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 8 hppodedIISoB-0125 Covered Services In-Network Benefits Your Cost Is: Out-of-Network Benefits Your Cost Is:  Routine adult care Routine medical exams and immunizations (one exam per member per calendar year) No charge 20% after deductible No charge 20% after deductible Routine tests These covered services include (but are not limited to): routine exams; immunizations; routine lab tests and x-rays; routine mammograms; blood tests to screen for lead poisoning; and routine colonoscopies. Annual mental health wellness exams No charge No charge (deductible does not apply)  Routine GYN care Routine GYN exams (one exam per member per calendar year) No charge 20% after deductible Routine Pap smear tests (one test per member per calendar year) No charge 20% after deductible  Family planning No charge 20% after deductible  Routine hearing care Routine hearing exams/tests No charge 20% after deductible Newborn hearing screening tests No charge 20% after deductible Hearing aids/related services for members age 21 or younger ($2,000 for one hearing aid per hearing-impaired ear every 36 months) No charge 20% after deductible  Routine vision care Routine vision exams (one exam per member every 24 months) No charge 20% after deductible Preventive Health Services (continued) Vision supplies/related services Not covered; you pay all charges Not covered; you pay all charges  Ostomy supplies No charge after deductible 20% after deductible Prosthetic Devices  Artificial limb devices (includes repairs) and other external prosthetic devices 20% after deductible 40% after deductible Radiation Therapy and Chemotherapy Outpatient services No charge after deductible 20% after deductible