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 Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Surgery Services* 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 Telemedicine Services 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 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 Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* 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 Telemedicine Services 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

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered 20% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered 20% - After deductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered 20% - After deductible In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 020% - After deductible Not Covered Respiratory Therapy Outpatient 0% - After deductible Not Covered 20% - 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 Not Covered 20% - 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 Not Covered 20% - After deductible Surgery Services* Inpatient physician services 0% - After deductible Not Covered 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered 20% - After deductible In a physician’s office 0% 20% - After deductible Not Covered Telemedicine Services When rendered by our a 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 you pay See the covered healthcare service being provided for the amount you pay$30 Not Covered

Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 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 Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* 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 Telemedicine Services 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 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 Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* 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 Telemedicine Services 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 Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% $300 per admission - After deductible Afterdeductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% $40 - After deductible Not Covered Surgery Services* 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 Telemedicine Services 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 Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Surgery Services* Services 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 Telemedicine Services 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