TELADOC SERVICES Note: Teladoc Services described below are subject to state availability. Access to telephonic or video- based consultations may be restricted in some states. This Plan has a special benefit allowing Covered Persons of all ages to receive telephone or web-based video consultations with Physicians for routine primary medical diagnoses. Teladoc may be used: • When immediate care is needed. • When considering the ER or Urgent Care center for non-Emergency issues. • When You are on vacation or on a business trip. Teladoc can be used for the following types of conditions: • General medicine, including, but not limited to: ➢ Colds and flu ➢ Allergies ➢ Bronchitis ➢ Pink eye ➢ Upper respiratory infections • A refill of a recurring Prescription. • Pediatric care. • Non-Emergency medical assistance. In order to obtain this benefit, a Covered Person must complete a medical history disclosure form that will serve as an electronic medical record for consulting Physicians. This form can be completed via the Teladoc website, via the call center, or via the Teladoc mobile app. Once enrolled, a Covered Person may phone 1-800-TELADOC (1-800-835-2362) and request a consultation with a Physician. A Physician will then return the Covered Person’s phone call. If a Covered Person requests a web-based video consultation, the consultation will be scheduled and an appointment reminder notification will be sent prior to the appointed time. If necessary, the Physician will write a Prescription. The Prescription will be called in to a pharmacy of the Covered Person’s choice. Benefits for this service are shown in the Schedule of Benefits. Teladoc does not guarantee that every consultation will result in a Prescription. Medications are prescribed at the Physician’s discretion based on the symptoms reported at the time of the consultation. A Covered Person has 72 hours after their consultation to call Teladoc with any clarification questions. A member of the Teladoc clinical team will assist the Covered Person at no additional cost during this time. If a Covered Person requests another Physician consultation, they will be charged the Teladoc consultation fee. Teladoc may not be used for: • Drug Enforcement Agency (DEA) controlled Prescriptions. • Charges for telephone or online consultations with Physicians and/or other providers who are not contracted through Teladoc. -68- .