COVERED SERVICE BENEFIT 100% subject to $20 Copayment after Partial hospitalization Deductible per office visit or per day (100% after Deductible for Members age 17 years and younger) 22. Naturopathic Medicine 100% subject to $20 Copayment after Evaluation and treatment Deductible (100% after Deductible for Members age 17 years and younger) 23. Obstetrics, Maternity and Newborn Care Scheduled prenatal care visits and postpartum visits 100% Inpatient hospital Services 100% subject to 15% Coinsurance after Deductible Home birth obstetrical care and delivery 100% subject to $30 Copayment after Deductible per visit 24. Office Visits 100% subject to $20 Copayment after Primary care visits Deductible per visit (100% after Deductible for Members age 17 years and younger) Specialty care visits 100% subject to $30 Copayment after Deductible per visit Urgent Care visits 100% subject to $40 Copayment after Deductible per visit Nurse treatment room visits to receive injections 100% subject to $10 Copayment after Deductible per visit 25. Organ Transplants Inpatient facility Services 100% subject to 15% Coinsurance after Deductible Inpatient professional Services 100% subject to 15% Coinsurance after Deductible 26. Out-of-Area Coverage for Dependents Limited office visits, laboratory, diagnostic X-rays, and prescription drug fills as described in the EOC under “Out-of- 100% subject to 20% Coinsurance after Area Coverage for Dependents” in the “Benefit Details” section. Deductible (Coinsurance is based on the actual fee the provider, facility or vendor charged for the Service). 27. Outpatient Surgery Visit 100% subject to 15% Coinsurance after Deductible 28. Prescription Drugs, Insulin, and Diabetic Supplies Certain preventive medications (including, but not limited to, aspirin, fluoride, liquid iron for infants, and tobacco use cessation 100% drugs) Certain self-administered IV drugs, fluids, additives, and nutrients including the supplies and equipment required for their 100% after Deductible administration Blood glucose test strips Subject to the generic drug tier Copayment or Coinsurance FDA approved prescription and over-the-counter contraceptive 100% drugs or devices EWCLGHDHP1983ACT0124 4 WAPEBB-CD-ACT