Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. 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. $40 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Standard $750 - After deductible Not Covered Enhanced $375 Not Covered When rendered by our designated telemedicine provider. $15 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled or sub-acute care 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. $40 20% - After deductible Not Covered Physician Inpatient physician services 20% - After deductible Not Covered Outpatient services - includes physician services received inpatient, and outpatient hospital, hospital or ambulatory surgical center facility, or physician’s officefacility services. 020% Not Covered Standard $750 - After deductible Not Covered Enhanced In a physician’s office $375 35 Not Covered When rendered by our designated telemedicine provider. $15 40 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. 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. $40 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Standard $750 - After deductible Not Covered Enhanced $375 Not Covered When rendered by our designated telemedicine provider. $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 the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. 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. $40 45 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Standard $750 1,000 - After deductible Not Covered Enhanced $375 500 Not Covered When rendered by our designated telemedicine provider. $15 20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. 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. $40 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 020% Not Covered Standard $750 - After deductible Not Covered Enhanced $375 Inpatient physician services 0% - After deductible Not Covered Outpatient physician services 0% - After deductible Not Covered In a physician’s office 0% Not Covered When rendered by our a designated telemedicine provider. $15 20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay $20 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled or sub-acute care 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. $40 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 020% Not Covered Standard $750 - After deductible Not Covered Enhanced $375 Inpatient physician services 20% - After deductible Not Covered Outpatient physician services 20% - After deductible Not Covered In a physician’s office 0% Not Covered When rendered by our a designated telemedicine provider. $15 20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay $20 Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled or sub-acute care 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. $40 20% - After deductible Not Covered Physician Inpatient physician services 20% - After deductible Not Covered Outpatient services - includes physician services received inpatient, and outpatient hospital, hospital or ambulatory surgical center facility, or physician’s officefacility services. 020% Not Covered Standard $750 - After deductible Not Covered Enhanced In a physician’s office $375 25 Not Covered When rendered by our designated telemedicine provider. $15 30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. $40 Not Covered Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 010% Not Covered Standard $750 - After deductible Not Covered Enhanced Inpatient physician services 10% - After deductible Not Covered Outpatient physician services 10% - After deductible Not Covered In a physician’s office $375 30 - After deductible Not Covered When rendered by our a designated telemedicine provider. $15 20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay $20 Not Covered