Schedule of Benefits (continued) Preferred Blue PPO Deductible II This chart shows your cost share for covered services. You must pay all charges in excess of a benefit limit. Page 3 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  In a Skilled Nursing Facility (100-day benefit limit per member per calendar year) Facility services No charge after deductible 20% after deductible Admissions for Inpatient Medical and Surgical Care (continued) Physician and other covered professional provider services No charge after deductible 20% after deductible  Emergency ambulance No charge after deductible same as in-network benefits Ambulance Services (ground or air ambulance transport)  Other ambulance No charge after deductible 20% after deductible Cardiac Rehabilitation Outpatient services $40 copayment per visit after deductible 20% after deductible  Outpatient lab tests and x-rays See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests Chiropractor Services (for members of any age)  Outpatient medical care services, including spinal manipulation (a benefit limit does not apply) $40 copayment per visit after deductible 20% after deductible Dialysis Services Outpatient services and home dialysis No charge after deductible 20% after deductible  Covered medical equipment rented or purchased for home use 20% after deductible 40% after deductible No charge (deductible does not apply) 20% after deductible Durable Medical Equipment  One breast pump per birth (rented or purchased), including related parts and supplies No coverage is provided for hospital-grade breast pumps. Early Intervention Services Outpatient intervention services for eligible child from birth through age two No charge (deductible does not apply) No charge (deductible does not apply)  Emergency room services No charge after deductible same as in-network benefits Emergency Medical Outpatient Services  Hospital outpatient department services $40 copayment per visit after deductible 20% after deductible