Common use of Copayment Clause in Contracts

Copayment. For Preventive Care NONE For all other Primary Care Physician Visits [amount consistent with N.J.A.C. 11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR •For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity (pre-natal care) NONE. •Second Surgical Opinion NONE •for all other Covered Services and Supplies •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the age of 18) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the age of 18) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Visits [amount consistent with N.J.A.C. 11:22- 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR •For For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity Maternity (pre-natal care) NONE. •Second Second Surgical Opinion NONE •for for all other Covered Services and Supplies •Per Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] •  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the age of 18) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the age of 18) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Provider Visits [amount consistent with N.J.A.C. 11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR [CALENDAR] [PLAN] YEAR •For Primary Care Physician Provider Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity (pre-natal care) NONE. •Second Surgical Opinion NONE •for all other Covered Services and Supplies •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age of 1819) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age of 1819) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Visits [amount consistent with N.J.A.C. 11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR •For For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity Maternity (pre-natal care) NONE. •Second Second Surgical Opinion NONE •for for all other Covered Services and Supplies •Per Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] •  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the age of 18) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the age of 18) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Visits [amount consistent with N.J.A.C. 11:22- 5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR [CALENDAR] [PLAN] YEAR •For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity (pre-natal care) NONE. •Second Surgical Opinion NONE •for all other Covered Services and Supplies •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] • [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the age of 18) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the age of 18) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Provider Visits [amount consistent with N.J.A.C. 11:22- 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR [CALENDAR] [PLAN] YEAR •For For Primary Care Physician Provider Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity Maternity (pre-natal care) NONE. •Second Second Surgical Opinion NONE •for for all other Covered Services and Supplies •Per Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] •  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the end of the month in which the Member turns age of 1819) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the end of the month in which the Member turns age of 1819) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).

Copayment. For Preventive Care NONE For all other Primary Care Physician Visits [amount consistent with N.J.A.C. 11:22- 11:22-5.5(a)] ] per visit Maternity (pre-natal care) NONE For Prescription Drugs [Copayments consistent with N.J.A.C. 11:22-5.5] For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR [CALENDAR] [PLAN] YEAR •For For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity Maternity (pre-natal care) NONE. •Second Second Surgical Opinion NONE •for for all other Covered Services and Supplies •Per Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] •  [Per Covered Family [Dollar amount which is two times the individual Deductible.] COINSURANCE For Preventive Care 0% Prescription Drugs 50% [Vision Benefits (for Covered Persons through the age of 18) V2500 – V2599 Contact Lenses [50%] Optional lenses and treatments [50%]] [Dental Benefits (for Covered Persons through the age of 18) Preventive, Diagnostic and Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [20%] Orthodontic Treatment [50%]] For all other services and supplies to which a Copayment does not apply [10% - 50%, in 5% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).