Common use of Transplant Benefits Clause in Contracts

Transplant Benefits. Special Blue Shield requires prior authorization for all Special Transplant Services, and all services must be provided at a Special Transplant Facility designated by Blue Shield. See the Transplant Benefits – Special Transplants section of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this Benefit. Facility services in a Special Transplant Facility 10% Not covered Professional (Physician) services 10% Not covered Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Pediatric Vision Benefits 25 Pediatric vision benefits are available for members through the end of the month in which the member turns 19. All Services provided through Blue Shield’s Vision Plan Administrator (VPA). Comprehensive examination 21 One comprehensive eye examination per Calendar Year. Includes dilation, if professionally indicated. Ophthalmologic New Patient (S0620) Established Patient (S0621) You pay nothing Up to $30 Optometric New Patient (92002/92004) Established Patient (92012/92014) You pay nothing Up to $30 Eyewear/materials One pair of eyeglasses (frames and lenses) or one pair of contact lenses per Calendar Year (unless otherwise noted) as follows: Lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglass. Polycarbonate lenses are covered in full for eligible Members. Single Vision (V2100-V2199) You pay nothing Up to $25 Lined Bifocal (V2200-V2299) You pay nothing Up to $35 Lined Trifocal (V2300-V2399) You pay nothing Up to $45 Lenticular (V2121, V2221, V2321) You pay nothing Up to $45 Optional Lenses and Treatments Ultraviolet Protective Coating (standard only) You pay nothing Not covered Standard Progressive Lenses $55 Not covered Premium Progressive Lenses $95 Not covered Anti-Reflective Lens Coating (standard only) $35 Not covered Photochromic- Glass Lenses $25 Not covered Photochromic- Plastic Lenses $25 Not covered Hi Index Lenses $30 Not covered Polarized Lenses $45 Not covered Frames 23 Collection frames You pay nothing Up to $40 Non-Collection frames Up to $150 Up to $40 Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Contact Lenses 24 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year. You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard soft (V2521- V2523) One pair per month, up to 3 months, per Calendar Year. You pay nothing Up to $75 Supplemental Low-Vision Testing and Equipment 26 35% Not covered Diabetes Management Referral You pay nothing Not covered Benefit Member Copayment 3 Services by Preferred and Participating Dentist Services by Non- Preferred and Non- Participating Dentist 32 Pediatric Dental Benefits 27 Pediatric dental benefits are available for Members through the end of the month in which the Member turns 19. Diagnostic and Preventive Care Services 28 You pay nothing 20% Restorative Services 29 20% 30% Oral surgery 29, 30 50% 50% Endodontics 29, 30 50% 50% Periodontics 29, 30 50% 50% Crowns and Fixed Bridges 29, 30 50% 50% Removable Prosthetics 29, 30 50% 50% Orthodontics 29, 30, 31 50% 50% Other Benefits 20% 30%

Transplant Benefits. Special Blue Shield requires prior authorization for all Special Transplant Services, and all services must be provided at a Special Transplant Facility designated by Blue Shield. See the Transplant Benefits – Special Transplants section of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this Benefit. Facility services in a Special Transplant Facility 10% You pay nothing Not covered Professional (Physician) services 10% You pay nothing Not covered Benefit Member Copayment 2 3 Participating Provider Non-Participating Provider 4, 22 23 Pediatric Vision Benefits 25 26 Pediatric vision benefits are available for members through the end of the month in which the member turns 19. All Services provided through Blue Shield’s Vision Plan Administrator (VPA). Comprehensive examination 21 22 One comprehensive eye examination per Calendar Year. Includes dilation, if professionally indicated. Ophthalmologic 1 New Patient (S0620) Established Patient (S0621) You pay nothing Up to $30 Optometric 1 New Patient (92002/92004) Established Patient (92012/92014) You pay nothing Up to $30 Eyewear/materials One pair of eyeglasses (frames and lenses) or one pair of contact lenses per Calendar Year (unless otherwise noted) after meeting the Calendar Year Medical Deductible as follows: Lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglass. Polycarbonate lenses are covered in full for eligible Members. Single Vision (V2100-V2199) You pay nothing Up to $25 Lined Bifocal (V2200-V2299) You pay nothing Up to $35 Lined Trifocal (V2300-V2399) You pay nothing Up to $45 Lenticular (V2121, V2221, V2321) You pay nothing Up to $45 Optional Lenses and Treatments Ultraviolet Protective Coating (standard only) You pay nothing Not covered Standard Progressive Lenses $55 Not covered Premium Progressive Lenses $95 Not covered Anti-Reflective Lens Coating (standard only) $35 Not covered Photochromic- Glass Lenses $25 Not covered Photochromic- Plastic Lenses $25 Not covered Hi Index Lenses $30 Not covered Polarized Lenses $45 Not covered Frames 23 24 Collection frames You pay nothing Up to $40 Non-Collection frames Up to $150 Up to $40 Benefit Member Copayment 2 3 Participating Provider Non-Participating Provider 4, 22 23 Contact Lenses 24 25 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year. You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard soft (V2521- V2523) One pair per month, up to 3 months, per Calendar Year. You pay nothing Up to $75 Supplemental Low-Vision Testing and Equipment 26 Equipment27 (Subject to meeting the Calendar Year Medical Deductible) 35% Not covered Diabetes Management Referral You pay nothing Not covered Benefit Member Copayment 3 Services by Preferred and Participating Dentist Services by Non- Preferred and Non- Participating Dentist 32 33 Pediatric Dental Benefits 27 28 Pediatric dental benefits are available for Members through the end of the month in which the Member turns 19. Diagnostic and Preventive Care Services 28 1, 29 You pay nothing 20% Restorative Services 29 20% Services30 You pay nothing 30% Oral surgery 2930, 30 50% 31 You pay nothing 50% Endodontics 2930, 30 50% 31 You pay nothing 50% Periodontics 2930, 30 50% 31 You pay nothing 50% Crowns and Fixed Bridges 2930, 30 50% 31 You pay nothing 50% Removable Prosthetics 2930, 30 50% 31 You pay nothing 50% Orthodontics 29, 30, 31 50% 31, 32 You pay nothing 50% Other Benefits 20% You pay nothing 30%

Transplant Benefits. Special Blue Shield requires prior authorization for all Special Transplant Services, and all services must be provided at a Special Transplant Facility designated by Blue Shield. See the Transplant Benefits – Special Transplants section of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this Benefit. Facility services in a Special Transplant Facility 10% Not covered Professional (Physician) services 10% Not covered Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Pediatric Vision Benefits 25 Pediatric vision benefits are available for members through the end of the month in which the member turns 19. All Services provided through Blue Shield’s Vision Plan Administrator (VPA). Comprehensive examination 21 One comprehensive eye examination per Calendar Year. Includes dilation, if professionally indicated. Ophthalmologic New Patient (S0620) Established Patient (S0621) You pay nothing Up to $30 Optometric New Patient (92002/92004) Established Patient (92012/92014) You pay nothing Up to $30 Eyewear/materials One pair of eyeglasses (frames and lenses) or one pair of contact lenses per Calendar Year (unless otherwise noted) as follows: Lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglass. Polycarbonate lenses are covered in full for eligible Members. Single Vision (V2100-V2199) You pay nothing Up to $25 Lined Bifocal (V2200-V2299) You pay nothing Up to $35 Lined Trifocal (V2300-V2399) You pay nothing Up to $45 Lenticular (V2121, V2221, V2321) You pay nothing Up to $45 Optional Lenses and Treatments Ultraviolet Protective Coating (standard only) You pay nothing Not covered Standard Progressive Lenses $55 Not covered Premium Progressive Lenses $95 Not covered Anti-Reflective Lens Coating (standard only) $35 Not covered Photochromic- Glass Lenses $25 Not covered Photochromic- Plastic Lenses $25 Not covered Hi Index Lenses $30 Not covered Polarized Lenses $45 Not covered Frames 23 Collection frames You pay nothing Up to $40 Non-Collection frames Up to $150 Up to $40 Benefit Member Copayment 2 Participating Provider Non-Participating Provider 4, 22 Contact Lenses 24 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year. You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard soft (V2521- V2523) One pair per month, up to 3 months, per Calendar Year. You pay nothing Up to $75 Supplemental Low-Vision Testing and Equipment 26 35% Not covered Diabetes Management Referral You pay nothing Not covered Benefit Member Copayment 3 2 Services by Preferred and Participating Dentist Services by Non- Preferred and Non- Participating Dentist 32 Pediatric Dental Benefits 27 Pediatric dental benefits are available for Members through the end of the month in which the Member turns 19. Diagnostic and Preventive Care Services 28 Services28 You pay nothing 20% Restorative Services 29 20% 30% Oral surgery 29, 30 50% 50% Endodontics 29, 30 50% 50% Periodontics 29, 30 50% 50% Crowns and Fixed Bridges 29, 30 50% 50% Removable Prosthetics 29, 30 50% 50% Orthodontics 29, 30, 31 50% 50% Other Benefits 20% 30%% Orthodontics 29, 30, 31 50% 50% Summary of Benefits Endnotes: 1 For an individual on a family coverage plan, a Member can receive 100% benefits for covered services once the individual out-of-pocket maximum is met in a calendar year and before the family out-of-pocket maximum is met. Copayments or Coinsurance for Covered Services accrue to the Calendar Year Out-of-Pocket Maximum, except Copayments or Coinsurance for Covered Services listed in the following sections of this Summary of Benefits: Charges in excess of specified benefit maximums Bariatric surgery: covered travel expenses for bariatric surgery Dialysis center benefits: dialysis services from a Non-Participating Provider Note: Copayments, Coinsurance, and charges for services not accruing to the Calendar Year Out-of-Pocket Maximum continue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 2 Any Coinsurance is calculated based on the Allowable Amount unless otherwise specified. 3 For Covered Services from Other Providers, you are responsible for any Copayment/Coinsurance and all charges above the Allowable Amount.

Transplant Benefits. Special Blue Shield requires prior authorization for all Special Transplant Services, and all services must be provided at a Special Transplant Facility designated by Blue Shield. See the Transplant Benefits – Special Transplants section of the Principal Benefits (Covered Services) section in the Evidence of Coverage for important information on this Benefit. Facility services in a Special Transplant Facility 10% You pay nothing Not covered Professional (Physician) services 10% You pay nothing Not covered Benefit Member Copayment 2 3 Participating Provider Non-Participating Provider 4, 22 23 Pediatric Vision Benefits 25 26 Pediatric vision benefits are available for members through the end of the month in which the member turns 19. All Services provided through Blue Shield’s Vision Plan Administrator (VPA). Comprehensive examination 21 22 One comprehensive eye examination per Calendar Year. Includes dilation, if professionally indicated. Ophthalmologic 1 New Patient (S0620) Established Patient (S0621) You pay nothing Up to $30 Optometric 1 New Patient (92002/92004) Established Patient (92012/92014) You pay nothing Up to $30 Eyewear/materials One pair of eyeglasses (frames and lenses) or one pair of contact lenses per Calendar Year (unless otherwise noted) after meeting the Calendar Year Medical Deductible as follows: Lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglass. Polycarbonate lenses are covered in full for eligible Members. Single Vision (V2100-V2199) You pay nothing Up to $25 Lined Bifocal (V2200-V2299) You pay nothing Up to $35 Lined Trifocal (V2300-V2399) You pay nothing Up to $45 Lenticular (V2121, V2221, V2321) You pay nothing Up to $45 Optional Lenses and Treatments Ultraviolet Protective Coating (standard only) You pay nothing Not covered Standard Progressive Lenses $55 Not covered Premium Progressive Lenses $95 Not covered Anti-Reflective Lens Coating (standard only) $35 Not covered Photochromic- Glass Lenses $25 Not covered Photochromic- Plastic Lenses $25 Not covered Hi Index Lenses $30 Not covered Polarized Lenses $45 Not covered Frames 23 24 Collection frames You pay nothing Up to $40 Non-Collection frames Up to $150 Up to $40 Benefit Member Copayment 2 3 Participating Provider Non-Participating Provider 4, 22 23 Contact Lenses 24 25 Non-Elective (Medically Necessary) – Hard or soft You pay nothing Up to $225 Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year. You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) You pay nothing Up to $75 Elective (Cosmetic/Convenience) – Non-standard soft (V2521- V2523) One pair per month, up to 3 months, per Calendar Year. You pay nothing Up to $75 Supplemental Low-Vision Testing and Equipment 26 27 (Subject to meeting the Calendar Year Medical Deductible) 35% Not covered Diabetes Management Referral You pay nothing Not covered Benefit Member Copayment 3 Services by Preferred and Participating Dentist Services by Non- Preferred and Non- Participating Dentist 32 33 Pediatric Dental Benefits 27 Benefits28 Pediatric dental benefits are available for Members through the end of the month in which the Member turns 19. Diagnostic and Preventive Care Services 28 1, 29 You pay nothing 20% Restorative Services 29 20% 30 You pay nothing 30% Oral surgery 2930, 30 50% 31 You pay nothing 50% Endodontics 2930, 30 50% 31 You pay nothing 50% Periodontics 2930, 30 50% 31 You pay nothing 50% Crowns and Fixed Bridges 2930, 30 50% 31 You pay nothing 50% Removable Prosthetics 2930, 30 50% 31 You pay nothing 50% Orthodontics 29, 30, 31 50% 31, 32 You pay nothing 50% Other Benefits 20% You pay nothing 30%