Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that yo r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of the PHP Service Area Important  Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received outside of New Mexico, you may seek services from the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Pr

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx bill you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that yo r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  ⮚ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ⮚ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ⮚ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ⮚ Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  ⮚ Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of the PHP Service Area Important  🖐 Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received outside of New Mexico, you may seek services from the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Pr

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that yo r your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstancescircumstances:  ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ➢ Continuity –– If the requested Out-of-network Practitioner/Provider has a well- well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of the PHP Service Area Important  Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received outside of New Mexico, you may seek services from the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Pr.

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbersnum ers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Refer to Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that yo r your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstancescircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –– If the requested Out-of-network Practitioner/Provider has a well- well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of the PHP Service Area Important  Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received outside of New Mexico, you may seek services from the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Pr

Benefits and Coverage. The In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our amounts you pay will apply toward the In-network Annual Out-of- pocket Maximum after which In-network claims will be paid at 100%. These Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visitsare not responsible for obtaining Prior Authorization (if required). You must obtain Prior Authorization (if required) for services provided by a National PPO Provider and follow all other rules regarding Out-of-network Practitioners/Providers. For additional information regarding National PPO Providers or to see if you need a Prior Authorization for Out-of-network Practitioners/Providers are health care Practitioners/ProvidersServices, including non- medical facilities, who have not entered into an agreement with us please call our Presbyterian Customer Service Center prior to provide obtaining services Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call the TTY 711. Cost-sharing – Your Out-of-pocket Costs Many Health Care Services to PHP Members. Covered Health Care Services obtained you receive from an In-network and Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services Practitioners and Providers require some payment from you. We refer to these payments as Cost Sharing. These are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an your Out-of-network Practitioner/Providerpocket costs and may be Deductibles, except Emergency services, require that yo r Primary Care Physician request Coinsurance and/or Copayment amounts. Cost-Sharing and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible benefits for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed emergency health care service rendered by a specialist similar non-participating provider shall be the same as if rendered by a participating provider. Cost-Sharing and benefit limitations for medically necessary, non-emergent health care services rendered by a non- participating provider at a participating facility where the covered person had no ability or opportunity to choose to receive the type of specialist to whom the Prior Authorization service from a participating provider or where no participating provider is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatmentshall be the same as if the service was rendered by a participating provider.  Geography – Annual Contract Year Deductible Certain services are subject to an Annual Contract Year Deductible. The Annual Contract Year Deductible is the amount you and your Covered Dependents must pay for Covered Health Care Services each Contract Year before we begin to pay Covered Benefits for that Member. The Annual Contract Year Deductible may not apply to all Health Care Services. You will pay a lower Annual Contract Year Deductible amount when you visit In-network PractitionerPractitioners/Provider is not located within a reasonable distance from Providers. Refer to your residenceSummary of Benefits and Coverage for the amount of your Annual Contract Year Deductible. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-ofCovered charges for In-network Practitioner/Practitioner and Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed services only apply to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-ofthe In-network Practitioner/Provider will Annual Contract Year Deductible limits and do not be Covered unless this Prior Authorization is obtained prior apply to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/ProviderAnnual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioners/Providers may require you Practitioner and Provider services only apply to pay them the Out-of- network Annual Contract Year Deductible limits and do not apply to the In-network Annual Contract Year Deductible limits shown in full at the time Summary of serviceBenefits and Coverage. You may have to pay them For Single coverage, the annual Contract Year Deductible requirement is fulfilled when one Member meets the individual Deductible listed in the Summary of Benefits and then file your claim for reimbursement Coverage. For double or family coverage, with us. We will only pay this claim if two or more enrolled Members, the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of entire Family the PHP Service Area Important  Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico annual Contract Year Deductible must be met before benefits will be Coveredpaid for the family. For Emergency Health Care Services and/or Urgent Care However, if one (family) Member reaches the Individual Deductible amount before the Family has met the annual Contract Year Family Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The annual Contract Year Family and Individual Deductible amounts are listed in the Summary of Benefits and Coverage. Coinsurance Certain services received outside are subject to a Coinsurance amount. Coinsurance is the percentage of New Mexico, Covered charges that you may seek services from and your Covered Dependents must pay directly to the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care for Covered Services outside after the Annual Contract Year Deductible has been met. After you pay your Coinsurance amount, we will pay our percentage of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Prcharges.

Benefits and Coverage. The In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our amounts you pay will apply toward the In-network Annual Out-of- pocket Maximum after which In-network claims will be paid at 100%. These Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visitsare not responsible for obtaining Prior Authorization (if required). You must obtain Prior Authorization (if required) for services provided by a National PPO Provider and follow all other rules regarding Out-of-network Practitioners/Providers. For additional information regarding National PPO Providers or to see if you need a Prior Authorization for Out-of-network Practitioners/Providers are health care Practitioners/ProvidersServices, including non- medical facilities, who have not entered into an agreement with us please call our Presbyterian Customer Service Center prior to provide obtaining services Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call the TTY 711. Cost-sharing – Your Out-of-pocket Costs Many Health Care Services to PHP Members. Covered Health Care Services obtained you receive from an In-network and Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services Practitioners and Providers require some payment from you. We refer to these payments as Cost Sharing. These are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an your Out-of-network Practitioner/Providerpocket costs and may be Deductibles, except Emergency services, require that yo r Primary Care Physician request Coinsurance and/or Copayment amounts. Cost Sharing and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible benefits for Refer to payment. Please refer to the Authorization requirements. Prior Authorization Section for more information on Prior If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed emergency health care service rendered by a specialist similar non-participating provider shall be the same as if rendered by a participating provider. Cost Sharing and benefit limitations for medically necessary, non-emergent health care services rendered by a non- participating provider at a participating facility where the covered person had no ability or opportunity to choose to receive the type of specialist to whom the Prior Authorization service from a participating provider or where no participating provider is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatmentshall be the same as if the service was rendered by a participating provider.  Geography – Annual Contract Year Deductible Certain services are subject to an Annual Contract Year Deductible. The Annual Contract Year Deductible is the amount you and your Covered Dependents must pay for Covered Health Care Services each Contract Year before we begin to pay Covered Benefits for that Member. The Annual Contract Year Deductible may not apply to all Health Care Services. You will pay a lower Annual Contract Year Deductible amount when you visit In-network PractitionerPractitioners/Provider is not located within a reasonable distance from Providers. Refer to your residenceSummary of Benefits and Coverage for the amount of your Annual Contract Year Deductible. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-ofCovered charges for In-network Practitioner/Practitioner and Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed services only apply to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-ofthe In-network Practitioner/Provider will Annual Contract Year Deductible limits and do not be Covered unless this Prior Authorization is obtained prior apply to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/ProviderAnnual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioners/Providers may require you Practitioner and Provider services only apply to pay them the Out-of- network Annual Contract Year Deductible limits and do not apply to the In-network Annual Contract Year Deductible limits shown in full at the time Summary of serviceBenefits and Coverage. You may have to pay them For Single coverage, the annual Contract Year Deductible requirement is fulfilled when one Member meets the individual Deductible listed in the Summary of Benefits and then file your claim for reimbursement Coverage. For double or family coverage, with us. We will only pay this claim if two or more enrolled Members, the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation. Restrictions on Services Received Outside of entire Family the PHP Service Area Important  Informati n Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico annual Contract Year Deductible must be met before benefits will be Coveredpaid for the family. For Emergency Health Care Services and/or Urgent Care However, if one (family) Member reaches the Individual Deductible amount before the Family has met the annual Contract Year Family Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The annual Contract Year Family and Individual Deductible amounts are listed in the Summary of Benefits and Coverage. Coinsurance Certain services received outside are subject to a Coinsurance amount. Coinsurance is the percentage of New Mexico, Covered charges that you may seek services from and your Covered Dependents must pay directly to the nearest appropriate facility where o Emergency Health Care Services / Urgent Care services may be rendered. National Health Care Practitioner/Provider Network When receiving Urgent or Emergency Health Care for Covered Services outside after the Annual Contract Year Deductible has been met. After you pay your Coinsurance amount, we will pay our percentage of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases. Prcharges.