Common use of Important Information Clause in Contracts

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special circumstances: • emergency room services; • urgent care services; • ground ambulance services; • air ambulance services; • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed by a non-network provider at a network facility as described in Section 6; • otherwise, as required by law. In these special circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstances, please see How Non-Network Providers are Paid in Section 6. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members. $7,500 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 Not Applicable

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special circumstances: • emergency room services; • urgent care services; • ground ambulance services; • air ambulance services; • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed by a non-network provider at a network facility as described in Section 6; • otherwise, as required by law. In these special circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstances, please see How Non-Network Providers are Paid in Section 6. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members. $7,500 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 Not Applicable.

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special limited circumstances: • emergency care (emergency room services; • urgent care services; • ground services and ambulance services; • air ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed are rendered by a non-non- network provider at a network facility outside of your control as described in Section 65; • otherwise, as required by law. In these special limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstancesThe reimbursement is based on the lesser of our allowance, please see How Nonthe non-Network Providers are Paid in Section 6network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members. $7,500 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 Not Applicable.

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special circumstances: • emergency room services; • urgent care services; • ground ambulance services; • air ambulance services; • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed by a non-network provider at a network facility as described in Section 6; • otherwise, as required by law. In these special circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstances, please see How Non-Network Providers are Paid in Section 6. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 7,000 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members. $7,500 14,000 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 Not Applicable

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special limited circumstances: • emergency care (emergency room services; • urgent care services; • ground services and ambulance services; • air ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed are rendered by a non-non- network provider at a network facility outside of your control as described in Section 65; • otherwise, as required by law. In these special limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstancesThe reimbursement is based on the lesser of our allowance, please see How Nonthe non-Network Providers are Paid in Section 6network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 3,400 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members. $7,500 6,800 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 6,350 Not Applicable

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special circumstances: • emergency room services (including ancillary and post- stabilization services, as described in Section 3 and further described in Section 6); • urgent care services; • ground ambulance services; • air ambulance services; • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • certain non-emergency covered healthcare services performed by a non-network provider at a network facility as described in Section 6; • otherwise, as required by law. In these special circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. For detailed information about these special circumstances, please see How Non-Network Providers are Paid in Section 6. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwise specifically stated. You may be responsible up to the provider’s charge. For additional information on how we pay non-network providers please see Section 6. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible/Maximum Out-of-Pocket Expense Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $3,750 1,500 Not Applicable Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however, no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $7,500 3,000 Not Applicable Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit applies to both the network and limited non-network services combined. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copaymentsdrug) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $7,000 4,500 Not Applicable