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SCHEDULE OF BENEFITSSmall GroupFlex G500-SG21SG-1395This Schedule of Benefits outlines your cost-sharing and limitations that apply to specific covered services under your Plan. It isintended only to highlight your benefits. Your Medical and Hospital Service Contract provides a detailed description of coverageand the limitations and exclusions to these benefits. Please review your Contract for a complete explanation of your benefitsand the terms and conditions of coverage. Note: you may receive bills from one or more providers per visit or service. ThisSchedule of Benefits replaces any Schedule of Benefits previously in use.SCHEDULE OF SERVICESCOST-TO-MEMBERDEDUCTIBLE Individual / FamilyIN-NETWORKOUT-OF-NETWORK 5,000 / 10,000 15,000 / 30,000The deductible is the amount you owe each calendar year for covered services before AvMed begins to pay. It may notapply to all services. Amounts paid toward the individual deductible apply toward any applicable family deductible. Themost any covered family member will pay toward the family deductible is the individual deductible amount.OUT-OF-POCKET MAXIMUM Individual / Family 7,550 / 15,100 22,650 / 45,300The out-of-pocket maximum is the most you pay each calendar year for covered services, such as deductible payments,copayments, and coinsurances. Once you reach the out-of-pocket maximum, AvMed will pay for your covered services for therest of the year. Amounts paid toward the individual out-of-pocket maximum apply toward any applicable family out-of-pocketmaximum. The most any covered family member will pay toward the family out-of-pocket maximum is the individual out-ofpocket maximum amount.PRIMARY CARE PHYSICIAN SERVICES Office visits (including consultations) Services in Physicians’ office include: 30 copay per visit50% coinsurance afterdeductibleoMinor surgical proceduresNo additional charge50% coinsurance afterdeductibleoDiagnostic imaging, radiology and laboratory servicesNo additional charge50% coinsurance afterdeductibleNo ChargeNot CoveredVirtual Visits (services are available from AvMed designatedTelehealth providers only)Additional charges may apply for other non-preventive services performed in the Physician’s office. Office visit charges may also apply.SPECIALTY PHYSICIAN SERVICES Office visits (including consultations) Services in Physicians’ office include: 60 copay per visit50% coinsurance afterdeductibleoMinor surgical procedures 60 copay per visit50% coinsurance afterdeductibleoDiagnostic laboratory servicesNo additional charge50% coinsurance afterdeductibleoSimple diagnostic imaging 60 copay per visit50% coinsurance afterdeductibleoComplex diagnostic imaging 60 copay per visit50% coinsurance afterdeductibleAdditional charges may apply for other non-preventive services performed in the Physician’s office. Office visit charges may also apply.OTHER PHYSICIAN SERVICES Allergy injections and allergy skin testingAVSG-DSOB-21 60 copay per visitPage 1 of 750% coinsurance afterdeductibleSGDS-PG-1395-(01/21)

SCHEDULE OF BENEFITSSmall GroupFlex G500-SG21SG-1395COST-TO-MEMBERSCHEDULE OF SERVICESIN-NETWORKOUT-OF-NETWORK Podiatry serviceso Routine foot care is limited to medically necessaryservices for individuals with diabetes, peripheralcirculatory or neurovascular disease 30 copay per visit50% coinsurance afterdeductible Diabetes self-managementoIncludes care, education, and nutritional counseling 60 copay per visit50% coinsurance afterdeductibleCounseling by licensed nutritionist limited to 3 visits per calendar year. Additional charges may apply for other non-preventive servicesperformed in the Physician’s office. Office visit charges may also apply.PREVENTIVE CARE AND SERVICES Preventive care services:o Annual physical examinations and immunizationso Lactation support/counseling and breast pump supplieso Colorectal cancer screening, including colonoscopieso HIV screeningo Preventive radiology and laboratory serviceso Prostate specific antigen (PSA) testingo Routine screening mammogramso Voluntary family planning serviceso Well-child care and immunizations, including routinevision and hearing screenings by a pediatriciano Well-woman examinations, including Pap smearsNo Charge50% coinsurance afterdeductibleFor a comprehensive list of covered preventive services, visit e-benefits/.OUTPATIENT FACILITY SERVICES & DIAGNOSTIC TESTS OUTPATIENT FACILITY SERVICESoOutpatient surgeries (include cardiac catheterizationsand angioplasty) 750 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductibleoPhysician charges for surgical and medical servicesNo Charge50% coinsurance afterdeductibleoDialysis services 750 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilitiesNot CoveredoRadiation therapy (covers administration and facilitycharges) 750 copay per course oftreatment at independentfacilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductibleOUTPATIENT DIAGNOSTIC TESTSoRoutine outpatient laboratory tests and blood work 30 copay per visit50% coinsurance afterdeductibleoSpecialty labs 750 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductibleAVSG-DSOB-21Page 2 of 7SGDS-PG-1395-(01/21)

SCHEDULE OF BENEFITSSmall GroupFlex G500-SG21SG-1395COST-TO-MEMBERSCHEDULE OF SERVICESIN-NETWORKOUT-OF-NETWORKoSimple diagnostic tests (including x-rays, ultrasounds,echocardiograms, fluoroscopes, diagnosticmammography, and other standard radiology services) 100 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductibleoComplex diagnostic tests (MRI, MRA, PET, CT, NuclearMedicine) 350 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductibleOutpatient facility services require prior authorization. Please see your Contract for details.PRESCRIPTION DRUGS Tier 1: Value Generic Drugs 10 copay per prescription(retail); 25 copay per prescription(mail order)Not Covered Tier 2: Generic Drugs 20 copay per prescription(retail); 50 copay per prescription(mail order)Not Covered Tier 3: Preferred Brand Drugs 50 copay per prescription(retail); 125 copay per prescription(mail order)Not Covered Tier 4: Non-Preferred Brand Drugs 75 copay per prescription(retail); 187.50 copay perprescription (mail order)Not Covered Tier 5: Specialty Drugs50% coinsurance afterdeductible (retail only)Not CoveredBrand additional charge may apply if a Brand is selected when a Generic is available. Certain drugs require prior authorization. AvMed doesnot apply manufacturer or provider cost-share assistance program payments (e.g. manufacturer cost-share assistance, manufacturer discountplans, and/or manufacturer coupons) to the deductible or out-of-pocket maximums. Retail charge applies per 30-day supply. Mail-order chargeapplies per 60-90 day supply. AvMed’s commercial Formulary List is available at www.avmed.org under the Preferred Medication Lists section.INFUSION AND OTHER DRUG THERAPY Drug therapy administered by a medical professionaloin a Physician’s office 60 copay per visit50% coinsurance afterdeductibleoin the home 30 copay per visit50% coinsurance afterdeductibleoin an outpatient facility 120 copay per visit atindependent facilities;50% coinsurance afterdeductible at hospitalowned or affiliated facilities50% coinsurance afterdeductible50% coinsurance afterdeductible50% coinsurance afterdeductibleRequires prior authorization Chemotherapy (covers administration and facility charges)Requires prior authorizationAVSG-DSOB-21Page 3 of 7SGDS-PG-1395-(01/21)

SCHEDULE OF BENEFITSSmall GroupFlex G500-SG21SG-1395COST-TO-MEMBERSCHEDULE OF SERVICESIN-NETWORKOUT-OF-NETWORK 550 copay per visit 550 copay per visitIMMEDIATE / EMERGENCY CARE Emergency room services at participating or nonparticipating hospitals (copay waived if admitted)Charges for Physician services may also apply, and may be billed separately. AvMed must be notified within 24 hours of inpatient admissionfollowing emergency services or as soon as reasonably possible. Ambulance transport for emergency servicesoGround transport 150 copay per one wayground transport afterdeductible 150 copay per one wayground transport after InNetwork deductibleoAir and water transport50% coinsurance afterdeductible50% coinsurance after InNetwork deductible 150 copay per one wayground transport afterdeductible 150 copay per one wayground transport afterdeductibleNon-emergent ambulance serviceso Covered when the skill of medically trained personnel isrequired and the Member cannot be safely transportedby other meansRequires prior authorization Medical services at urgent/immediate care facilities 100 copay per visit atindependent facilities;30% coinsurance afterdeductible at hospitalowned or affiliated facilities 100 copay per visit afterdeductible at independentfacilities;50% coinsurance afterdeductible at hospitalowned or affiliated facilities Medical services at retail clinics 40 copay per visit 40 copay per visit afterdeductibleINPATIENT HOSPITAL Inpatient services at hospitals includes:o Room and board - unlimited days (semi-private)o Anesthesia, use of operating and recovery rooms,oxygen, drugs and medicationo Intensive care unit and other special units, general andspecial duty nursingo Laboratory and diagnostic imagingo Required special dietso Radiation and inhalation therapieso Acute rehabilitation services (limited to 30 days percalendar year) 750 copay per day for thefirst 3 days per admissionafter deductible50% coinsurance afterdeductible Physician charges for surgical and medical servicesNo charge after deductible50% coinsurance afterdeductibleInpatient services require prior authorization.MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT Office visits 30 copay per visit50% coinsurance afterdeductible Partial hospitalization.No Charge50% coinsurance afterdeductibleAVSG-DSOB-21Page 4 of 7SGDS-PG-1395-(01/21)