Common use of Surgery Services Clause in Contracts

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible Lab and pathology services. 0% 20% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 20% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After Deductible

Surgery Services. Inpatient doctor services 0% - After Deductible 20% - After Deductible Outpatient doctor services 0% - After Deductible 20% - After Deductible In a doctor’s office 0% 20% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 30 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 20% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible Lab and pathology services. 0% 20% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 20% - After Deductible Lyme disease-diagnosis 0% - After Deductible 20% - After DeductibleDeductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $50 20% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14

Surgery Services. Inpatient doctor physician services 0% - After Deductible deductible 20% - After Deductible deductible Outpatient doctor physician services 0% - After Deductible deductible 20% - After Deductible deductible In a doctorphysician’s office 0% 20% - After Deductible deductible Telemedicine Telemedicine services Services When rendered by a designated provider. $25 15 Not Covered When rendered by a network provider. $15 Not Covered Tests, ImagingLabs, Imaging and Labs (includes machine tests and xX-rays) (Diagnostic) rays - Diagnostic Outpatient/, in a doctorphysician’s office/, urgent care center or free- free-standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, and nuclear cardiac imaging* and sleep medicine*. 0% 20% - After deductible Sleep studies.* 0% - After Deductible 20% - After Deductible deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20% - After Deductible deductible Lab and pathology services. 0% 20% - After Deductible deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 20% - After Deductible deductible Lyme disease-disease diagnosis and treatment 0% - After Deductible 20% - After Deductibledeductible Urgent Care Urgent care services $25 20% plus $25 - After deductible Vision Care Services Vision exam - one routine eye exam per member per plan year. $25 20% plus $25 - After deductible Non-routine eye exam $25 20% plus $25 - After deductible

Surgery Services. Inpatient doctor services 0% - After Deductible 200% - After Deductible Outpatient doctor services 0% - After Deductible 200% - After Deductible In a doctor’s office 0% 20- After Deductible 0% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 0% - After Deductible Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 0% - After Deductible 200% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 20- After Deductible 0% - After Deductible Lab and pathology services. 0% 20- After Deductible 0% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After Deductible 200% - After Deductible Lyme disease-diagnosis 0% - After Deductible 200% - After Deductible

Surgery Services. Inpatient doctor services 020% - After Deductible 2040% - After Deductible Outpatient doctor services 020% - After Deductible 2040% - After Deductible In a doctor’s office 0% 2040% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 020% - After Deductible 2040% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 2040% - After Deductible Lab and pathology services. 0% 2040% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After Deductible 2040% - After Deductible Lyme disease-diagnosis 020% - After Deductible 2040% - After DeductibleDeductible Urgent Care Center Urgent care center/walk-in $50 $50 Vision Care Services Vision exam One routine eye exam per member per plan year. $40 40% - After Deductible BENEFIT BOOKLET Blue Cross & Blue Shield of Rhode Island TABLE OF CONTENTS SUMMARY OF MEDICAL BENEFITS 3 FLEX PLAN 4 1.0 INTRODUCTION 14

Surgery Services. Inpatient doctor services 020% - After Deductible 2040% - After Deductible Outpatient doctor services 020% - After Deductible 2040% - After Deductible In a doctor’s office 0% 2040% - After Deductible Telemedicine Telemedicine services When rendered by a designated provider. $25 20 Not Covered Tests, Imaging, and Labs (includes machine tests and x-rays) (Diagnostic) Outpatient/in a doctor’s office/urgent care center or free- standing laboratory: MRI*, MRA*, CAT scans*, CTA scans*, PET scans*, nuclear cardiac imaging* and sleep studies.* 020% - After Deductible 2040% - After Deductible Diagnostic imaging and machine tests, other than the diagnostic imaging services listed above. Copayment is per provider per day. 0% 2040% - After Deductible Lab and pathology services. 0% 2040% - After Deductible Diagnostic colorectal services (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 020% - After Deductible 2040% - After Deductible Lyme disease-diagnosis 020% - After Deductible 2040% - After Deductible