Benefit Summary

Virginia - Choice Traditional - 30/100% Plan D3S

YOUR BENEFITS

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PLAN HIGHLIGHTS Types of Coverage Annual Deductible Individual Deductible Family Deductible No Annual Deductible No Annual Deductible Network Benefits

Out-of-Pocket Maximum Individual Out-of-Pocket Maximum $3,000 per year Family Out-of-Pocket Maximum $9,000 per year > OP Surgery Copayments and IP Copayments accumulate towards the Out-of-Pocket Maximum. > All individual Out-of-Pocket Maximum amounts will count toward the family Out-of-Pocket Maximum, but an individual will not have to pay more than the individual Out-of-Pocket Maximum amount.

Benefit Plan Coinsurance - The Amount We Pay 100% Deductible does not apply. Maximum Policy Benefit The maximum amount we will pay during the entire period of time you are enrolled under the Policy. No Maximum Benefit.

This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Certificate of Coverage (COC), the COC shall prevail. It is recommended that you review your COC for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. VAWEMD3S07 Item# Rev. Date Benefit Accumulator 445-5131 0709_rev01 Policy Year PVY/Sep/Emb/55916 UnitedHealthcare Insurance Company Page 1 of 14

Prescription Drug Benefits Prescription drug benefits are shown under separate cover. Information on Benefit Limits > The Out-of-Pocket Maximum and Benefit limits are calculated on a Policy year basis. > All Benefits are reimbursed based on Eligible Expenses. For a definition of Eligible Expenses, please refer to your Certificate of Coverage. MOST COMMONLY USED BENEFITS Types of Coverage Primary Physician Office Visit Specialist Physician Office Visit Network Benefits 100% after you pay a $30 Copayment per visit. 100% after you pay a $60 Copayment per visit.

Physicians Office Services - Sickness and Injury

> In addition to the visit Copayment, the applicable Copayment and any Deductible/Coinsurance applies when these services are done: CT, PET, MRI, Nuclear Medicine; Scopic Procedures; Surgery; Therapeutic Treatments. Preventive Care Services Covered Health Services include but are not limited to: Primary Physician Office Visit Specialist Physician Office Visit Lab, X-Ray or other preventive tests Urgent Care Center Services 100% after you pay a $100 Copayment per visit. > In addition to the visit Copayment, the applicable Copayment and any Deductible/Coinsurance applies when these services are done: CT, PET, MRI, Nuclear Medicine; Scopic Procedures; Surgery; Therapeutic Treatments. Emergency Health Services - Outpatient 100% after you pay a $200 Copayment per visit. Hospital - Inpatient Stay 100% after you pay a $1,000 Copayment per Inpatient Stay. 100% Deductible does not apply. 100% Deductible does not apply. 100% Deductible does not apply.

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ADDITIONAL CORE BENEFITS Types of Coverage Ground Ambulance Air Ambulance Network Benefits 100% Deductible does not apply. 100% Deductible does not apply. Ambulance Service - Emergency and Non-Emergency

YOUR BENEFITS

Pre-service Notification is required for Non-Emergency Ambulance. Congenital Heart Disease (CHD) Surgeries 100% after you pay a $1,000 Copayment per Inpatient Stay.

Dental Services - Accident Only Benefits are limited as follows: $3,000 maximum per year $900 maximum per tooth Diabetes Services Diabetes Self Management and Training Diabetic Eye Examinations/Foot Care Diabetes Self Management Items Benefits for diabetes equipment that meets the definition of Durable Medical Equipment are not subject to the limit stated under Durable Medical Equipment. Durable Medical Equipment Benefits are limited as follows: $5,000 per year and are limited to a single purchase of a type of Durable Medical Equipment (including repair and replacement) every three years. 100% Deductible does not apply. Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under Durable Medical Equipment and in the Outpatient Prescription Drug Rider. 100% Deductible does not apply.

Pre-service Notification is required.

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid. Hearing Aids Benefits are limited as follows: $5,000 per year and are limited to a single purchase (including repair/ replacement) every three years. 100% Deductible does not apply.

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ADDITIONAL CORE BENEFITS Types of Coverage Home Health Care Benefits are limited as follows: In accordance with Virginia law, coverage is provided for one home visit for a newborn following obstetrical care in a Hospital and an additional visit as prescribed by a Physician. Such visits are not subject to any per year visit and/ or dollar maximum. 60 visits per year Hospice Care 100% Deductible does not apply. Lab, X-Ray and Diagnostics - Outpatient For Preventive Lab, X-Ray and Diagnostics, refer to the Preventive Care Services category. 100% Deductible does not apply. 100% Deductible does not apply. Network Benefits

Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient 100% Deductible does not apply. Ostomy Supplies Benefits are limited as follows: $2,500 per year Pharmaceutical Products - Outpatient This includes medications administered in an outpatient setting, in the Physician's Office and by a Home Health Agency. 100% Deductible does not apply. 100% Deductible does not apply.

Physician Fees for Surgical and Medical Services 100% Deductible does not apply. Pregnancy - Maternity Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. For services provided in the Physician's Office, a Copayment will only apply to the initial office visit. Prosthetic Devices Benefits are limited as follows: $5,000 per year and are limited to a single purchase of each type of prosthetic device every three years. 100% Deductible does not apply.

This benefit category contains services/devices that may be Essential or non-Essential Health Benefits as defined by the Patient Protection and Affordable Care Act depending upon the service or device delivered. A benefit review will take place once the dollar limit is exceeded. If the service/device is determined to be rehabilitative or habilitative in nature, it is an Essential Health Benefit and will be paid. If the benefit/device is determined to be non-essential, the maximum will have been met and the claim will not be paid. Reconstructive Procedures Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary.

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ADDITIONAL CORE BENEFITS Types of Coverage Benefits are limited as follows: 20 visits of Manipulative Treatment 20 visits of physical therapy 20 visits of occupational therapy 20 visits of speech therapy 20 visits of pulmonary rehabilitation 36 visits of cardiac rehabilitation 30 visits of post-cochlear implant aural therapy Note: Rehabilitation Services Outpatient Therapy in connection with the Early Intervention Services Benefit are not subject to the limits stated above. Scopic Procedures - Outpatient Diagnostic and Therapeutic Diagnostic scopic procedures include, but are not limited to: Colonoscopy Sigmoidoscopy Endoscopy For Preventive Scopic Procedures, refer to the Preventive Care Services category. Benefits are limited as follows: 60 days per year Surgery - Outpatient 100% Deductible does not apply. Network Benefits 100% after you pay a $30 Copayment per visit. Rehabilitation Services - Outpatient Therapy and Manipulative Treatment

YOUR BENEFITS

Skilled Nursing Facility / Inpatient Rehabilitation Facility Services 100% after you pay a $1,000 Copayment per Inpatient Stay.

100% after you pay a $500 Copayment per date of service. Therapeutic Treatments - Outpatient Therapeutic treatments include, but are not limited to: Dialysis Intravenous chemotherapy or other intravenous infusion therapy Radiation oncology Transplantation Services 100% after you pay a $1,000 Copayment per Inpatient Stay. For Network Benefits, services must be received at a Designated Facility. Pre-service Notification is required. Vision Examinations Benefits are limited as follows: 1 exam every 2 years 100% after you pay a $30 Copayment per visit. 100% Deductible does not apply.

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STATE MANDATED BENEFITS Types of Coverage Cleft Lip and Cleft Palate Treatment Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Pre-service Notification is required. Clinical Trials Participation in a qualifying clinical trial for the treatment of: Cancer Cardiovascular (cardiac/stroke) Surgical musculoskeletal disorders of the spine, hip and knees Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Network Benefits

Pre-service Notification is required. Congenital Defects and Birth Abnormalities Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Pre-service Notification is required. Dental Services - Hospital and Alternate Facility Health Services Related to Dental Care Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Pre-service Notification is required. Early Intervention Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. Home Treatment of Hemophilia and Congenital Bleeding Disorders Depending upon where the Covered Health Service is provided, Benefits for blood infusion equipment and blood products will be the same as those stated under Durable Medical Equipment, Pharmaceutical Products-Outpatient, or in the Outpatient Prescription Drug Rider. Pre-Service Notification is required.

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STATE MANDATED BENEFITS Types of Coverage Mental Health Services For groups with 50 or less total employees: Benefits are limited for Mental Health Services as follows: 30 days per year for adult Covered Persons and 25 days for an Enrolled Dependent child for Inpatient/ Intermediate. 20 visits per year for Outpatient. Benefit limits do not apply to outpatient visits for medication management. Benefit limits do not apply to Mental Health Services for Biologically Based Mental Illness. When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. For groups with 51 or more total employees: Benefit limits do not apply When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. Network Benefits

YOUR BENEFITS

For groups with 50 or less total employees: Inpatient: Non-Biologically Based Mental Illness 100% after you pay a $1,000 Copayment per Inpatient Stay.

Outpatient: 100% after you pay a $60 Copayment per visit.

For groups with 51 or more total employees: Inpatient: 100% after you pay a $1,000 Copayment per Inpatient Stay. Outpatient: 100% after you pay a $30 Copayment per visit.

Neurobiological Disorders Autism Spectrum Disorder Services For groups with 50 or less total employees: Benefit limits do not apply When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. For groups with 51 or more total employees: Benefit limits do not apply When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. For groups with 50 or less total employees: Inpatient: 100% after you pay a $1,000 Copayment per Inpatient Stay. Outpatient: 100% after you pay a $60 Copayment per visit. For groups with 51 or more total employees: Inpatient: 100% after you pay a $1,000 Copayment per Inpatient Stay. Outpatient: 100% after you pay a $30 Copayment per visit.

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STATE MANDATED BENEFITS Types of Coverage Substance Use Disorder Services For groups with 50 or less total employees: Benefit limits do not apply When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. For groups with 51 or more total employees: Benefit limits do not apply When outpatient visits are subject to payment of a Copayment, the Copayment will not exceed 50% of Eligible Expenses. Temporomandibular Joint Services Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary. For groups with 50 or less total employees: Inpatient: 100% after you pay a $1,000 Copayment per Inpatient Stay. Outpatient: 100% after you pay a $60 Copayment per visit. For groups with 51 or more total employees: Inpatient: 100% after you pay a $1,000 Copayment per Inpatient Stay. Outpatient: 100% after you pay a $30 Copayment per visit. Network Benefits

This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Certificate of Coverage (COC), the COC shall prevail. It is recommended that you review your COC for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. Page 8 of 14

MEDICAL EXCLUSIONS It is recommended that you review your COC for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. Alternative Treatments Acupressure; acupuncture; aromatherapy; hypnotism; massage therapy; rolfing; art therapy, music therapy, dance therapy, horseback therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. This exclusion does not apply to Manipulative Treatment and nonmanipulative osteopathic care for which Benefits are provided as described in Section 1 of the COC. Dental Dental care (which includes dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia). This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1 of the COC. This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Policy, limited to: Transplant preparation; prior to initiation of immunosuppressive drugs; the direct treatment of cancer, cleft lip/palate and ectodermal dysplasia. Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of dental caries resulting from dry mouth after radiation treatment or as a result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. Preventive care, diagnosis, treatment of or related to the teeth or gums. Examples include: extraction, restoration, and replacement of teeth; medical or surgical treatment of dental conditions; and services to improve dental clinical outcomes. This exclusion does not apply to accidental-related dental services for which Benefits are provided as described under Dental Services Accidental Only in Section 1 of the COC. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1 of the COC. Dental braces (orthodontics). This exclusion does not apply to cleft lip/palate or ectodermal dysplasia related dental services for which Benefits are provided as described under Cleft Lip and Cleft Palate Treatment in Section 1 of the COC. Treatment of congenitally missing, malpositioned, or supernumerary teeth, even if part of a Congenital Anomaly. Devices, Appliances and Prosthetics Devices used specifically as safety items or to affect performance in sports-related activities. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics, cranial banding and some types of braces, including over-the-counter orthotic braces. The following items are excluded, even if prescribed by a Physician: blood pressure cuff/monitor; enuresis alarm; non-wearable external defibrillator; trusses and ultrasonic nebulizers. Devices and computers to assist in communication and speech except for speech generating devices and tracheo-esophogeal voice devices for which Benefits are provided as described under Durable Medical Equipment in Section 1 of the COC. Oral appliances for snoring. Repairs to prosthetic devices due to misuse, malicious damage or gross neglect. Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace lost or stolen items. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self-injectable medications except insulin for which Benefits are provided as described under Diabetes Services in Section 1 of the COC. This exclusion does not apply to medications which, due to their characteristics (as determined by us), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. Non-injectable medications given in a Physician's office. This exclusion does not apply to non-injectable medications that are required in an Emergency and consumed in the Physician's office. Over-the-counter drugs and treatments. Growth hormone therapy. Experimental, Investigational or Unproven Services Experimental or Investigational and Unproven Services and all services related to Experimental or Investigational and Unproven Services are excluded. The fact that an Experimental or Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular condition. There are three exceptions to this exclusion: Covered Health Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1 of the COC. No prescribed drug shall be excluded as Experimental or Investigational or Unproven on the basis that the drug has not been approved by the Food and Drug Administration (FDA) for the treatment of the specific condition for which the drug has been prescribed provided that (1) the drug has been approved by the FDA for at least one indication and (2) the drug has been recognized as safe and effective for the treatment of the specific condition in one of the standard reference compendia or in substantially accepted peer-reviewed medical literature; and Benefits for any drug approved by the FDA for use in the treatment of cancer pain are covered even if the dosage is in excess of the recommended dosage of the pain relieving agent, if the prescription in excess of the recommended dosage has been prescribed for a patient with intractable cancer pain. Foot Care Routine foot care. Examples include the cutting or removal of corns and calluses. This exclusion does not apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided as described under Diabetes Services in Section 1 of the COC. Nail trimming, cutting, or debriding. Hygienic and preventive maintenance foot care. Examples include: cleaning and soaking the feet; applying skin creams in order to maintain skin tone. This exclusion does not apply to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes. Treatment of flat feet or subluxation of the foot. Shoes; shoe orthotics; shoe inserts and arch supports. Page 9 of 14

MEDICAL EXCLUSIONS CONTINUED Medical Supplies Prescribed or non-prescribed medical supplies and disposable supplies. Examples include: elastic stockings, ace bandages, gauze and dressings, urinary catheters. This exclusion does not apply to: Disposable supplies necessary for the effective use of Durable Medical Equipment for which Benefits are provided as described under Durable Medical Equipment in Section 1 of the COC. Diabetic supplies for which Benefits are provided as described under Diabetes Services in Section 1 of COC. Blood infusion equipment for which Benefits are provided as described under Home Treatment of Hemophilia and Congenital Blood Disorders in Section 1 of the COC. Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in Section 1 of the COC. Tubing and masks, except when used with Durable Medical Equipment as described under Durable Medical Equipment as described in Section 1 of the COC. Mental Health Services performed in connection with conditions not classified as Mental Illnesses in the most commonly recognized professional psychiatric guidelines and reference materials. Mental Health Services as treatments for V-code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. These V-code conditions are: Noncompliance with treatment, partner relational problem, physical/sexual abuse of an adult, parent-child relational problem, child neglect, physical/sexual abuse of a child, sibling relational problem, relational problem related to a mental disorder or general medical condition, occupational problem, academic problem, relational problems, bereavement, borderline intellectual functioning, phase of life problem, religious of spiritual problem, malingering, adult antisocial behavior, child or adolescent antisocial behavior, no diagnosis or condition on Axis 1, no diagnosis on Axis II . Mental Health Services that extend beyond the period necessary for evaluation, diagnosis, the application of evidence-based treatments or crisis intervention to be effective. Mental Health Services as treatment for a primary diagnosis of insomnia and other sleep disorders, sexual dysfunction disorders, feeding disorders, neurological disorders and other disorders with a known physical basis. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders, paraphilias, and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Use Disorder Designee. This exclusion does not apply to Biologically Based Mental Illnesses as described under Mental Health Services or Substance Use Disorder Services in Section 1 of the COC. Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning. This exclusion does not apply to Biologically Based Mental Illnesses as described under Mental Health Services or Substance Use Disorder Services in Section 1 of the COC. Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act. Learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Mental retardation and autism spectrum disorder as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Benefits for autism spectrum disorder as a primary diagnosis are described under Neurobiological Disorders Autism Spectrum Disorder Services in Section 1 of the COC. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Use Disorder Designee. Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental. Typically do not result in outcomes demonstrably better than other available treatment alternatives that are less intensive or more cost effective. Not consistent with the Mental Health/Substance Use Disorder Designees level of care guidelines or best practices as modified from time to time. Not clinically appropriate in terms of type, frequency, extent, site and duration of treatment, and considered ineffective for the patients Mental Illness, substance use disorder or condition based on generally accepted standards of medical practice and benchmarks. The Mental Health/Substance Use Disorder Designee may consult with professional clinical consultants, peer review committees or other appropriate sources for recommendations and information regarding whether a service or supply meets any of these criteria.

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MEDICAL EXCLUSIONS CONTINUED Neurobiological Disorders Autism Spectrum Disorders Services as treatments of sexual dysfunction and feeding disorders as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Any treatments or other specialized services designed for Autism Spectrum Disorder that are not backed by credible research demonstrating that the services or supplies have a measurable and beneficial health outcome and therefore considered Experimental or Investigational or Unproven Services. Mental retardation as the primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act. Learning, motor skills and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association and which are not a part of Autism Spectrum Disorder. Treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders and paraphilias. Intensive behavioral therapies such as applied behavioral analysis for Autism Spectrum Disorder. Services or supplies for the diagnosis or treatment of Mental Illness that, in the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental. Not consistent with the Mental Health/Substance Use Disorder Designees level of care guidelines or best practices as modified from time to time. Not clinically appropriate for the patients Mental Illness or condition based on generally accepted standards of medical practice and benchmarks. Nutrition Individual and group nutritional counseling. This exclusion does not apply to medical nutritional education services that are provided by appropriately licensed or registered health care professionals when both of the following are true: Nutritional education is required for a disease in which patient self-management is an important component of treatment. There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional. Enteral feedings, even if the sole source of nutrition. Infant formula and donor breast milk. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements and other nutrition-based therapy. Examples include supplements, electrolytes, and foods of any kind (including high protein foods and low carbohydrate foods). Personal Care, Comfort or Convenience Television; telephone; beauty/barber service; guest service. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include: air conditioners, air purifiers and filters, dehumidifiers; batteries and battery chargers; breast pumps; car seats; chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners; electric scooters; exercise equipment; home modifications such as elevators, handrails and ramps; hot tubs; humidifiers; Jacuzzis; mattresses; medical alert systems; motorized beds; music devices; personal computers, pillows; power-operated vehicles; radios; saunas; stair lifts and stair glides; strollers; safety equipment; treadmills; vehicle modifications such as van lifts; video players, whirlpools. Physical Appearance Cosmetic Procedures. See the definition in Section 9 of the COC. Examples include: pharmacological regimens, nutritional procedures or treatments. Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures). Skin abrasion procedures performed as a treatment for acne. Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple. Treatment for skin wrinkles or any treatment to improve the appearance of the skin. Treatment for spider veins. Hair removal or replacement by any means. Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. See Reconstructive Procedures in Section 1 of the COC. Treatment of benign gynecomastia (abnormal breast enlargement in males). Physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Wigs regardless of the reason for the hair loss.

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MEDICAL EXCLUSIONS CONTINUED Procedures and Treatments Excision or elimination of hanging skin on any part of the body. Examples include plastic surgery procedures called abdominoplasty or abdominal panniculectomy, and brachioplasty. Medical and surgical treatment of excessive sweating (hyperhidrosis). Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea. Rehabilitation services and Manipulative Treatment to improve general physical condition that are provided to reduce potential risk factors, where significant therapeutic improvement is not expected, including but not limited to routine, long-term or maintenance/ preventive treatment. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cancer, Congenital Anomaly, or Autism Spectrum Disorders or qualifies as an Early Intervention Service as described under Early Intervention Services in Section 1 of the COC. Psychosurgery. Sex transformation operations. Physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or office encounter. Biofeedback. The following services for the treatment of TMJ; craniosacral therapy; orthodontics; occlusal adjustment; dental restorations. Surgical and non-surgical treatment of obesity. Stand-alone multi-disciplinary smoking cessation programs. Breast reduction except as coverage is required by the Womens Health and Cancer Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in Section 1 of the COC. Providers Services performed by a provider who is a family member by birth or marriage. Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services performed by a provider with your same legal residence. Services provided at a free-standing or Hospital-based diagnostic facility without an order written by a Physician or other provider. Services which are self-directed to a free-standing or Hospital-based diagnostic facility. Services ordered by a Physician or other provider who is an employee or representative of a free-standing or Hospital-based diagnostic facility, when that Physician or other provider has not been actively involved in your medical care prior to ordering the service, or is not actively involved in your medical care after the service is received. This exclusion does not apply to mammography. Reproduction Health services and associated expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment. This exclusion does not apply to services required to treat or correct underlying causes of infertility. Surrogate parenting, donor eggs, donor sperm and host uterus. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and ovarian tissue. The reversal of voluntary sterilization. Services Provided under Another Plan Health services for which other coverage is required by federal, state or local law to be paid or to be payable through other arrangements. Examples include coverage paid or payable by workers' compensation or similar legislation. If coverage under workers' compensation or similar legislation is optional for you because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness, or Mental Illness that would have been covered under workers' compensation or similar legislation had that coverage been elected. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. Substance Use Disorders Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents. Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction and learning. Services or supplies for the diagnosis or treatment of alcoholism or substance use disorders that, in the reasonable judgment of the Mental Health/Substance Use Disorder Designee, are any of the following: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental. Not consistent with the Mental Health/Substance Use Disorder Designees level of care guidelines or best practices as modified from time to time. Not clinically appropriate for the patients substance use disorder or condition based on generally accepted standards of medical practice and benchmarks. Transplants Health services for organ and tissue transplants, except those described under Transplantation Services in Section 1 of the COC. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs that are directly related to organ removal are payable for a transplant through the organ recipient's Benefits under the Policy.) Health services for transplants involving permanent mechanical or animal organs. Transplant services that are not performed at a Designated Facility. This exclusion does not apply to cornea transplants.

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MEDICAL EXCLUSIONS CONTINUED Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to Covered Health Services received from a Designated Facility or Designated Physician may be reimbursed at our discretion. Types of Care Multi-disciplinary pain management programs provided on an inpatient basis. Custodial care or maintenance care; Domiciliary care. Private Duty Nursing. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which Benefits are described under Hospice Care in Section 1 of the COC. Rest cures; services of personal care attendants. Work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work). Vision and Hearing Purchase cost and fitting charge for eye glasses and contact lenses. Implantable lenses used only to correct a refractive error (such as Intacs corneal implants). Eye exercise or vision therapy. Surgery that is intended to allow you to see better without glasses or other vision correction. Examples include radial keratotomy, laser, and other refractive eye surgery. Bone anchored hearing aids except when either of the following applies; For Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid. For Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. More then one bone anchored hearing aid per Covered Person who meets the above coverage criteria during the entire period of time the Covered Person is enrolled under the Policy. Repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the above coverage criteria, other than for malfunctions. All Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service see the definition in Section 9 of the COC. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered under the Policy when: required solely for purposes of school, sports or camp, travel, career or employment, insurance, marriage or adoption; related to judicial or administrative proceedings or orders; conducted for purposes of medical research; required to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. This exclusion does not apply to Covered Persons who are civilians Injured or otherwise affected by war, any act of war, or terrorism in non-war zones. Health services received after the date your coverage under the Policy ends. This applies to all health services, even if the health service is required to treat a medical condition that arose before the date your coverage under the Policy ended. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. In the event a non-Network provider waives Copayments, Coinsurance and/or any deductible for a particular health service, no Benefits are provided for the health service for which the Copayments, Coinsurance and/or deductible are waived. Charges in excess of Eligible Expenses or in excess of any specified limitation. Long term (more than 30 days) storage. Examples include cryopreservation of tissue, blood and blood products. Autopsy. Foreign language and sign language services. Preexisting Conditions (Applies only to groups of 50 or less employees) Benefits for the treatment of a Preexisting Condition are excluded until the earlier of the following: The date you have had Continuous Creditable Coverage for 12 months; or the date you have had Continuous Creditable Coverage for 12 months if you are a Late Enrollee. This exclusion does not apply to Covered Persons under age 19.

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