Community Blue Copay (PCP) 60/40 $6000 Standardized · 19636LA0230010

Diabetes coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by a Member’s Physician.

Coverage is available for self-management training and education, dietician visits and for the equipment and necessary available for self-management training and education, dietician visits and for the equipment and necessary supplies for the training, if prescribed by the Member’s Physician. Coverage is available for the equipment, supplies, and Outpatient self-treatment training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by the Member’s Physician. The program must be determined to be medically necessary by a physician and provided by a licensed health care professional and shall comply with the National standard for diabetes self-management education program as developed by the ADA.

Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization.

Use the following Non-Grandfathered Preventive Care Services Brochure link for a complete list – limitation and ages may vary: https://www.lablue.com/preventive\nListed below is a sample of the Preventative/Screening/Immunization Benefits. Please refer to the member contract for more comprehensive list. EXAMINATIONS AND TESTING: Routine Wellness Physical Examination–Certain routine wellness diagnostic tests ordered by Your Physician are covered. Well Baby Care; Prostate Cancer Screening; Colorectal Cancer Screening; IMMUNIZATION: All state mandated immunizations including the complete basic immunization series as defined by the state health officer and required for school entry for children up to age six (6) SCREENING AND COUNSELING: Abdominal Aortic Aneurysm Screening; Alcohol Misuse Screening and Counseling; Blood Pressure Screening; Cholesterol Screening; Depression Screening; Type 2 Diabetes Screening; Diet Counseling; HIV Screening; Obesity Screening and Counseling; Sexually Transmitted Infection Counseling; Tobacco Use Screening; Syphilis Screening; COVERED SERVICES FOR WOMEN: Counseling for - BRCA genetic testing and breast cancer chemoprevention; Routine Gynecologist / Obstetrician Visits; Mammography Examination; Osteoporosis Screening; Routine Pap Smear; Screening –Chlamydia Infection and Gonorrhea; COVERED SERVICES FOR PREGNANT WOMEN: Anemia Screening; Bacteriuria Screening; Breast Feeding Intervention; Folic Acid Supplements; Hepatitis B Screening; Rh Incompatibility Screening; COVERED SERVICES FOR CHILDREN: Alcohol and Drug Use Assessments; Autism Screening; Behavioral Assessments; Cervical Dysplasia Screening; Congenital Hypothyroidism Screening; Developmental Screening; Dyslipidemia Screening

Exclusions: Any services not included in the following Non-Grandfathered Preventive Care Services Brochure link is excluded: https://www.lablue.com/preventive

The Physician Office Copayment may be reduced or waived when services are rendered by a Provider participating in the Quality Blue Program (QB). QB Providers include family practitioners, general practitioners, pediatricians, internists, geriatricians, nurse practitioners, and physician assistants, but more Providers may contract to participate in the Quality Blue program. On eligible plans, members may also receive up to 2 $0 PCP Virtual Visits (includes PCP, Urgent Care, and Behavioral Health visits).

Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services.

Rehabilitative Care Benefits will be available for Services provided on a Inpatient or Outpatient basis, including services for Occupational Therapy, Physical Therapy, Speech/Language Pathology Therapy, and/or Chiropractic Services.

The Member must pay applicable Copayment, Deductible Amount and/or Coinsurance.

Limitations in connection with Durable Medical Equipment are but not limited to:\n(1) There is no coverage during rental of Durable Medical Equipment for repair, adjustment, or replacement of components and accessories necessary for the effective functioning and maintenance of covered equipment as this is the responsibility of the Durable Medical Equipment supplier.\n(2) There is no coverage for equipment where a commonly available supply or appliance can substitute to effectively serve the same purpose.\n(3) There is no coverage for the repair or replacement of equipment lost or damaged due to neglect or misuse.\n(4) Reasonable quantity limits on Durable Medical Equipment items and supplies will be determined by Us.\n2. Orthotic Devices, Prosthetic Appliances and Devices (non-limb) and Prosthetic Appliances and Devices and Prosthetic Services of the Limb Limitations:\na. There is no coverage for fitting, or adjustments as this is, included in the Allowable Charge \nb. Repair or replacement is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the device. We will determine this time period. Repair or replacement of the device will not be covered when provided under warranty.\nc. When Orthotic Devices are approved by Us, Benefits for standard devices will be provided toward any deluxe device.\n(1) Deluxe devices or deluxe features and functionalities of devices are those:\n(a) that do not serve a medical purpose; \n(b) that are not required to complete daily living activities;\n(c) that are solely for the Member’s comfort or convenience; or \n(d) that are not determined by Us to be Medically Necessary. \n(2) Regardless of Claims of Medical Necessity, deluxe devices and deluxe features and functionalities of devices that are not approved by Us are not covered\nd. No Orthotics Benefits are available for supportive devices for the foot, except when used in the treatment of diabetic foot disease.

Exclusions: Exclusions are but not limited to: hairpieces, wigs, hair growth, and/or hair implants; Personal comfort, personal hygiene and convenience items including, but not limited to, air conditioners, humidifiers, personal fitness equipment, or alterations to a Member’s home or vehicle.

The ER copayment is waived if the visit results in an Inpatient Admission.

Emergency Transportation/ Ambulance Includes but not limited to:\nTo or from the nearest Hospital (when medically necessary);\nBenefits for air ambulance servcies are available only if this type of ambulance service is requested by policing or medical authorities at the site in an emergency situation or if the member is in a location that cannot be reached for a ground ambulance;

Exclusions: No benefits are available if transportation is provided for the Member's comfort or convenience, or when a hospital transports members between parts of its own campus.

Inpatient Bed, Board and General Nursing Services include but not limited to: \n1. Hospital room and board and general nursing services.\n2. In a Special Care Unit for a critically ill Member requiring an intensive level of care.\n3. In a Skilled Nursing Facility or Unit or while receiving skilled nursing services in a Hospital, for the maximum\nnumber of days per Benefit Period shown in the Schedule of Benefits.\n4. In a Residential Treatment Center for Members with Mental Disorders and Alcohol and/or Drug Abuse\nBenefits.\nB. Other Hospital Services (Inpatient and Outpatient)\n1. Use of operating, delivery, recovery and treatment rooms and equipment.\n2. Drugs and medicines including take-home Prescription Drugs.\n3. Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges,\nadministrative charges, equipment and supplies.\n4. Anesthesia, anesthesia supplies and anesthesia services rendered by a Hospital employee.\n5. Medical and surgical supplies, casts, and splints.\n6. Diagnostic Services rendered by a Hospital employee.\n7. Physical Therapy provided by a Hospital employee.\n8. Psychological testing when ordered by the attending Physician and performed by an employee of the hospital.

Surgical services examples include but not limited to:\n1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative\nmedical visits.\n2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or\nother multiple surgical procedures) are performed at the same surgical setting\n3. Assistant Surgeon\n4. General anesthesia services are covered when requested by the operating Physician and performed by\na certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the\nassistant surgeon, for covered surgical services.\n Inpatient Medical Services - Subject to provisions in the sections pertaining to Surgery and Pregnancy Care in\nthis Benefit Plan, Inpatient Medical Services include:\n1. Inpatient medical care visits\n2. Concurrent Care\n3. Consultation (as defined in this Benefit Plan)

Office visits are covered same as primary care physician benefit.\n\nThe cost sharing that displays applies to outpatient office visits only. Other outpatient services may be subject to deductible, coinsurance, and/or copays. Please refer to the plan policy documents for detailed information.

Exclusions: Coverage for treatment of Mental Disorders does NOT include counseling services such as career counseling, marriage counseling, divorce counseling, parental counseling and job counseling.\nEducation services and supplies including training or re-training for a vocation, except as specifically provided in this Benefit Plan for diagnosis, testing, or treatment for remedial reading and learning\ndisabilities, including dyslexia.

Rehabilitative Benefits are available for services provided on an Outpatient basis when the services are rendered by a licensed Provider.

Exclusions: Other exclusions include but not limited to:\nVisual therapy lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs

Surgical services examples include but not limited to:\n1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative\nmedical visits.\n2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or\nother multiple surgical procedures) are performed at the same surgical setting\n3. Assistant Surgeon\n4. General anesthesia services are covered when requested by the operating Physician and performed by\na certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the\nassistant surgeon, for covered surgical services.\nOutpatient Medical and Surgical Services include:\n1. Home, office, and other Outpatient visits for examination, diagnosis, and treatment of an illness or injury. Benefits for Outpatient medical services do not include separate payments for routine pre-operative and\npost-operative medical visits for Surgery or Pregnancy Care.\n2. Services of an Ambulatory Surgical Center\n3. Consultation (as defined in this Benefit Plan)

Exclusions: Exclusions include but not limited to:\na. rhinoplasty;\nb. blepharoplasty services identified by CPT codes 15820, 15821, 15822, 15823; brow ptosis identified by CPT code 67900; or any revised or equivalent codes;\nc. gynecomastia;\nd. breast enlargement or reduction, except for breast reconstructive services as specifically provided in this Benefit Plan;\ne. implantation, removal and/or re-implantation of breast implants and services, illnesses, conditions,\ncomplications and/or treatment in relation to or as a result of breast implants;\nf. implantation, removal and/or re-implantation of penile prosthesis and services, illnesses, conditions,\ncomplications and/or treatment in relation to or as a result of penile prosthesis;\ng. diastasis recti;\nh. biofeedback;\ni. treatment related to erectile or sexual dysfunctions, low sexual desire disorder or other sexual inadequacies.\nj. Surgical and medical treatment for snoring in the absence of obstructive sleep apnea, including laser assisted uvulopalatoplasty (LAUP).\nk. Reversal of a voluntary sterilization procedure.

Office visits are covered same as primary care physician benefit. Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use.

Benefit available in network only.

Exclusions: Exclusions are but not limited to: any costs of donating an organ or tissue for transplant when a Member is a donor; the transplant of any non-human organ or tissue; or bone marrow transplants and stem cell rescue (autologous and allogeneic) are not covered, except as\nprovided in this Benefit Plan. If any organ, tissue or bone marrow is sold rather than donated to a Member, the purchase price of such organ, tissue or bone marrow is not covered.

Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply.

Limit: 1.0 Item(s) per 3 Years

1 hearing aid per ear every 3 years; hearing aids or for examinations for the prescribing or fitting of hearing aids. Benefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us.

Exclusions: Certain exclusion apply - Please see the contract book. \nBenefits are available for hearing aids for covered Members when obtained from a Network Provider or another Provider approved by Us. This Benefit is limited to one hearing aid, per ear, in a thirty-six (36) month period. The hearing aid must be fitted and dispensed by a licensed audiologist or licensed hearing aid specialist or hearing aid dealer following the medical clearance of a Physician and an audiological evaluation medically appropriate to the patient.

Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply.

Limit: 1.0 Visit(s) per Year

Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. All pharmacy plans have preventive drugs per USPSTF for $0. For 2-tier pharmacy plans, additional selected generic preventive care drugs in certain classes cost $0. For 3-tier and 4-tier pharmacy plans, additional selected drugs in certain classes used to treat selected chronic conditions cost $0.

Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.

Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay the Tier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member’s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent.

Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.

Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier and 4-tier plans, when a Brand-Name Drug is dispensed and a generic equivalent exists, Members must pay theTier 1 Drug Copayment amount, plus the difference in cost between the Brand-Name Drug dispensed and its generic equivalent. The Copayment for the Brand-Name Drug will not apply. The Member’s payment will apply to the Out-of-Pocket Amount. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent.

Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.

Some drugs covered under medical benefit.

Specialty drugs are distributed throughout all tiers including 2-tier, 3-tier, and 4-tier plans and the member is responsible to pay the applicable deductible/copay/coinsurance for that tier. Retail day supply limits (typically 30-day supply) apply. In addition, quantity per dispensing (QPD) limits/allowances are placed on certain specialty medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us.

Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.

Dental Care and Treatment including Surgery and dental appliances required to correct Accidental Injuries of the jaws, cheeks, lips, tongue, roof or floor of mouth, and of sound natural teeth. (For the purposes of this section, sound natural teeth include those which are capped, crowned or attached by way of a crown or cap to a bridge. Sound natural teeth may have fillings or a root canal.)

Issuer did not share extra notes for this benefit beyond the summary above.

Limit: 1.0 Visit(s) per 6 Months

Limitations may apply. Subject to Dental deductible, if applicable.

Issuer did not share extra notes for this benefit beyond the summary above.

Covered under Dietician visits.

Issuer did not share extra notes for this benefit beyond the summary above.

Limitations, including dollar limits, may apply. Subject to Dental deductible, if applicable. Limitations may apply.

Benefits will be available for the purchase of Prosthetic Appliances and Devices and Prosthetic Services of the limbs that we Authorize. Repair or replacement of the Prosthetic Appliance or Device is covered only within a reasonable time period from the date of purchase subject to the expected lifetime of the appliance. We will determine this time period. Prosthetic Appliances and Devices of the limb must be prescribed by a licensed Physician and provided by a facility accredited by the American Board for Certification in Orthotics Prosthetics and Pedorthics (ABC) or by the Board for Orthotist/Prosthetist Certification (BOC).

Issuer did not share extra notes for this benefit beyond the summary above.

Issuer did not share extra notes for this benefit beyond the summary above.

Issuer did not share extra notes for this benefit beyond the summary above.

Issuer did not share extra notes for this benefit beyond the summary above.

Issuer did not share extra notes for this benefit beyond the summary above.

Exclusions: The following services are not covered: \na. Non-healthcare services provided as part of the clinical trial;\nb. Costs for managing research data associated with the clinical trial;\nc. Investigational drugs or devices; and/or\nd. Services, treatment or supplies not otherwise covered under this Benefit Plan.

Cleft Lip and Cleft Palate Services include but not limited to: 1. Oral and facial Surgery, surgical management, and follow-up care.\n2. Prosthetic treatment, such as obturators, speech appliances, and feeding appliances.\n3. Orthodontic treatment and management.\n4. Preventive and restorative dentistry to ensure good health and adequate dental structures for orthodontic\ntreatment or prosthetic management or therapy.\n5. Speech-language evaluation and therapy.\n6. Audiological assessments and amplification devices.\n7. Otolaryngology treatment and management.\n8. Psychological assessment and counseling.\n9. Genetic assessment and counseling for patient and parents.\nIncludes benefits for secondary conditions and treatment attributable to the primary medical condition of either cleft lip and cleft palate. \n

Unless required for a Congenital Anomaly.

Limit: 1.0 Item(s) per Year

Pediatric selection of eyeglass frames or if a member chooses a Non-Selection frame he/she will pay the difference in retail price between the Selection and the Non-Selection frame. Prescription Contact Lenses may be selected in lieu of eyeglasses from the Pediatric Selection of Contact Lenses up to a maximum of 2 pairs of disposable or 2 pairs of planned replacement Contact Lenses. If a member chooses Non-Selection Contact Lenses he/she will pay the difference in retail price between the Selection and the Non-Selection contact lenses. Evaluation, fitting and follow-up care up to 1 visit are included when Prescription Contact Lenses are selected in lieu of eyeglasses.

An Inpatient rehabilitation Admission must begin within seventy-two (72) hours following the discharge from an Inpatient Hospital Admission for the same or similar condition. Day Rehabilitation Programs for Rehabilitative Care may be Authorized in place of Inpatient stays for rehabilitation. Day Rehabilitation Programs must begin within seventy-two (72) hours following discharge from an Inpatient Admission for the same or similar condition. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings

Exclusions: Other exclusions include but not limited to: \nVisual therapy; lifestyle/habit changing clinics and/or programs; recreational therapy; primarily to enhance athletic abilities; and/or inpatient pain rehabilitation and inpatient pain control programs

Issuer did not share extra notes for this benefit beyond the summary above.

Low Protein Food Products shall not include natural foods that are naturally low\nin protein. Benefits for Low Protein Food Products are limited to the treatment of the following diseases:\nPhenylketonuria (PKU); Maple Syrup Urine Disease (MSUD);\nMethylmalonic Acidemia (MMA);\nIsovaleric Acidemia (IVA);\nPropionic Acidemia;\nGlutaric Acidemia;\nUrea Cycle Defects;\nTyrosinemia.

Exclusions: Exclusions are but not limited to: food or food supplements, formulas and medical foods, including those used for gastric tube feedings.

Issuer did not share extra notes for this benefit beyond the summary above.

Inpatient Private Duty Nursing Services are not covered. Plan limits coverage for Outpatient Private Duty Nursing Services to three hundred (300) hours per Benefit Period.

1. Under the Women’s Health and Cancer Rights Act, a Member who is receiving Benefits in connection with a mastectomy and elects breast reconstruction will also receive Benefits for the following Covered Services:\na. All stages of reconstruction of the breast on which a partial or full unilateral mastectomy has been performed or reconstruction of both breasts if a bilateral mastectomy has been performed;\nb. Surgery and reconstruction of the other breast to produce a symmetrical appearance, including but not limited to liposuction performed for transfer to a reconstructed breast or to repair a donor site deformity, tattooing the areola of the breast, surgical adjustments of the non-mastectomized breast, unforeseen medical Complications which may require additional reconstruction in the future; \nc. prostheses; and \nd. treatment of physical Complications of all stages of the mastectomy, including lymphedemas.

Issuer did not share extra notes for this benefit beyond the summary above.

Benefits are excluded for palliative or cosmetic care or treatment of the foot; supportive devices of the foot; and treatment of flat feet, except for Medically Necessary Surgery. \nBenefits are excluded for routine foot care, except as specifically provided.

Issuer did not share extra notes for this benefit beyond the summary above.