Common use of SUMMARY OF MEDICAL BENEFITS Clause in Contracts

SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.

SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this serviceservice or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.

SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and Permitted Self-referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* - Up to the benefit limit of $50 3,000 per occurrence. 10% - After deductible The level of coverage is the same as network provider.

SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Ambulance Services Ground $50 0% - After deductible The level of coverage is the same as network provider. Air/water* $50 0% - After deductible The level of coverage is the same as network provider.