Common use of COVERED SERVICES AND BENEFITS Clause in Contracts

COVERED SERVICES AND BENEFITS. Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit Limits. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Calendar Year. Note: Your Group has made the following additional benefits available. Copayments for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Benefits Requirements All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in Limitations and Exclusions; • may require Preauthorization.

COVERED SERVICES AND BENEFITS. Copayments All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found further treatment by Providers in the Schedule applicable network of Copayments Participating Specialists and Benefit LimitsHospitals. Urgent Care, Retail Health Clinics and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Preauthorization by HMO. A Copayment for Basic Benefits Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- Out-of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. NoteIMPORTANT NOTE: Your Group has made Copayments shown below indicate the following additional benefits availableamount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for these services do not apply to the out- of- pocket maximum amountvarious reasons as permitted by applicable law. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Requirements All Covered Per Individual Member Per Family $7,350 $14,700 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $25 Copay $45 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy No Copay -Dialysis -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure -Other X-Ray Services -Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Therapies, per visit Habilitation Services, and $100 Copay; unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in Limitations and Exclusions; • may require Preauthorizationcovered under Inpatient Hospital Services.

COVERED SERVICES AND BENEFITS. Copayments All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found further treatment by Providers in the Schedule applicable network of Copayments Participating Specialists and Benefit LimitsHospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMO. A Copayment for Basic Benefits Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. NoteIMPORTANT NOTE: Your Group has made Copayments shown below indicate the following additional benefits availableamount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for these services do not apply to the out- of- pocket maximum amountvarious reasons as permitted by applicable law. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Out-of-Pocket Maximums Per Calendar Year including Pharmacy Benefits Requirements All Covered Per Individual Member Per Family $8,700 $17,400 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, for each admission $150 Copay Outpatient Facility Services Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay -Urgent Care Facility Services Outpatient Infusion Therapy Services Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Outpatient Laboratory and X-Ray Services Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services and Habilitation Services Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in Limitations and Exclusions; • may require Preauthorizationcovered under Inpatient Hospital Services.

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Some services may require Preauthorization by HMO. IMPORTANT NOTE: Copayments shown below indicate the amount You are liable required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for certain Copayments to Participating Providers, which are due at the time of serviceeach occurrence unless otherwise indicated. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit Limits. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will maximums may be applied towards the out-of-pocket maximum amountadjusted for various reasons as permitted by applicable law. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Out- of- Pocket Maxi mums Per Calendar Year. Note: Your Group has made the following additional benefits available. Copayments for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Yea r i ncl udi ng Pha rma cy Benefits Requirements All Covered Per Individual Member Per Family $6,850 $13,700 Pro fes s i onal Serv i ces Primary Care Physician (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $35 Copay $70 Copay I npa ti ent Hospi tal Servi ces Inpatient Hospital Services, unless otherwise specifically described: • must be Medically Necessary; • must be performedfor each admission $1,500 Copay Outpa ti ent Facili xx Xxxxx ces Outpatient Surgery Outpatient Hospital based Infusion Therapy -Radiation Therapy -Dialysis -Urgent Care Facility Services $500 Copay 20% Copay No Copay Outpa t i ent Labora t ory a nd X- Xxx Xxxxx ces Computerized Tomography (CT Scan), prescribedComputerized Tomography Angiography (CTA), directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure -Other X-Ray Services -Outpatient Lab $250 Copay $100 Copay Rehabilita tion Serv i ces Rehabilitation Services and Benefit Limits; • may have limitationsTherapies, restrictions or exclusions described in Limitations and Exclusions; • may require Preauthorization.per visit $100 Copay

COVERED SERVICES AND BENEFITS. Copayments All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found further treatment by Providers in the Schedule applicable network of Copayments Participating Specialists and Benefit LimitsHospitals. Female Members may visit a Participating OB/GYN Physician in their PCP's Provider network for diagnosis and treatment without a Referral from their PCP. Urgent Care and Retail Health Clinics do not require Primary Care Physician Referral. A Copayment for Basic Benefits Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket Out‐of‐pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. NoteIMPORTANT NOTE: Your Group has made Copayments shown below indicate the following additional benefits availableamount You are required to pay, expressed as either a fixed dollar amount or a percentage of the Allowable Amount. Copayments will be applied for these services do not apply to the out- of- pocket maximum amounteach occurrence unless otherwise indicated. You will not be responsible for any Copayments once the out-of-pocket maximum(s) listed below have to make been met. Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Benefits Requirements All Covered and out‐of‐pocket maximums may be adjusted for various reasons as permitted by applicable law. Some services may require Preauthorization by HMO. Out‐of‐Pocket Maximums Per Calendar Year Per Individual Member Per Family $4,000 $8,000 Professional Services Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $40 Copay $60 Copay Inpatient Hospital Services Inpatient Hospital Services, unless otherwise specifically described: • must be Medically Necessary; • must be performedfor each admission $1,500 Copay Outpatient Facility Services Outpatient Surgery Radiation Therapy and Chemotherapy Dialysis $750 Copay No Copay No Copay Outpatient Laboratory and X‐Ray Services Arteriograms, prescribedComputerized Tomography (CT Scan), directed Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Myelogram, Positron Emission Tomography (PET Scan), per procedure Other X‐Ray Services Other Outpatient Lab $250 Copay No Copay No Copay Rehabilitation Services Rehabilitation Services and Therapies $40 Copay for PCP or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment in the Schedule of Copayments and Benefit Limits; • may have limitations$60 Copay for Specialist, restrictions $1,500 Copay for Inpatient Hospital Services or exclusions described in Limitations and Exclusions; • may require Preauthorization$60 Copay for Outpatient Facility Services, as applicable.

COVERED SERVICES AND BENEFITS. Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit LimitsSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Calendar Year. Note: Your Group has made the following additional benefits available. Copayments for these services do not apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S Pharmacy Benefits Requirements All Covered Services, unless otherwise specifically described: •  must be Medically Necessary; •  must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; •  must be rendered by a Participating Provider; •  are subject to the Copayment in the Schedule of Copayments and Benefit LimitsSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; •  may have limitations, restrictions or exclusions described in Limitations and ExclusionsLIMITATIONS AND EXCLUSIONS; •  may require Preauthorization.

COVERED SERVICES AND BENEFITS. Copayments You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment amount for specific Covered Services, benefit limitations and out- of- pocket maximums can be found in the Schedule of Copayments and Benefit LimitsSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. A Copayment for Basic Benefits shall not exceed fifty percent (50%) of the total cost of the services provided. Out- of- Pocket Maximums Out- of- pocket maximums paid by You or on Your behalf in a Calendar Year for Basic Benefits Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the out-of-pocket maximum amount. When the family out-of-pocket maximum amount is reached, You are not required to make additional Copayments for Covered Services for the remainder of the Calendar Year. Note: Your Group has made the following additional pharmacy benefits available. Copayments Copayment for these services pharmacy benefits do not apply to the medical out- of- pocket maximum amount, but will apply to the out- of- pocket maximum amount. You will have to make Copayments under these benefits even if the out- of- pocket maximum amount has been reached: S maximums for Pharmacy Benefits indicated on the PHARMACY BENEFITS; SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. Requirements All Covered Services, unless otherwise specifically described: •  must be Medically Necessary; •  must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; •  must be rendered by a Participating Provider; •  are subject to the Copayment in the Schedule of Copayments and Benefit LimitsSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; •  may have limitations, restrictions or exclusions described in Limitations and ExclusionsLIMITATIONS AND EXCLUSIONS; •  may require Preauthorization.