BENEFIT In-Network ALLERGY CARE Testing and Treatment $50 copay per visit CHIROPRACTIC CARE Chiropractic Care $50 copay per visit SHORT TERM REHAB OR HABILITATIVE SERVICES Inpatient limited to 60 Days per Calendar Year Deductible & 20% Coinsurance Outpatient limited to 60 combined PT/OT/ST Visits per Calendar $50 copay per visit Year DURABLE MEDICAL EQUIPMENT Unlimited Deductible & 20% Coinsurance (Precert required for items over $500) HEARING AIDS Limited to a single purchase (including repair/replacement) Deductible & 20% Coinsurance every 3 Years. MEDICAL SUPPLIES Medical Supplies when Medically Necessary Deductible & 20% Coinsurance EXERCISE FACILITY Subscriber $200 reimbursement per 6 month period Spouse/Dependents over age 13 $100 reimbursement per 6 month period INFERTILITY (Covers all services in compliance with the NY Infertility Mandate) Specialist Office Visits $50 copay per visit Inpatient Facility Services Deductible & 20% Coinsurance Outpatient Surgery - Hospital Setting Deductible & 20% Coinsurance Outpatient Surgery - Freestanding Facility Deductible & 20% Coinsurance OUTPATIENT PRESCRIPTION DRUGS - DEDUCTIBLE $100 Deductible (waived for Tier 1 Drugs) OUTPATIENT PRESCRIPTION DRUGS - RETAIL The Prescription Drug Benefit is based on a per Calendar Year limit for any applicable deductibles and/or maximum limits. Tier 1 $20 copay Tier 2 $60 copay Tier 3 $80 copay OUTPATIENT PRESCRIPTION DRUGS - MAIL ORDER Tier 1 $50.00 copay Tier 2 $150.00 copay Tier 3 $200.00 copay DEPENDENT ELIGIBILITY: Eligible dependents include the employee's spouse and dependent children until the child reaches age 26. Benefits discontinue at the end of the Month. Domestic Partners covered with proper documentation. Please be advised this sample summary of coverage is provided for informational purposes only. The information contained herein is subject to the approval of the New York Department of Insurance and Oxford home office approval as appropriate. The applicable Summary of Benefits will be issued to eligible enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate. Refer to the Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxford, cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders, Workers' Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies. NYLG_EPO_01.01.23_v.1 1280471 January 1, 2023 Page 2 of 2