50 on your Effective Date and in your second or third trimester of pregnancy (13 weeks or later) as of the Effective Date, benefits for obstetrical care will be available at the Participating level even if a Non- Participating Provider is used if you fill out a Continuation of Care Request Form and send it to the Claims Administrator. Covered Services will include the obstetrical care given by that Provider through the end of the pregnancy and the immediate post-partum period. Important Note About Maternity Admissions: Under federal law, the Plan may not limit benefits for any Hospital length of stay for childbirth for the mother or newborn to less than 48 hours after vaginal birth, or less than 96 hours after a cesarean section (C-section). However, federal law as a rule does not stop the mother’s or newborn’s attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours, or 96 hours, as applicable. In any case, as provided by federal law, the Plan may not require a Provider to get authorization from the Claims Administrator before prescribing a length of stay which is not more than 48 hours for a vaginal birth or 96 hours after a C-section. In addition, coverage is provided for an examination given at the earliest feasible time to your newborn child for the detection of the following disorders: • Phenylketonuria. • Hypothyroidism • Hemoglobinopathies, including sickle cell anemia. • Galactosemia. • Maple syrup urine disease. • Homocystinuria. • Inborn errors of metabolism that result in an intellectual disability and that are designated by State of Indiana • Congenital adrenal hyperplasia. • Biotinidase deficiency. • Disorders detected by tandem mass spectrometry or other technologies with the same or greater detection capabilities as tandem mass spectrometry, if the state determines that the technology is available for use by a designated laboratory under the applicable state law. • Spinal muscular atrophy • Severe combined immunodeficiency • Physiologic hearing screening examination at the earliest feasible time for the detection of hearing impairments • Pulse oximetry screening examination at the earliest feasible time for the detection of low oxygen levels. • Krabbe disease. • Pompe disease. • Hurler syndrome (MPS1). • Adrenoleukodystrophy (ALD). Contraceptive Benefits Benefits include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain contraceptives are covered under the “Preventive Care” benefit. Please see that section for further details.

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