Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Exclusions.‌ Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including BenefitsBenefit , Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when Refer to necessary. The Section being referenced will be bolded. Exclusion Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Auth Required Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- In-network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- of-network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must ake action within a certain timeframe to comply with your Plan. An Timeframe associated with this item  Important Information CSC Call P 505‐923‐6980 1‐800‐923‐6980 ample of a Time Requirement is when you must enroll your newborn within 31 days birth. ex of

Benefits and Coverage. The After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a chart single procedure code that shows some specific Covered Benefits includes all of the procedures that were performed. When this Plan providesoccurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. PROVIDER NETWORK STATUS The allowed amount you may vary depending upon whether the Provider is an In-Network or an Out-of- Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay (Cost Sharing) and all or a portion of the Coverage Limitations and Exclusionsallowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please take call Client Services at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and are not in any of our networks are Out-of- Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our out-of-network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to read this Agreement and Summary of Benefits and Coveragetime, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When after considering one or more of the symbols is usedfollowing: reimbursement amounts accepted by like/similar providers contracted with Alliant, we will use bold print in reimbursement amounts paid by the paragraph Centers for Medicare and Medicaid Services for the same services or section to point out the exact requirement, restrictionsupplies, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related other industry cost, reimbursement and utilization data; or an amount based on information in other sections provided by a third-party vendor, which may reflect one or more of the Agreement following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only ifsuch charges are less than the MACcalculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the non participating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non emergency medical services from an out-of- network provider, and You did NOT actively choose the out-of-network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (000)000-0000 for help in finding an In-Network Provider or visit Our website at XxxxxxxXxxxx.xxx. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum 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 for Your cost share responsibilities and limitations or call Client Services at (000) 000-0000 to learn how 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 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, calendar year day/visit limits. In some instances, You may only be asked to pay the lower In- Network cost sharing amount when necessaryYou use an Out-of-Network Provider. For example, if You go to an In-Network Hospital or 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 MAC and the Out-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 Section being referenced will be boldedHospital has contracted with an Out- of-Network Provider to perform the anesthesiology services for the surgery. Exclusion – This “Exclusion” symbol will appear next to You have no control over the description of certain Covered Benefitsanesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The Exclusion symbol will alert you that there are some services that are excluded 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 Benefits and will not be paidService, 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 should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) must contact Us in advance of those servicesobtaining the Covered Service. To We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Emergency Services from an Out-of- networkof-Network Provider and are not able to contact Us until after the Covered Service is rendered. In If We authorize a Covered Service so that You are responsible for the case of a Hospital in-patient admission following an Emergency Room visitnetwork cost share amounts, you You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (000)000-0000 for Authorized Services information or your physician should call as soon as possibleto request authorization.

Benefits and Coverage. The After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is a chart no annual or lifetime dollar limit for Covered Services that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You should keep this Agreementin understanding the MAC language as described below, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should please refer to the Exclusion Section when you see definition of In-Network Provider contained in the Definitions section of this symbolbooklet. Prior Authorization Required – MAXIMUM ALLOWED COST (MAC) This “Prior Authorization” symbol section describes how We determine the amount of reimbursement for Covered Services. You will appear next be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Benefits Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that require our Authorization (approval) in advance the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional,We may reduce the MAC for those services. To receive full benefits, your In- network Practitioner/Provider must call us secondary and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the case of a Hospital in-patient admission following an Emergency Room visit, you primary procedure that may be considered incidental or your physician should call as soon as possibleinclusive.

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP)Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- networknetwork (outside of the 5-county area). In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must take action within a certain timeframe to comply with your Plan. An example of a Timeframe Requirement is when you must enroll your newborn within 31 days of birth. Important Information – This “Important Information” symbol appears when there are special instructions or important information about your Covered Benefits or your Plan that requires special attention. An example of Important Information would be how Dependent Students may receive Covered Benefits. Call Presbyterian Customer Service Center – This “Call PCSC” symbol appears whenever we refer to our Presbyterian Customer Service Center or to remind you to call us for information. In addition, some important terms used throughout this Agreement and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section.

Benefits and Coverage. The After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is a chart no annual or lifetime dollar limit for Covered Services that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You should keep this Agreementin understanding the MAC language as described below, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should please refer to the Exclusion Section definition of In-Network Provider and Out-of-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when you see this symbolYou receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. Prior Authorization Required – This “Prior Authorization” symbol will appear next amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Benefits Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect our determination of the MAC. Our application of these rules does not mean that require our Authorization (approval) in advance the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those services. To receive full benefits, your In- network Practitioner/Provider must call us secondary and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the case of a Hospital in-patient admission following an Emergency Room visit, you primary procedure that may be considered incidental or your physician should call as soon as possibleinclusive.

Benefits and Coverage. The After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a chart single procedure code that shows some specific Covered Benefits includes all of the procedures that were performed. When this Plan providesoccurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. PROVIDER NETWORK STATUS The allowed amount you may vary depending upon whether the Provider is an In-Network or an Out-of- Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay (Cost Sharing) and all or a portion of the Coverage Limitations and Exclusionsallowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please take call Client Services at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to read this Agreement and Summary of Benefits and Coveragetime, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When after considering one or more of the symbols is usedfollowing: reimbursement amounts accepted by like/similar providers contracted with Alliant, we will use bold print in reimbursement amounts paid by the paragraph Centers for Medicare and Medicaid Services for the same services or section to point out the exact requirement, restrictionsupplies, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related other industry cost, reimbursement and utilization data; or an amount based on information in other sections provided by a third-party vendor, which may reflect one or more of the Agreement following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only ifsuch charges are less than the MACcalculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the non-participating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non emergency medical services from an Out-of- Network Provider, and You did NOT actively choose the Out-of-Network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-Network Provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (000) 000-0000 for help in finding an In-Network Provider or visit Our website at XxxxxxxXxxxx.xxx. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum 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 for Your cost share responsibilities and limitations or call Client Services at (000) 000-0000 to learn how 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 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, calendar year day/visit limits. In some instances, You may only be asked to pay the lower In- Network cost sharing amount when necessaryYou use an Out-of-Network Provider. For example, if You go to an In-Network Hospital or 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 MAC and the Out-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 Section being referenced will be boldedHospital has contracted with an Out- of-Network Provider to perform the anesthesiology services for the surgery. Exclusion – This “Exclusion” symbol will appear next to You have no control over the description of certain Covered Benefitsanesthesiologist used. • The Out-of-Network Provider’s charge for the service is $1,200. The Exclusion symbol will alert you that there are some services that are excluded 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 Benefits and will not be paidService, 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 should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) must contact Us in advance of those servicesobtaining the Covered Service. To We also may authorize the In-Network cost share amounts to apply to a claim for Covered Services if You receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Emergency Services from an Out-of- networkof-Network Provider and are not able to contact Us until after the Covered Service is rendered. In If We authorize a Covered Service so that You are responsible for the case of a Hospital inIn-patient admission following an Emergency Room visitNetwork cost share amounts, you You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (000)000-0000 for Authorized Services information or your physician should call as soon as possibleto request authorization.

Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP)Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded. Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- networknetwork (outside of the 5-county area). In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.

Benefits and Coverage. The After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a chart single procedure code that shows some specific Covered Benefits includes all of the procedures that were performed. When this Plan providesoccurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount you paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (000)000-0000 for help in finding an In-Network Provider or visit Our website at XxxxxxxXxxxx.xxx. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay (Cost Sharing) and all or a portion of the Coverage Limitations and Exclusionsallowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please take time to read this Agreement call Client Services at(866) 403-2785 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Provider (PCP), what limits are placed on certain benefits, and what services are not in any of Our networks are Out-of- Network Providers. MEMBER COST SHARE For certain Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. Services and depending on Your plan design, You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. Understanding This Agreement We use visual symbols throughout this Agreement be required to alert you to important requirements, restrictions and information. When one or more pay a part of the symbols is usedMAC as Your cost share amount (e.g., we will use bold print in Deductible, copayment, and/ or Coinsurance). Please see the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessaryfor Your cost share responsibilities and limitations or call Client Services at (000) 000-0000 to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. The Section being referenced Alliant will not provide any reimbursement for non-Covered Services. You will be boldedresponsible for the total amount billed by Your Provider for Non-Covered Services. Exclusion – This “Exclusion” symbol will appear next to Both services specifically excluded by the description terms of certain Your policy/plan and those received after benefits have been exhausted are Non-Covered BenefitsServices. The Exclusion symbol will alert you that Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there are some services that are excluded from is no In-Network Provider available for the Covered Benefits and will not be paidService, 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 should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) must contact Us in advance of those servicesobtaining the Covered Service. To We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Emergency Services from an Out-of- networkof-Network Provider and are not able to contact Us until after the Covered Service is rendered. In If We authorize a Covered Service so that You are responsible for the case of a Hospital in-patient admission following an Emergency Room visitnetwork cost share amounts, you You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (000)000-0000 for Authorized Services information or your physician should call as soon as possibleto request authorization.