Substance Use Disorder Services) • Virtual Visits from $30 Copayment per visit Please refer to the Virtual Care-Only “Office and Home Providers Visits” section. (Specialty Care Services) Vision Services Benefits are based on the setting in which Covered Services are received. (For medical and surgical treatment of injuries and/or diseases of the eye) Certain vision screenings required by Federal law are covered under the "Preventive Care" benefit. Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services Please call our Transplant Department as soon as you think you may need a Covered Procedure to talk about your benefit options. To get the In-Network Level of benefits under your Plan, you must get certain Covered Procedures from an Approved In-Network Provider. Even if a Hospital is an In-Network Provider for other services, it may not be an Approved In-Network Provider for certain Covered Procedures. Please see the “What’s Covered” section for further details. The requirements described below do not apply to the following: • Cornea transplants, which are covered as any other surgery; and • Any Covered Services related to a Covered Procedure that you get before or after the Benefit Period. Benefits for Covered Services that are not part of the Covered Procedure will be based on the setting in which Covered Services are received. Please see the “What’s Covered” section for additional details. Approved In-Network In-Network Provider for Out-of-Network Provider this Plan Provider for this Plan Covered Procedure The number of days or Not applicable – There is Not applicable – There Benefit Period the applicable case rate no unique Benefit Period is no unique Benefit / global time period will for services Period for services vary depending on the type of Covered Procedure and the Approved In-Network Provider agreement. Before and after the Covered Procedure 30