 0% $50 - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $25 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine medicine, and cardiac imaging. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Diagnostic colorectal services - (Including, but not butnot limited to, fecal occult blood testing, flexible sigmoidoscopy, 0% 20% - After deductible Covered Benefits - See Covered Healthcare Services for additionalbenefit limitsand details. Network Providers Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay colonoscopy, and barium enemabariumenema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 4020% - After deductible Urgent Care Urgent care Urgentcare services 0$50 20% plus $50 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One one routine eye exam per examper member per plan year. 0$40 20% - After deductible 40% plus $40 - After deductible Non-routine eye exam 0$40 20% plus $40 - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 020% - After deductible 40% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 20% - After deductible 40% - After deductible In a physician’s office 20% - After deductible 40% - After deductible Respiratory Therapy Inpatient 20% - After deductible 40% - After deductible Outpatient 20% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 20% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 20% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 20% - After deductible 40% - After deductible In a physician’s office $10 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 020% - After deductible 40% - After deductible Sleep studies.* 020% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible $100 40% - After deductible Lab and pathology services. 0% - After deductible $50 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 020% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible $125 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible $50 40% - After deductible Non-routine eye exam 0% - After deductible $50 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $30 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 4020% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.pay

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Not Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Not Covered Outpatient 0% - After deductible 40% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible Not Covered In a physician’s office 0% - After deductible 40% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% $15 - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Not Covered Sleep studies.* 0% - After deductible 40% - After deductible Not Covered Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Not Covered Lab and pathology services. 0% - After deductible 40% - After deductible 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 for preventive colorectal services.) 0% - After deductible 40% - After deductible Not Covered Lyme disease diagnosis and treatment 0% - After deductible 40% Not Covered Covered Benefits - After deductible See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Urgent Care Urgent care services 0% $50 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% $25 - After deductible 40% - After deductible Not Covered Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% $25 - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For Tiered BlueHPN Markets This section provides information about our pharmacy networkcovered healthcare services received from participating network providers in the Philadelphia and New Jersey BlueHPN Markets, visit our website or call our Customer Service Departmentwhich have tiered benefits. As indicated below, when seeking covered healthcare services from network providers in these BlueHPN Markets your copayment and deductible will differ depending on the tier of the network provider you choose.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for fo details. 0% 40% - After deductible 40%- Afterdeductible Private Duty Nursing Services* Service*s Must be performed by a certified home health care agencyage 20%- Afterdeductible 40%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 20%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 20%- Afterdeductible 40%- Afterdeductible Respiratory Therapy Inpatient 20%- Afterdeductible 40%- Afterdeductible Outpatient 20%- Afterdeductible 40%- Afterdeductible Skilled Care in a Nursing Facilit*y Skilled or su-bacute care 20%- Afterdeductible 40%- Afterdeductible Speech Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD Limited to30 speech therapy visits peprlan year. 20%- Afterdeductible 40%- Afterdeductible Surgery Services Inpatient physiciasnervices 20%- Afterdeductible 40%- Afterdeductible Outpatientservices - includesphysicianservices and outpatient hospitaolr ambulatory surgical centfearcility services. 20%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce. L F L D Q ¶ V 0% 40%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $25 Not Covered When rendered by anetworkprovider. $25 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans PET scans, nuclear medicine and cardiac imaging. 20%- Afterdeductible 40%- Afterdeductible Sleep studies*. 20%- Afterdeductible 40%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted abov 0% 40%- Afterdeductible Lab and pathology services. 0% - After deductible 40% - After deductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits benefitlimits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but not buntot limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See S Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible andretatment 20%- Afterdeductible 40%- Afterdeductible Urgent Care Urgent care services 0% - After deductible $50 The level of coverage is the same as network provider. xxxxxx.xx Vision Care Services Vision exam - One exam- one routine eye exam per member per pemr emberper plan year. 0% - After deductible 40% - After deductible $40 40%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered $40 40%- Afterdeductible SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible 40%- Afterdeductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay agen 0%- Afterdeductible 40%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible In a physician’s office 0% - After deductible 40% - After deductible S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Outpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or subsu-acute bacute care 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Speech Therapy Outpatient hospital/in hospitainl/ a physician’s/therapist’s office. 0% - After deductible 40% - After deductible S K \ WV KL XX XX DD 0%- Afterdeductible 40%- Afterdeductible Surgery Services* Services Inpatient physician services 0% - After deductible 40% - After deductible physiciasnervices 0%- Afterdeductible 40%- Afterdeductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible physiciasnervices 0%- Afterdeductible 40%- Afterdeductible In a physician’s office 0% - After deductible 40% - After deductible S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Telemedicine Services When rendered by our designated telemedicine providera designatepdrovider. 0% - After deductible 0%- Afterdeductible Not Covered When rendered by a network provider other than our designated telemedicine provideranetworkprovider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay 0%- Afterdeductible Not Covered Tests, Labs, Imaging and XandX-rays - Diagnostic OutpatientOutpatien,tin a S K o\ ffiVce, in a physician’s office, urgent care center or uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI*, MRA*, CAT scans*, CTA scans*, PET scans, * nuclear medicine and cardiac imagingmedicine*. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Sleep studies.* 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic the diagnosti imaging and testing services noted listed above. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Lab and pathology services. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Diagnostic colorectal services - (Includingservice-s(Including, but not limited limite to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Urgent Care Urgent care services 0% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Vision Care Services Vision exam - One exam- one routine eye exam per member per pemr emberper plan year. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Pediatric Vision Care for members under vision care fomrembersunder age 19: See Vision Care Services in Section 3 for benefit limits and fboer nefitlimitsand details. These services only apply to an enrolled member under enrolmledemberunder the age of 19: :. Prescription glasses - Frame glasses- frame and lenses 0% - After deductible 0%- Afterdeductible Not Covered Contact lens (in lieu inlieu of prescription glasses) 0% - After deductible 0%- Afterdeductible Not Covered Vision hardware for enrolled members aged enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Departmentpharmacy.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 4020% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $15 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 4020% - After deductible Urgent Care Urgent care services 0% - After deductible $50 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40$25 20% - After deductible Non-routine eye exam 0$25 20% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider networkprovider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits- See Covered Healthcare Services for additionalbenefit limitsand details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40% - After deductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% $100 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision Routine vision exam - One one routine eye vision exam per member per plan year. 0% $20 - After deductible 40% - After deductible Non-routine eye exam 0% vision exam. $20 - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for fo details. 0% 40% - After deductible 20%- Afterdeductible Private Duty Nursing Services* Must be performed by a certified home health care agency. age 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Respiratory Therapy Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Speech Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40%- Afterdeductible Surgery Services Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% 20%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. $20 Not Covered When rendered by anetworkprovider. $20 Not Covered Tests, Labs, Imaging and X-rays - After deductible 40% - After deductible Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear medicine*. 0%- Afterdeductible 20%- Afterdeductible Sleep studies.* 0%- Afterdeductible 20%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 40% - After deductible $50 20%- Afterdeductible Lab and pathology services. 0% - After deductible 40% - After deductible $20 20%- Afterdeductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but not limited to, fecal occult blood occulbtlood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible $20 20%- Afterdeductible Urgent Care Urgent care services 0% - After deductible $75 The level of coverage is the same as network provider. xxxxxx.xx Vision Care Services Vision exam - One exam- one routine eye exam per member per pemr emberper plan year. 0% - After deductible 40% - After deductible $0 20%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.$0 20%- Afterdeductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4050% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 030% - After deductible 4050% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 30% - After deductible 50% - After deductible In a physician’s office 30% - After deductible 50% - After deductible Respiratory Therapy Inpatient 30% - After deductible 50% - After deductible Outpatient 30% - After deductible 50% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 30% - After deductible 50% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 30% - After deductible 50% - After deductible Surgery Services* Inpatient physician services 30% - After deductible 50% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 30% - After deductible 50% - After deductible In a physician’s office $20 50% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 030% - After deductible 4050% - After deductible Sleep studies.* 030% - After deductible 4050% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40$100 50% - After deductible Lab and pathology services. 0% - After deductible 40$50 50% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 030% - After deductible 4050% - After deductible Lyme disease diagnosis and treatment 030% - After deductible 4050% - After deductible Urgent Care Urgent care services 0% - After deductible $125 The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% - After deductible 40$50 50% - After deductible Non-routine eye exam 0% - After deductible 40$50 50% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0Limited to 30 speech therapy visits per plan year. 20% - After deductible 4020% - After deductible Surgery Services* Services Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $25 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear medicine and cardiac imagingmedicine*. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Flex Plan (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 4020% - After deductible Lab and pathology services. 0% - After deductible 4020% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 4020% - After deductible Urgent Care Urgent care services 0$50 20% - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One one routine eye exam per member per plan year. 0% - After deductible 40$40 20% - After deductible Non-routine eye exam 0$40 20% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for fo details. 0% 40% - After deductible 40%- Afterdeductible Private Duty Nursing Services* Service*s Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay age 0%- Afterdeductible 40%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible In a physician’s office 0% - After deductible 40% - After deductible S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Outpatient 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Skilled Care in a Nursing Facility* Facilit*y Skilled or subsu-acute bacute care 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Speech Therapy Outpatient hospitalOutpatienthospitali/in n a physician’s/therapist’s officeS K \ WV KL XX XX DD Limited to30 speech therapy visits peprlan year. 0% 0%- Afterdeductible 40%- Afterdeductible Surgery Services Inpatient physiciasnervices 0%- Afterdeductible 40%- Afterdeductible Outpatientservices - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services includesphysicianservices and outpatient hospital or hospitaolr ambulatory surgical center facility centfearcility services. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible In a physician’s office 0% - After deductible 40% - After deductible S K o\ ffiVce. L F L D Q ¶ V 0%- Afterdeductible 40%- Afterdeductible Telemedicine Services When rendered by our designated telemedicine providera designatepdrovider. 0% - After deductible 0%- Afterdeductible Not Covered When rendered by a network provider other than our designated telemedicine provideranetworkprovider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay 0%- Afterdeductible Not Covered Tests, Labs, Imaging and X-rays - Diagnostic OutpatientOutpatien,tin a S K o\ ffiVce, in a physician’s office, urgent care center or uLrgenFt caLre cDenterQor ¶ free-standing laboratory: Major diagnostic imaging and testing* including tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans, scans PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Sleep studies.* 0% - After deductible 40% - After deductible *. 0%- Afterdeductible 40%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible abov 0%- Afterdeductible 40%- Afterdeductible Lab and pathology services. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See S Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Urgent Care Urgent care services 0% - After deductible 0%- Afterdeductible The level of coverage is the same as network provider. Vision Care xxxxxx.xx VisionCare Services Vision exam - One exam- one routine eye exam per member per pemr emberper plan year. 0% - After deductible 40% - After deductible 0%- Afterdeductible 40%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered 0%- Afterdeductible 40%- Afterdeductible SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Departmentpharmacy.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for fo details. 0% 40% - 40%- After deductible Private Duty Nursing Services* Must be performed by a certified home health care agencyage 20%- Afterdeductible 40%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 20%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 20%- Afterdeductible 40%- Afterdeductible Respiratory Therapy Inpatient 20%- Afterdeductible 40%- Afterdeductible Outpatient 20%- Afterdeductible 40%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care 20%- Afterdeductible 40%- Afterdeductible Speech Therapy Outpatient hospitainl/ a S K \ WV KL XX XX DD Limitedto 30 speechtherapy visits peprlan year. 0% 20%- Afterdeductible 40%- Afterdeductible Surgery Services Inpatient physiciasnervices 20%- Afterdeductible 40%- Afterdeductible Outpatient physiciasnervices 20%- Afterdeductible 40%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 20%- Afterdeductible 40%- Afterdeductible Telemedicine Services When rendered by a designatepdrovider. 20%- Afterdeductible Not Covered When rendered by anetworkprovider. 20%- Afterdeductible Not Covered Tests, Labs, Imaging and X-rays - After deductible 40% - After deductible Diagnostic Outpatien,tin a S K o\ ffiVce, uLrgenFt caLre cDenterQor ¶ free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*s,cPaEnsT*, and nuclear medicine*. 20%- Afterdeductible 40%- Afterdeductible Sleep studies.* 20%- Afterdeductible 40%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major the diagnostic imaging and testing services noted listed above. 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Lab and pathology services. 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention SePerevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Urgent Care Urgent care services 0% - After deductible 20%- Afterdeductible The level of coverage is the same as network provider. xxxxxx.xx Vision Care Services Vision exam - One exam- one routine eye exam per member per pemr emberper plan year. 0% - After deductible 40% - After deductible 20%- Afterdeductible 40%- Afterdeductible Non-routine eye exam 0% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.20%- Afterdeductible 40%- Afterdeductible

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible Urgent Care Urgent care services 0% $100 - After deductible The level of coverage is the same as network provider. Vision Care Services Vision exam - One routine eye exam per member per plan year. 0% $20 - After deductible 40% - After deductible Non-routine eye exam 0% $20 - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,, pharmacy. For information about our pharmacy network, visit our website or call our Customer Service Department.

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 4020% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 4020% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 4020% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 4020% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Telemedicine Services When rendered by our a designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for theamount you pay See the covered healthcare service being provided for the amount you pay $30 Not Covered Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine medicine, and cardiac imaging. 0% - After deductible 4020% - After deductible Sleep studies.* 0% - After deductible 4020% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40$0 20% - After deductible Lab and pathology services. 0% - After deductible 40$0 20% - After deductible Diagnostic colorectal services - (Including, but not butnot limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enemabariumenema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 4020% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40$0 20% - After deductible Urgent Care Urgent care Urgentcare services 0% - After deductible $50 The level of coverage is the same as network provider. Vision Care Services Vision exam - One one routine eye exam per examper member per plan year. 0% - After deductible 40$0 20% - After deductible Non-routine eye exam 0$0 20% - After deductible 40% - After deductible Pediatric Vision Care for members under age 19: See Vision Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19: Prescription glasses - Frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% - After deductible Not Covered Vision hardware for enrolled members aged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty,. For information about our pharmacy network, visit our website or call our Customer Service Department.deductible