IN-NETWORK OUT-OF-NETWORK Preventive / Routine PSA Test And Prostate Exams: • Maximum Exams Per Calendar Year 1 Exam • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Screenings / Services At Appropriate Ages And Gender: • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Colonoscopies, Sigmoidoscopies, And Similar Routine Surgical Procedures Performed For Preventive Reasons: • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Hearing Exams: • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Eye Exams And Glaucoma Testing: • Maximum Exams Per Calendar Year 1 Exam • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Counseling For Alcohol Or Substance Use Disorder, Tobacco / Nicotine Use, Obesity, Diet, And Nutrition: • Paid By Plan After Deductible 100% 60% (Deductible Waived) Preventive / Routine Tobacco Addiction: • Paid By Plan After Deductible 100% 60% (Deductible Waived) In Addition, The Following Preventive / Routine Services Are Covered For Women: ➢ Treatment For Gestational Diabetes ➢ Papillomavirus DNA Testing* ➢ Counseling For Sexually Transmitted Infections (Provided Annually)* ➢ Counseling For Human Immune-Deficiency Virus (Provided Annually)* ➢ Breastfeeding Support, Supplies, And Counseling ➢ Counseling For Interpersonal And Domestic Violence For Women (Provided Annually)* • Paid By Plan After Deductible 100% 60% (Deductible Waived) *These Services May Also Apply To Men. Private Duty Nursing: • Maximum Visits Per Calendar Year 82 Visits • Paid By Plan After Deductible 80% 60% -20- 7670-00-413597