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% Not Covered Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $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 the amount you pay See the covered healthcare service being provided for the amount you pay

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $15 - After deductible 25 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 the amount theamount you pay See the covered healthcare service being provided for the amount you payNot Covered

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $15 - 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 the amount theamount you pay See the covered healthcare service being provided for the amount you payNot Covered

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% $300 per admission - After deductible Afterdeductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% $40 - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered 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 When rendered by our designated telemedicine provider. $15 0% - 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 the amount you pay See the covered healthcare service being provided for the amount you payNot Covered

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office office. 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $15 - 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 the amount you pay See the covered healthcare service being provided for the amount you payNot Covered

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered When rendered by our designated telemedicine provider. $15 - 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 the amount theamount you pay See the covered healthcare service being provided for the amount you payNot Covered