Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled or sub-acute care 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled or sub-acute care 0% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible 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 When rendered by our designated telemedicine provider. 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 pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible 40% - After deductible In a physician’s office 020% - After deductible 40% - After deductible Inpatient 020% - After deductible 40% - After deductible Outpatient 020% - After deductible 40% - After deductible Skilled or sub-acute care 020% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Inpatient physician services 020% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 020% - After deductible 40% - After deductible In a physician’s office 0% - After deductible $20 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible 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$15 20% - After deductible 40% 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 When rendered by our 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 4020% - After deductible 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$20 20% - After deductible 40% 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible 40% - After deductible In a physician’s office 020% - After deductible 40% - After deductible Inpatient 020% - After deductible 40% - After deductible Outpatient 020% - After deductible 40% - After deductible Skilled or sub-acute care 020% - After deductible 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 40% - After deductible Inpatient physician services 020% - 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 4020% - After deductible In a physician’s office 0% - After deductible 4020% - After deductible Inpatient 0% - After deductible 4020% - After deductible Outpatient 0% - After deductible 4020% - After deductible Skilled or sub-acute care 0% - After deductible 4020% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible 4020% - After deductible 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 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 the amount you pay See the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 400% - After deductible In a physician’s office 0% - After deductible 400% - After deductible Inpatient 0% - After deductible 400% - After deductible Outpatient 0% - After deductible 400% - After deductible Skilled or sub-acute care 0% - After deductible 400% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 400% - After deductible Inpatient physician services 0% - After deductible 400% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 400% - After deductible In a physician’s office 0% - After deductible 400% - After deductible When rendered by our designated telemedicine provider. 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 pay