COVERED SERVICE BENEFIT 100% subject to $20 primary care office visit Copayment after Deductible per visit; (100% after Deductible for 7. Diabetic Education Members age 17 years and younger) 100% subject to $30 specialty care office visit Copayment after Deductible per visit 8. Diagnostic Testing, Laboratory, Mammograms, and X-ray 100% subject to 15% Coinsurance after Laboratory Deductible per visit, 100% for preventive tests 100% subject to 15% Coinsurance after Genetic Testing Deductible per visit, 100% for preventive tests 100% subject to 15% Coinsurance after X-ray, imaging and special diagnostic procedures Deductible per visit, 100% for preventive tests 100% after meeting $1,600 of the self- Diagnostic and supplemental breast imaging only or $3,200 of the individual Family Member Deductible or the Family Deductible (whichever applies) 100% subject to 15% Coinsurance after CT, MRI, PET scans Deductible per visit, 100% for preventive tests 9. Dialysis Outpatient dialysis visit 100% subject to $30 Copayment after Deductible per visit Home dialysis 100% after Deductible 10. Durable Medical Equipment (DME) and External Prosthetic Devices and Orthotic Devices Outpatient Durable Medical Equipment (DME) 100% subject to 20% Coinsurance after Deductible External Prosthetic Devices 100% subject to 20% Coinsurance after Deductible Orthotic Devices 100% subject to 20% Coinsurance after Deductible Home ultraviolet light therapy equipment 100% after Deductible Peak flow meters, blood glucose monitors, and lancets 100% subject to 20% Coinsurance 11. Emergency Services Emergency department visit 100% subject to 15% Coinsurance after Deductible 12. Habilitative Services (Visit maximums do not apply to habilitative Services for treatment of mental health conditions.) Outpatient Services (limited to 60 visits combined physical, 100% subject to $30 Copayment after speech, and occupational therapies per Year) Deductible per visit Inpatient Services 100% subject to 15% Coinsurance after Deductible EWCLGHDHP1983ACT0124 2 WAPEBB-CD-ACT