Common use of Retail Prescriptions Clause in Contracts

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 25, 26 $35 45 per prescription Not covered Non-Formulary Brand Name Drugs 25, 26 The greater of $50 60 or 50% of Blue Shield’s contracted rate 27 28 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 25, 27 $70 90 per prescription Not covered Non-Formulary Brand Name Drugs 26 25, 27 The greater of $100 120 or 50% of Blue Shield’s contracted rate 28 27 Not covered Home Self-Administered Injectables 3035% per prescription Not covered Oral Anticancer Medication 3035% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferredPreferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 3035% 109, 28 50% 9, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 3035% Not covered Podiatric Benefits Podiatric Services $40 per visit 35% 50% Benefit Member Copayment 4 Services by Preferred, Participat- ingPartici- pating, and Other Pro- viders Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 3035% 50% of up to $500 per day 15 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facilityfacili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- tyFacility), an additional facility Coinsurance/Copayment may apply. 3035% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 3035% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Care Benefits 30 29 Annual Physical Examination including only the annual routine physical exam- ination ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening screen- ing test; and the human papillomavirus (HPV) screening test $40 35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 35 per visit Not covered Colorectal Cancer Screening Services 3035% Not covered Osteoporosis Screening Services 3035% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication Medications 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 35 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferredPreferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 3025% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 3025% Not covered Podiatric Benefits Podiatric Services $40 30 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 3025% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 3025% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 3025% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 30 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 30 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 30 per visit Not covered Colorectal Cancer Screening Services 3025% Not covered Osteoporosis Screening Services 3025% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication Medications 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 35 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 35 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 27 $35 45 per prescription Not covered Non-Formulary Brand Name Drugs 26 27 The greater of $50 60 or 50% of Blue Shield’s contracted rate 27 28 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 27 $70 90 per prescription Not covered Non-Formulary Brand Name Drugs 26 27 The greater of $100 120 or 50% of Blue Shield’s contracted rate 28 29 Not covered Home Self-Administered Injectables 3035% per prescription Not covered Oral Anticancer Medication 3035% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferredPreferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 3035% 109, 29 30 50% 109, 29 Benefit Member Copayment 4 30 PKU Related Formulas and Special Food Products Benefits PKU 3035% Not covered Podiatric Benefits Podiatric Services $40 per visit 35% 50% Benefit Member Copayment 4 Services by Preferred, Participat- ingPartici- pating, and Other Pro- viders Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 3035% 50% of up to $500 per day 15 14 Abortion Services Coinsurance shown is for physician services in the office or outpatient facilityfacili- ty. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- tyFacility), an additional facility Coinsurance/Copayment may apply. 3035% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 3035% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Care Benefits 30 31 Annual Physical Examination including only the annual routine physical exam- ination ex- amination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 35 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening screen- ing test; and the human papillomavirus (HPV) screening test $40 35 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 35 per visit Not covered Colorectal Cancer Screening Services 3035% Not covered Osteoporosis Screening Services 3035% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication Medications 30% ($200 maximum per prescription) prescription Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fitsBenefits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferredPreferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 3025% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 3025% Not covered Podiatric Benefits Podiatric Services $40 30 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 3025% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 3025% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 3025% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 30 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 30 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 30 per visit Not covered Colorectal Cancer Screening Services 3025% Not covered Osteoporosis Screening Services 3025% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 50% 10, 29 Benefit Member Copayment 4 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 45 per visit 50% Benefit Member Copayment 4 Services by Preferred, Participat- ing, and Other Pro- viders 5 Services by Non- Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- ty), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Benefits 30 Annual Physical Examination including only the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric and adult immunizations and the immunizing agent $40 45 per visit Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 45 per visit Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin test; and pediatric immunizations and the immunizing agent $40 45 per visit Not covered Colorectal Cancer Screening Services 30% Not covered Osteoporosis Screening Services 30% Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6

Retail Prescriptions. Formulary Generic Drugs $10 per prescription Not covered Formulary Brand Name Drugs 26 $35 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $50 or 50% of Blue Shield’s contracted rate 27 24 Not covered Mail Service Prescriptions Formulary Generic Drugs $20 per prescription Not covered Formulary Brand Name Drugs 26 $70 per prescription Not covered Non-Formulary Brand Name Drugs 26 The greater of $100 or 50% of Blue Shield’s contracted rate 28 25 Not covered Home Self-Administered Injectables 30% per prescription Not covered Oral Anticancer Medication Anti-Cancer Medications 30% ($200 maximum per prescription) Not covered Benefit Member Copayment 4 Services by Pre- ferredPreferred, Participating, and Other Providers 5 Services by Non- Preferred and Non-Participating Providers 6 Outpatient X-Ray, Pathology, Laboratory Benefits Note: Benefits in this section are for diagnostic, non-preventive health Ser- vices. For Benefits for Preventive Health Services, see the Preventive Health Benefits section of this Summary of Benefits. For Benefits for diagnostic radio- logical ra- diological procedures such as CT scans, MRIs, MRAs, PET scans, etc. see the Radiological and Nuclear Imaging Benefits section of this Summary of Bene- fits. Outpatient diagnostic X-ray, pathology, diagnostic examination and clinical laboratory Services, including mammography and Xxxxxxxxxxxx test. Outpatient X-Ray, pathology and laboratory 30% 10, 29 26 50% 10, 29 Benefit Member Copayment 4 26 PKU Related Formulas and Special Food Products Benefits PKU 30% Not covered Podiatric Benefits Podiatric Services $40 per visit provided by a licensed doctor of podiatric medicine 30% 50% Benefit Member Copayment 4 Services by Preferred, Participat- ingParticipating, and Other Pro- viders Providers 5 Services by Non- Non-Preferred and Non-Participating Providers 6 Pregnancy and Maternity Care Benefits Note: Routine newborn circumcision is only covered as described in the Cov- ered Services section. When covered, Services will pay as any other surgery as noted in this Summary of Benefits. All necessary Inpatient Hospital Services for normal delivery, Cesarean sec- tion, and complications of pregnancy $250 per admission plus 30% 50% of up to $500 600 per day 15 Abortion Services Coinsurance shown is for physician services in the office or outpatient facility. If the procedure is performed in a facility setting (Hospital or Outpatient Facili- tyFa- cility), an additional facility Coinsurance/Copayment may apply. 30% 50% Prenatal and postnatal Physician office visits, including prenatal diagnosis of genetic disorders of the fetus by means of diagnostic procedures in cases of high-risk pregnancy 30% 50% Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6 Preventive Health Care Benefits 30 27 Annual Physical Examination including only Office visit You pay nothing Not covered Routine laboratory testing for Sexually Transmitted Diseases [except for mammography, routine Papanicolaou (PAP) test or other FDA approved cer- vical cancer screening test, and the annual routine physical exam- ination office visit; urinalysis; eye and ear screening; and pediatric human papillomavirus (HPV) screening test] You pay nothing Not covered Pediatric and adult and immunizations and the immunizing agent $40 per visit during an Annual Physical Examination as above You pay nothing Not covered Annual Gynecological Examination including only the annual gynecological examination office visit; mammographyOffice visit You pay nothing Not covered Mammography; routine Papanicolaou (Pap) test or other Food and Drug Administration Ad- ministration (FDA) approved cervical cancer screening test; and the human papillomavirus (HPV) screening test $40 per visit only You pay nothing Not covered Well Baby Examinations including only the well baby examination office visit; tuberculin testvis- it; and pediatric tuberculin test You pay nothing Not covered Pediatric immunizations and the immunizing agent $40 per visit during a Well Baby Exam- ination as above You pay nothing Not covered Colorectal Cancer Screening Services 30% You pay nothing Not covered Osteoporosis Screening Services 30% You pay nothing Not covered NurseHelp 24/7 You pay nothing Not covered Benefit Member Copayment 4 Services by Preferred, Participating, and Other Providers 5 Services by Non-Preferred and Non-Participating Providers 6