COVERED SERVICE BENEFIT Physician-referred Spinal and Extremity Manipulation therapy 100% subject to $30 Copayment after Deductible per visit 35. Substance Use Disorder Services Inpatient and residential 100% subject to 15% Coinsurance after Deductible 100% subject to $20 Copayment after Outpatient Deductible per visit (100% after Deductible for Members age 17 years and younger) 100% subject to $20 Copayment after Day treatment Services Deductible per day (100% after Deductible for Members age 17 years and younger) 36. Telehealth Services Telemedicine Services, telephone visits, and e-visits 100% after Deductible 37. Temporomandibular Joint Dysfunction (TMJ) Non-surgical Services 100% subject to $30 Copayment per visit after Deductible Inpatient and outpatient surgical Services Payment levels are determined by the setting in which the Service is provided. 38. Tobacco Use Cessation 100% 100% after meeting $1,600 of the self- 39. Vasectomy Services only Deductible or $3,200 of the individual Family Member or Family Deductible (whichever applies) 40. Vision Services for Adults (for Members 19 years and older) Routine eye exams 100% subject to $20 Copayment after Deductible per exam Hardware once in a two-Year period: either prescription eyeglass lenses and a frame, or conventional or disposable prescription 100% up to $150 benefit maximum contact lenses, including Medically Necessary contact lenses 41. Vision Services for Children covered until the end of the month in which the Member turns 19 years of age Routine vision screening 100% Comprehensive eye exam (limited to one exam per Year) 100% Low vision evaluation and/or follow up exams (evaluations limited to once every five years; follow up exams limited to four exams 100% every five years) Eyeglasses (limited to one pair per Year) 100% Conventional or disposable contact lenses in lieu of eyeglasses (limited to one pair per Year for conventional contact lenses or up 100% to a 12-month supply of disposable contact lenses per Year) Medically Necessary contact lenses (limited to one pair per Year for conventional contact lenses or up to a 12-month supply of 100% after Deductible disposable contact lenses per Year, prior authorization required) Low vision aids (limited to one device per Year, prior 100% after Deductible authorization required) EWCLGHDHP1983ACT0124 6 WAPEBB-CD-ACT