Common use of Covered Services Clause in Contracts

Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: • The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury • The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. • The service is not excluded • The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: • Copays • Deductibles • Coinsurance • Benefit limits • Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the Prior Authorization section for more information. • Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: •  The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury •  The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. •  The service is not excluded •  The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: •  Copays •  Deductibles •  Coinsurance •  Benefit limits •  Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the Prior Authorization section for more information. •  Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: •  The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury •  The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. •  The service is not excluded •  The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: •  Copays •  Deductibles •  Coinsurance •  Benefit limits •  Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the Prior Authorization section for more information. •  Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx xxxxxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This plan requires the selection and use of a Primary Care Physician (PCP). Your PCP will coordinate your medical care, either by providing treatment or by issuing referrals. You do not need a referral for emergency services wherever you may travel. This section describes the services this plan covers. Covered service services means medically necessary services (see Definitions) and specified preventive care services you get receive when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get receive the services: • The reason for the service services is to prevent, diagnose or treat a covered illness, disease illness or injury • The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. • The service is not excluded • The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: • Copays • Deductibles • Coinsurance • Benefit limits • Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the For more information see Prior Authorization section for more informationAuthorization. • Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back coverlisted. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: • The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury • The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. • The service is not excluded • The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: • Copays • Deductibles • Coinsurance • Benefit limits • Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the Prior Authorization section for more information. • Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx xxxxxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This plan requires the selection and use of a Primary Care Physician (PCP). Your PCP will coordinate your medical care, either by providing treatment or by issuing referrals. You do not need a referral for emergency services wherever you may travel. This section describes the services this plan covers. Covered service services means medically necessary services (see Definitions) and specified preventive care services you get receive when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get receive the services: •  The reason for the service services is to prevent, diagnose or treat a covered illness, disease illness or injury •  The service takes place in a medically necessary setting. For more information about what medically necessary means, see Definitions. •  The service is not excluded •  The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: •  Copays •  Deductibles •  Coinsurance •  Benefit limits •  Prior Authorization. Some services must be authorized in writing before you get them. These services are identified in this section. See the For more information see Prior Authorization section for more informationAuthorization. •  Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back coverlisted. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.

Covered Services. This section describes the services this plan covers. Covered service means medically necessary services (see Definitions) and specified preventive care services you get when you are covered for that benefit. This plan provides benefits for covered services only if all of the following are true when you get the services: •  The reason for the service is to prevent, diagnose or treat a covered illness, disease or injury •  The service takes place in a medically necessary setting. For more information about what medically necessary means, see DefinitionsThis plan covers inpatient care only when you cannot get the services in a less intensive setting. •  The service is not excluded •  The provider is working within the scope of their license or certification This plan may exclude or limit benefits for some services. See the specific benefits in this section and the Exclusions section for details. Benefits for covered services are subject to the following: •  Copays •  Deductibles •  Coinsurance •  Benefit limits •  Prior Authorization. Some services must be authorized in writing by us before you get them. These services are identified in this section. See the Prior Authorization section for more information. •  Medical and payment policies. The plan has policies that are used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for a specific procedure, drugs, biologic agents, devices, level of care or services. Payment policies define provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at xxxxxxx.xxx xxxxxxxxxx.xxx or by calling Customer Service. If you have any questions regarding your benefits and how to use them, call Customer Service at the number listed on the back cover. COMMON MEDICAL SERVICES The services listed in this section are covered as shown on the Summary of Your Costs. Please see the summary for your copays, deductible, coinsurance, benefit limits and if out-of-network services are covered.