Common use of SUMMARY OF MEDICAL BENEFITS Clause in Contracts

SUMMARY OF MEDICAL BENEFITS. This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see:  Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy;  Covered Health Care Services - Section 3;  Health Care Services Not Covered Under This Agreement – Section 4;  Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see Preauthorization in Section 1 and Section 8 for more information.

SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see:  Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy;  Covered Health Care Services - Section 3;  Health Care Services Not Covered Under This Agreement – Section 4;  Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see Preauthorization in Section 1 and Section 8 for more information.

SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see:  • Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy;  • Covered Health Care Services - Section 3;  • Health Care Services Not Covered Under This Agreement – Section 4;  • Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see Preauthorization in Section 1 and Section 8 for more information.