Common use of Footnotes Clause in Contracts

Footnotes. 1 The Calendar Year Deductible (Medical Plan Deductible) may include Services on both a Copayment or Coinsurance basis and applies to all applicable Services except the Services listed below. Chiropractic Services; Covered travel expenses for bariatric surgery Services; Diabetes self-management training provided by Preferred Providers, a registered dietician or registered nurse who are certi- fied diabetes educators; Injectable contraceptive when administered by a Physician as specified in the Family Planning Services section; Internet Based Consultations; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Dis- turbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Outpatient routine newborn circumcision in a Preferred Providers’ office; Preferred Physician office visits; Services provided under the Outpatient Prescription Drug benefit; and Preventive Health Benefits; 2 Charges for covered Brand Name Drugs in excess of the Participating Pharmacy contracted rate do not apply to the Member Calendar Year Brand Name Drug Deductible. The Member Calendar Year Brand Name Drug Deductible must be satisfied once during each Calendar Year by or on behalf of the Member. The Member Calendar Year Brand Name Drug Deductible is separate from the Member Calendar Year Deductible (Medical Plan Deductible). The Member Calendar Year Brand Name Drug Deductible does not count towards the Member Calendar Year Deductible (Medical Plan Deductible) nor toward the Member Calendar Year Out-of-Pocket Maximum responsibility. 3 The following are not included in the Calendar Year Out-of-Pocket Maximum amount: Additional and reduced payments under the Benefits Management Program; Charges in excess of specified benefit maximums; Charges for Services which are not covered and charges by non-Preferred and MHSA Non-Participating Providers in ex- cess of covered amounts; Covered travel expenses for bariatric surgery Services; Family Planning injectable contraceptives administered by a Physician; Inpatient Hospital Facility Services for Mental Illness when Services are received from MHSA Non-Participating Provid- ers; Internet Based Consultations; Non-Emergency Services from a Non-Participating Hospital; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Disturbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Non-Preferred Hospital-based Inpatient Medically Necessary skilled nursing Services including Subacute Care; Outpatient Surgery from a Non-Participating Ambulatory Surgery Center; and Outpatient routine newborn circumcision in a Preferred Providers’ office; Physician office visit Copayment; Services as described in the Preventive Care Benefits section; Services provided under the Outpatient Prescription Drug benefit; The Calendar Year Medical Plan Deductible; The Calendar Year Brand Name Drug Deductible. Note: Copayments and charges for Services not accruing to the Calendar Year Out-of-Pocket Maximum Responsibility con- tinue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 4 Unless otherwise specified, Copayments/Coinsurance are calculated based on the Allowable Amount. 5 Other Providers are not Preferred Providers and so for Services by Other Providers you are responsible for all charges above the Allowable Amount. Other Providers include acupuncturists, nursing homes and certain labs (for a complete list of Other Providers see the Definitions section)

Footnotes. 1 The Calendar Year Deductible (Medical Plan Deductible) may include Services on both a Copayment or Coinsurance basis and applies to all applicable Services except the Services listed below. Chiropractic Services; Covered travel expenses for bariatric surgery Services; Diabetes self-management training provided by Preferred Providers, a registered dietician or registered nurse who are certi- fied diabetes educators; Injectable contraceptive when administered by a Physician as specified in the Family Planning Services section; Internet Based Consultations; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Dis- turbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Outpatient routine newborn circumcision in a Preferred Providers’ office; Preferred Physician office visits; Services provided under the Outpatient Prescription Drug benefit; and Preventive Health Benefits; 2 Charges for covered Brand Name Drugs in excess of the Participating Pharmacy contracted rate do not apply to the Member Calendar Year Brand Name Drug Deductible. The Member Calendar Year Brand Name Drug Deductible must be satisfied once during each Calendar Year by or on behalf of the Member. The Member Calendar Year Brand Name Drug Deductible is separate from the Member Calendar Year Deductible (Medical Plan Deductible). The Member Calendar Year Brand Name Drug Deductible does not count towards the Member Calendar Year Deductible (Medical Plan Deductible) nor toward the Member Calendar Year Out-of-Pocket Maximum responsibility. 3 The following are not included in the Calendar Year Out-of-Pocket Maximum amount: Additional and reduced payments under the Benefits Management Program; Charges in excess of specified benefit maximums; Charges for Services which are not covered and charges by non-Preferred and MHSA Non-Participating Providers in ex- cess of covered amounts; Covered travel expenses for bariatric surgery Services; Family Planning injectable contraceptives administered by a Physician; Inpatient Hospital Facility Services for Mental Illness when Services are received from MHSA Non-Participating Provid- ers; Internet Based Consultations; Non-Emergency Services from a Non-Participating Hospital; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Disturbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Non-Preferred Hospital-based Inpatient Medically Necessary skilled nursing Services including Subacute Care; Outpatient Surgery from a Non-Participating Ambulatory Surgery Center; and Outpatient routine newborn circumcision in a Preferred Providers’ office; Physician office visit Copayment; Services as described in the Preventive Care Benefits section; Services provided under the Outpatient Prescription Drug benefit; The Calendar Year Medical Plan Deductible; The Calendar Year Brand Name Drug Deductible. Deductible Note: Copayments and charges for Services not accruing to the Calendar Year Out-of-Pocket Maximum Maxiumum Responsibility con- tinue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 4 Unless otherwise specified, Copayments/Coinsurance are calculated based on the Allowable Amount. 5 Other Providers are not Preferred Providers and so for Services by Other Providers you are responsible for all charges above the Allowable Amount. Other Providers include acupuncturists, nursing homes and certain labs (for a complete list of Other Providers see the Definitions section)

Footnotes. 1 The Calendar Year Deductible (Medical Plan Deductible) may include Services on both a Copayment or Coinsurance basis and applies to all applicable Services except the Services listed below. Chiropractic Services; Covered travel expenses for bariatric surgery Services; Diabetes self-management training provided by Preferred Providers, a registered dietician or registered nurse who are certi- fied diabetes educators; Injectable contraceptive when administered by a Physician as specified in the Family Planning Services section; Internet Based Consultations; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Dis- turbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Outpatient routine newborn circumcision in a Preferred Providers’ office; Preferred Physician office visits; Services provided under the Outpatient Prescription Drug benefit; and Preventive Health Benefits; 2 Charges for covered Brand Name Drugs in excess of the Participating Pharmacy contracted rate do not apply to the Member Calendar Year Brand Name Drug Deductible. The Member Calendar Year Brand Name Drug Deductible must be satisfied once during each Calendar Year by or on behalf of the Member. The Member Calendar Year Brand Name Drug Deductible is separate from the Member Calendar Year Deductible (Medical Plan Deductible). The Member Calendar Year Brand Name Drug Deductible does not count towards the Member Calendar Year Deductible (Medical Plan Deductible) nor toward the Member Calendar Year Out-of-Pocket Maximum responsibility. 3 The following are not included in the Calendar Year Out-off-Pocket Maximum t amount: Additional and reduced payments under the Benefits Management Program; Charges in excess of specified benefit maximums; Charges for Services which are not covered and charges by non-Preferred and MHSA Non-Participating Providers in ex- cess of covered amounts; Covered travel expenses for bariatric surgery Services; Family Planning injectable contraceptives administered by a Physician; Inpatient Hospital Facility Services for Mental Illness when Services are received from MHSA Non-Participating Provid- ers; Internet Based Consultations; Non-Emergency Services from a Non-Participating Hospital; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Disturbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Non-Preferred Hospital-based Inpatient Medically Necessary skilled nursing Services including Subacute Care; Outpatient Surgery from a Non-Participating Ambulatory Surgery Center; and Outpatient routine newborn circumcision in a Preferred Providers’ office; Physician office visit Copayment; Services as described in the Preventive Care Benefits section; Services provided under the Outpatient Prescription Drug benefit; The Calendar Year Medical Plan Deductible; The Calendar Year Brand Name Drug Deductible. Note: Copayments and charges for Services not accruing to the Calendar Year Out-of-Pocket Maximum Responsibility con- tinue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 4 Unless otherwise specified, Copayments/Coinsurance are calculated based on the Allowable Amount. 5 Other Providers are not Preferred Providers and so for Services by Other Providers you are responsible for all charges above the Allowable Amount. Other Providers include acupuncturists, nursing homes and certain labs (for a complete list of Other Providers see the Definitions section)

Footnotes. 1 The Calendar Year Deductible (Medical Plan Deductible) may include Services on both a Copayment or Coinsurance basis and applies to all applicable Services except the Services listed below. Chiropractic Services; Covered travel expenses for bariatric surgery Services; Diabetes self-management training provided by Preferred Providers, a registered dietician or registered nurse who are certi- fied diabetes educators; Injectable contraceptive when administered by a Physician as specified in the Family Planning Services section; Internet Based Consultations; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Dis- turbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Outpatient routine newborn circumcision in a Preferred Providers’ office; Preferred Physician office visits; Services provided under the Outpatient Prescription Drug benefit; and Preventive Health Benefits; 2 Charges for covered Brand Name Drugs in excess of the Participating Pharmacy contracted rate do not apply to the Member Calendar Year Brand Name Drug Deductible. The Member Calendar Year Brand Name Drug Deductible must be satisfied once during each Calendar Year by or on behalf of the Member. The Member Calendar Year Brand Name Drug Deductible is separate from the Member Calendar Year Deductible (Medical Plan Deductible). The Member Calendar Year Brand Name Drug Deductible does not count towards the Member Calendar Year Deductible (Medical Plan Deductible) nor toward the Member Calendar Year Out-of-Pocket Maximum responsibility. 3 The following are not included in the Calendar Year Out-of-of –Pocket Maximum amount: Additional and reduced payments under the Benefits Management Program; Charges in excess of specified benefit maximums; Charges for Services which are not covered and charges by non-Preferred and MHSA Non-Participating Providers in ex- cess of covered amounts; Covered travel expenses for bariatric surgery Services; Family Planning injectable contraceptives administered by a Physician; Inpatient Hospital Facility Services for Mental Illness when Services are received from MHSA Non-Participating Provid- ers; Internet Based Consultations; Non-Emergency Services from a Non-Participating Hospital; Outpatient Mental Health Care from MHSA Participating Providers for Severe Mental Illnesses or Serious Emotional Disturbances of a Child, including the initial visit to determine the condition and diagnosis of the Member; Non-Preferred Hospital-based Inpatient Medically Necessary skilled nursing Services including Subacute Care; Outpatient Surgery from a Non-Participating Ambulatory Surgery Center; and Outpatient routine newborn circumcision in a Preferred Providers’ office; Physician office visit Copayment; Services as described in the Preventive Care Benefits section; Services provided under the Outpatient Prescription Drug benefit; The Calendar Year Medical Plan Deductible; The Calendar Year Brand Name Drug Deductible. Deductible Note: Copayments and charges for Services not accruing to the Calendar Year Out-of-Pocket Maximum Responsibility con- tinue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached. 4 Unless otherwise specified, Copayments/Coinsurance are calculated based on the Allowable Amount. 5 Other Providers are not Preferred Providers and so for Services by Other Providers you are responsible for all charges above the Allowable Amount. Other Providers include acupuncturists, nursing homes and certain labs (for a complete list of Other Providers see the Definitions section)