Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: Nothing, no deductible 20% coinsurance after deductible • Ten visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year for age 3 and older Routine adult physical exams, including related tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Mental health wellness exams (at least one per calendar year) Nothing, no deductible Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the 20% coinsurance after deductible maximum, no deductible and all charges beyond the maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services—office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits Nothing after deductible Nothing after deductible Office or health center visits, when performed by: • A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse $25 per visit after deductible 20% coinsurance after deductible midwife, limited services clinic, multi-specialty provider group, or by a physician assistant or nurse practitioner designated as primary care • Other covered providers, including a physician assistant or nurse practitioner designated as $40 per visit after deductible 20% coinsurance after deductible specialty care Mental health or substance use treatment $25 per visit after deductible 20% coinsurance after deductible Outpatient telehealth services • With a covered provider Same as in-person visit Same as in-person visit • With the in-network designated telehealth vendor $25 per visit after deductible Only applicable in-network Diabetic management services (first two visits per calendar year*) Nothing, no deductible 20% coinsurance after deductible Chiropractors’ office visits $40 per visit after deductible 20% coinsurance after deductible Acupuncture visits (up to 12 visits per calendar year) $40 per visit after deductible 20% coinsurance after deductible Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year**) $40 per visit after deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment—speech therapy $40 per visit after deductible 20% coinsurance after deductible Diagnostic x-rays and lab tests, including CT scans, MRIs, PET scans, Nothing after deductible 20% coinsurance after deductible and nuclear cardiac imaging tests Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Durable medical equipment—such as wheelchairs, crutches, hospital beds 20% coinsurance after 40% coinsurance after deductible*** deductible*** Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia in an office or health center, when performed by: † • A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, $25 per visit after deductible 20% coinsurance after deductible nurse midwife, multi-specialty provider group, or by a physician assistant or nurse practitioner designated as primary care † • Other covered providers, including a physician assistant or nurse practitioner designated as $40 per visit after deductible 20% coinsurance after deductible specialty care Surgery and related anesthesia in an ambulatory surgical facility, hospital outpatient department, Nothing after deductible 20% coinsurance after deductible or surgical day care unit Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible * These diabetic services are for diabetes evaluation and management services, diabetic eye exams, or diabetic foot care. ** No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. *** In-network cost share waived for one breast pump per birth, including supplies (20% coinsurance after deductible out-of-network). † Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate.