Common use of Member Cost Share Clause in Contracts

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) as your cost share amount (e.g., Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits may vary depending on whether you received services from an In-Network or Out-of-network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s for your cost share responsibilities and limitations, or call Customer Service to learn how this plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Non-Covered services. You will be responsible for the total amount billed by your Provider for Non-Covered services, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered services. Benefits may be exhausted by exceeding, for example, day/visit limits. In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility and receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the In-Network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) and the Out-of- Network Provider’s charge.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Non-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits For example, benefits may be exhausted by exceeding, for example, day/exceeding calendar year visit or day limits. In some instances instances, you may only be asked to pay the lower Inin-Network network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of-network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a bill from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an In-Network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The In-Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could bill you the difference between $2,500 and $1500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copaymentcopayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service at (000) 000-0000 to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Nonnon-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-of- Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances instances, you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of- network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a xxxx from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an in-network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could xxxx you the difference between $2,500 and $1,500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450.

Member Cost Share. For certain Covered Services and depending on your Your plan design, you You may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your Your cost share amount (e.g., Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you You received services from an In-In- Network or Out-of-network Network Provider. Specifically, you You may be required to pay higher cost sharing amounts or may have limits on your Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your Your cost share responsibilities and limitations, limitations or call Customer Service to learn how this Your plan’s benefits or cost share amounts may vary by the type of Provider you You use. Alliant will not provide any reimbursement for Non-Covered servicesServices. You will be responsible for the total amount billed by your Your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of your Your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits For example, benefits may be exhausted by exceeding, for example, day/exceeding calendar year visit or day limits. In some instances you instances, You may only be asked to pay the lower In-Network cost sharing amount when you You use an Out-of-Network Provider. For example, if you You go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist anesthesiologist, or pathologist who is employed by or contracted with an In-Network Hospital or facilityorfacility, you You will pay the Inin-Network network cost share amounts for those Covered Services. However, you You also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out-of-Network after the In- or Out-of-Network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from Us is 80% of $950, or $760. You may receive a bill from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, Your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an In-Network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; Your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The In-Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; Your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could bill You the difference between $2,500 and $1,500, so Your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service at (000) 000-0000 to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Non-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-of- Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances instances, you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of- network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a xxxx from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an in-network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could xxxx you the difference between $2,500 and $1,500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450. Authorized Services In some circumstances, such as where there is no In-Network Provider available for the Covered Service, we may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstance, you must contact us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if you receive Emergency Services from an Out-of-Network Provider and are not able to contact us until after the Covered Service is rendered. If we authorize a Covered Service so that you are responsible for the in-network cost share amounts, you may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (000) 000-0000 for Authorized Services information or to request authorization.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copaymentcopayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service customer service at (000) 000-0000 to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Nonnon-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-of- Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances instances, you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of- network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a bill from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an in-network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could bill you the difference between $2,500 and $1,500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450. Authorized Services In some circumstances, such as where there is no In-Network Provider available for the Covered Service, we may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstance, you must contact us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if you receive Emergency Services from an Out-of-Network Provider and are not able to contact us until after the Covered Service is rendered. If we authorize a Covered Service so that you are responsible for the in-network cost share amounts, you may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (000) 000-0000 for Authorized Services information or to request authorization.

Member Cost Share. For certain Covered Services and depending on your Your plan design, you You may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your Your cost share amount (e.g., Deductible, Copaymentcopayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you You received services from an In-In- Network or Out-of-network Network Provider. Specifically, you You may be required to pay higher cost sharing amounts or may have limits on your Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your Your cost share responsibilities and limitations, limitations or call Customer Service at (000) 000-0000 to learn how this Your plan’s benefits or cost share amounts may vary by the type of Provider you You use. Alliant will not provide any reimbursement for Nonnon-Covered servicesServices. You will be responsible for the total amount billed by your Your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-of- Network Provider. Both services specifically excluded by the terms of your Your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances you instances, You may only be asked to pay the lower In-Network cost sharing amount when you You use an Out-of-Network Provider. For example, if you You go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you You will pay the Inin-Network network cost share amounts for those Covered Services. However, you You also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of- network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from Us is 80% of $950, or $760. You may receive a xxxx from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, Your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an in-network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; Your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; Your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could xxxx You the difference between $2,500 and $1,500, so Your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Non-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits For example, benefits may be exhausted by exceeding, for example, day/exceeding calendar year visit or day limits. In some instances instances, you may only be asked to pay the lower Inin-Network network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of-network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a bill from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an In-Network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The In-Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could bill you the difference between $2,500 and $1500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450. Authorized Services In some circumstances, such as where there is no In-Network Provider available for the Covered Service, we may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstance, you must contact us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if you receive Emergency Services from an Out-of-Network Provider and are not able to contact us until after the Covered Service is rendered. If we authorize a Covered Service so that you are responsible for the in-network cost share amounts, you may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact customer service at (000) 000-0000 for authorized services information or to request authorization.

Member Cost Share. For certain Covered Services and depending on your plan design, you may be required to pay a part of the Maximum Allowed Cost (MAC) MAC as your cost share amount (e.g., Deductible, Copaymentcopayment, and/or Coinsurance). Your cost share amount and Out-of-Pocket Limits Maximum may vary depending on whether you received services from an In-In- Network or Out-of-network Network Provider. Specifically, you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage’s Coverage for your cost share responsibilities and limitations, limitations or call Customer Service customer service at (000) 000-0000 to learn how this your plan’s benefits or cost share amounts may vary by the type of Provider you use. Alliant will not provide any reimbursement for Nonnon-Covered servicesServices. You will be responsible for the total amount billed by your Provider for Non-Covered servicesServices, regardless of whether such services are performed by an In-Network or Out-of-of- Network Provider. Both services specifically excluded by the terms of your policy/plan and those received after benefits have been exhausted are Non-covered servicesCovered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances instances, you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility facility and receive Covered Services from an Out-of-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, you will pay the Inin-Network network cost share amounts for those Covered Services. However, you also may be liable for the difference between the Maximum Allowed Cost (MAC) MAC and the Out-of- of-Network Provider’s charge. Example: Your plan has a Coinsurance cost share of 20% for In-Network services, and 30% Out- of-Network after the in- or out-of- network Deductible has been met. You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-Network Provider to perform the anesthesiology services for the surgery. You have no control over the anesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The MAC for the anesthesiology service is $950; Your Coinsurance responsibility is 20% of $950, or $190 and the remaining allowance from us is 80% of $950, or $760. You may receive a xxxx from the anesthesiologist for the difference between $1,200 and $950 or $250. Provided the Deductible has been met, your total out of pocket responsibility would be $190 (20% Coinsurance responsibility) plus an additional $250, for a total of $440. • You choose an in-network surgeon. The charge was $2,500. The MAC for the surgery is $1,500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of $1,500, or $300. We allow 80% of $1,500, or $1,200. The Network surgeon accepts the total of $1,500 as reimbursement for the surgery regardless of the charges. Your total out of pocket responsibility would be $300. • You choose an Out-of-Network Provider for surgery. The Out-of-Network Provider’s charge for the service is $2,500. The MAC for the surgery service is $1,500; your Coinsurance responsibility for the Out-of-Network Provider is 30% of $1,500, or $450 after the Out-of-Network Deductible has been met. We allow the remaining 70% of $1,500, or $1,050. In addition, the Out-of-Network Provider could xxxx you the difference between $2,500 and $1,500, so your total out of pocket charge would be $450 plus an additional $1,000, for a total of $1,450. Authorized Services In some circumstances, such as where there is no In-Network Provider available for the Covered Service, we may authorize the in-network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstance, you must contact us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if you receive Emergency Services from an Out-of-Network Provider and are not able to contact us until after the Covered Service is rendered. If we authorize a Covered Service so that you are responsible for the in-network cost share amounts, you may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Customer Service at (000) 000-0000 for Authorized Services information or to request authorization.