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 9 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is: Second Opinions Outpatient second and third opinions See Medical Care Outpatient Visits See Medical Care Outpatient Visits Short-Term Rehabilitation Therapy (physical, occupational, and speech therapy) Includes habilitation services Outpatient services (60-visit benefit limit per member per calendar year for physical and occupational therapy, except for autism; a benefit limit does not apply for speech therapy) $40 copayment per visit after deductible 20% after deductible  Outpatient diagnostic tests See Lab Tests, X-Rays, and Other Tests See Lab Tests, X-Rays, and Other Tests  Outpatient speech therapy See Short-Term Rehabilitation Therapy See Short-Term Rehabilitation Therapy Speech, Hearing, and Language Disorder Treatment  Outpatient medical care services See Medical Care Outpatient Visits See Medical Care Outpatient Visits  Outpatient day surgery Hospital surgical day care unit or outpatient department services No charge after deductible 20% after deductible Ambulatory surgical facility services No charge after deductible 20% after deductible Physician and other covered professional provider services No charge after deductible 20% after deductible  Sterilization procedure for a female member when performed as the primary procedure for family planning reasons No charge (deductible does not apply) 20% after deductible  Office and health center surgical services Surgery as an Outpatient (excludes removal of impacted teeth whether or not the teeth are imbedded in the bone) by a family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, or multi-specialty provider group; or by a physician assistant or nurse practitioner designated by the health plan as primary care $25 copayment per visit after deductible 20% after deductible