48 Also covered is diabetes self-management training if you have insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition when: • Medically Necessary; • Ordered in writing by a Physician, a podiatrist, an advanced practice registered nurse or a physician assistant; and • Provided by a Health Care Professional who is licensed, registered, or certified under state law. For the purposes of this provision, a "Health Care Professional" means the Physician or podiatrist ordering the training or a Provider who has obtained certification in diabetes education by the American Diabetes Association. Diagnostic Services Your Plan includes benefits for tests or procedures to find or check a condition when specific symptoms exist. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or Hospital admission. Benefits include the following services: Diagnostic Laboratory and Pathology Services • Laboratory and pathology tests, such as blood tests. • Genetic tests, when allowed by the Plan. Diagnostic Imaging Services and Electronic Diagnostic Tests • X-rays / regular imaging services • Ultrasound • Electrocardiograms (EKG) • Electroencephalography (EEG) • Echocardiograms • Hearing and vision tests for a medical condition or injury (not for screenings or preventive care) • Tests ordered before a surgery or admission. Advanced Imaging Services Benefits are also available for advanced imaging services, which include but are not limited to: • CT scan • CTA scan • Magnetic Resonance Imaging (MRI) • Magnetic Resonance Angiography (MRA) • Magnetic Resonance Spectroscopy (MRS) • Nuclear Cardiology • PET scans • PET/CT Fusion scans • QCT Bone Densitometry • Diagnostic CT Colonography The list of advanced imaging services may change as medical technologies change.

Benefit Booklet: Plan 2 - Page 49 Benefit Booklet: Plan 2 Page 48 Page 50