Benefits Tier 1 In-Network Tier 2 All Other Tier 3 Out-of-Network Providers In-Network Providers Providers Allergy Services Benefits are based on Benefits are based on 50% Coinsurance after the setting in which the setting in which Deductible Covered Services are Covered Services are received. received. Ambulance Services 20% Coinsurance after Deductible (Ground, Air, and Water) Emergency Services For ground or water ambulance services, Out-of-Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out-of-Network Providers cannot bill you for more than your applicable In-Network Deductible, Coinsurance, and/or Copayment. Ambulance Services 20% Coinsurance after Deductible (Ground, Air, and Water) Non- Emergency Services For ground or water ambulance services, Out-of-Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out-of-Network Providers cannot bill you for more than your applicable In-Network Deductible, Coinsurance, and/or Copayment. Important Note: All scheduled ambulance services for non-Emergency transfers, except transfers from one acute Facility to another, must be approved through precertification. Please see “Getting Approval for Benefits” for details. Benefits for non-Emergency ground or water ambulance services will be limited to $50,000 per trip if an Out-of-Network Provider is used. This limit does not apply to air ambulance services. Autism Spectrum Benefits are based on the setting in which Covered Services are received. Disorders Behavioral Health Mental Health and Substance Use Disorder Services are covered as required Services by state and federal law. Please see the rest of this Schedule for the cost shares that apply in each setting. Cardiac Rehabilitation See “Therapy Services.” Cellular and Gene See the “Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Therapy Services Cellular and Gene Therapy Services” section later in this Schedule. Precertification required 16