COVERED SERVICE BENEFIT 30. Radiation and Chemotherapy Services 100% 31. Reconstructive Surgery Services Payment levels are determined by the setting in which the Service is provided 32. Rehabilitative Physical, Occupational, Speech, and Massage Therapies (Visit maximums do not apply for treatment of mental health conditions.) Inpatient 100% subject to 15% Coinsurance after Deductible Outpatient (up to 60 visits per Year for all therapies combined) 100% subject to $35 Copayment per visit 33. Skilled Nursing Facility Services (up to 150 days per Year) 100% subject to 15% Coinsurance after Deductible 34. Spinal and Extremity Manipulation Therapy Services Self-referred Spinal and Extremity Manipulation therapy (up to 12 100% subject to $35 Copayment per visit visits per Year) Physician-referred Spinal and Extremity Manipulation therapy 100% subject to $35 Copayment per visit 35. Substance Use Disorder Services Inpatient and residential 100% subject to 15% Coinsurance after Deductible 100% subject to $25 Copayment per visit Outpatient (100% for Members age 17 years and younger) 100% subject to $25 Copayment per day Day treatment Services (100% for Members age 17 years and younger) 36. Telehealth Services Telemedicine Services, telephone visits, and e-visits 100% 37. Temporomandibular Joint Dysfunction (TMJ) Non-surgical Services 100% subject to $35 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% 39. Vasectomy Services 100% 40. Vision Services for Adults (for Members 19 years and older) Routine eye exams 100% subject to $25 Copayment 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% EWCLGDED1983ACT0124 5 WAPEBB-CL-ACT