COVERED SERVICE BENEFIT 100% subject to $25 primary care office visit Copayment per visit; (100% for 7. Diabetic Education Members age 17 years and younger) 100% subject to $35 specialty care office visit Copayment per visit 8. Diagnostic Testing, Laboratory, Mammograms, and X-ray Laboratory 100% subject to $10 Copayment per visit, 100% for preventive tests Genetic Testing 100% subject to $10 Copayment per visit, 100% for preventive tests X-ray, imaging and special diagnostic procedures 100% subject to $10 Copayment per visit, 100% for preventive tests Diagnostic and supplemental breast imaging 100% CT, MRI, PET scans 100% subject to $10 Copayment per visit, 100% for preventive tests 9. Dialysis Outpatient dialysis visit 100% subject to $35 Copayment per visit Home dialysis 100% 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% 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, speech, 100% subject to $35 Copayment per visit and occupational therapies per Year) Inpatient Services 100% subject to 15% Coinsurance after Deductible 13. Hearing Instruments Visits for hearing instrument Services, such as assessment, fitting, 100% subject to $35 Copayment per adjustment, and auditory training exam Hearing instruments 100%; benefit maximum of $3,000 for each hearing aid per ear every 36 months Ear molds 100% subject to 20% Coinsurance 14. Home Health Services (up to 130 visits per Year) 100% subject to 15% Coinsurance after Deductible EWCLGDED1983ACT0124 2 WAPEBB-CL-ACT