Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. You will pay a lower percentage (Coinsurance) of Covered charges when you visit our In- network Practitioners/Providers. When you receive services from Out-of-network Practitioners/Providers, the Coinsurance you pay is higher and the Coinsurance will be applied to the Usual, Customary and Reasonable or billed charges, whichever is less, that we allow or the particular procedure. The Out-of-network Practitioner/Provider may bill you for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply to the In- network Coinsurance limits and do not apply to the Out-of-network Coinsurance limits shown in the Summary of Benefits and Coverage. Covered charges or Out-of-network Practitioner and Provider services only apply to the Out- of-network Coinsurance limits and do not apply to the In-network Coinsurance limits shown in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary Practitioners/Providers. by type of service and by In-network and Out-of-network Annual Out-of-pocket Maximum This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain  Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of- Important Information Covered Services. After you have met your Annual Out-of-pocket Maximum in a Contract Year, we pay 100% of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits and

Benefits and Coverage. You will pay a lower percentage (Coinsurance) of Covered charges when you visit our In- network Practitioners/Providers. When you receive services from Out-of-network Practitioners/Providers, the Coinsurance you pay is higher and the Coinsurance will be applied to the Usual, Customary and Reasonable Medicare Allowable or billed charges, whichever is less, that we allow or the particular procedure. The Out-of-network Practitioner/Provider may bill you for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply to the In- In-network Coinsurance limits and do not apply to the Out-of-network Coinsurance limits shown in the Summary of Benefits and Coverage. Covered charges or for Out-of-network Practitioner and Provider services only apply to the Out- ofOut-of- network Coinsurance limits and do not apply to the In-network Coinsurance limits shown in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary Practitioners/Providers. by type of service and by In-network and Out-of-network Practitioners/Providers. Annual Out-of-pocket Maximum This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of-pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain  Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of- Important Information Covered Services. After you have met your Annual Out-Out- of-pocket Maximum in a Contract Year, we pay 100% of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits andand Coverage for the Plan Annual Out-of- pocket Maximum. For single coverage, the Out-of-pocket Maximum requirement is fulfilled when one Member meets the Individual Out-of-pocket Maximum listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family Out-of- pocket Maximum must be met before benefits will be paid at 100%. However, if one (family) Member reaches the Individual Out-of-pocket maximum amount before the Family has met the Family Out-of-pocket maximum benefits will be paid at 100% for that Member who has met the Individual Out-of-pocket maximum. The Family and Individual Out-of-pocket maximums amounts are listed in the Summary of Benefits and Coverage. You will pay less out of your pocket (Cost Sharing) to meet your Annual Out-of-pocket Maximum when you visit an In-network Practitioner/Provider. Covered charges for In-network Practitioner and Provider services only apply to the In-network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum shown on the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioner and Provider services only apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the In-network Limits shown on the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Plan Annual Out-of-pocket Maximum. To inquire about the status of your specific Annual Out-of-pocket Maximum, you may call our Presbyterian Customer Service Center 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 line at 711. Office Visit Copayment If your Plan has an Office Visit Copayment, this is the amount of Cost Sharing you must pay each time you have an office visit with an In-network Practitioner/Provider. This Copayment is for the office visit only. All other services provided during the visit are subject to other Cost Sharing (Deductible and Coinsurance). Refer to your Summary of Benefits and Coverage for all Cost Sharing Copayment, Deductible and Coinsurance amounts. Utilization Management and Quality We may review medical records, claims, and requests for Covered Services to establish that the services are/were Medically Necessary, delivered in the appropriate setting, consistent with the condition reported and with generally accepted standards of medical and surgical practice in the area where performed and according to the findings and opinions of our professional medical consultants. Utilization management decisions are based only on appropriateness of care and service. We do not reward Practitioners or other Health Care Professionals conducting Utilization Review for denying coverage or services and we do not offer incentives to encourage underutilization.

Benefits and Coverage. 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 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 In-Network and 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 lower percentage portion of the MAC to the extent You have not met Your Deductible or 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 single procedure code that includes all 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 another health care 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 incidentalor inclusive. PROVIDER NETWORK STATUS The allowed amount 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 all or a portion of the allowed amount to the extent You have not met Your Deductible or have a Copayment or Coinsurance. Please call Customer Service at (Coinsurance000) 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 Covered charges when you visit our In- network Practitioners/Our networks are Out-of-Network Providers. When you For Covered Services You choose to receive services from Out-of-network Practitioners/ProvidersNetwork Providers (other than emergency services), the Coinsurance you pay is higher and the Coinsurance MAC for this plan will be applied 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 time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the 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 Usualtotal charges billed by the Provider, Customary and Reasonable or billed charges, whichever is less, that we allow or but only if such charges are less than the particular procedureMAC calculated by using one of the methods described above. The MAC for Out-of-network Practitioner/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 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 You for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible coinsurance, copayment, or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply deductible You may owe according to the In- network Coinsurance limits terms of Your policy. In the event You receive a surprise bill for nonemergency medical services from an Out-of-Network provider, and do not apply to You did NOT actively choose the Out-of-network Coinsurance limits shown in Network provider prior to receiving services, We calculate the Summary of Benefits and CoverageMAC as described above. Covered charges or Alliant reserves the right to request documentation from the Out-of-network Practitioner and Provider Network provider to confirm whether You received services only apply to the Out- of-network Coinsurance limits and do not apply to the through no choice of Your own. Choosing an In-network Coinsurance limits shown Network Provider will likely result in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary Practitioners/Providers. by type of service and by In-network and Out-of-network Annual Outlower out-of-pocket Maximum This Plan includes costs to You. Please call Customer Service at (000)000-0000 for help in finding an Annual OutIn-of-pocket Maximum amount to help protect you and your pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain  Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of- Important Information Covered Services. After you have met your Annual Out-of-pocket Maximum in a Contract Year, we pay 100% of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits andNetwork Provider or visit Our website at XxxxxxxXxxxx.xxx.

Benefits and Coverage. You will pay a lower percentage (Coinsurance) of Covered charges when you visit our In- network Practitioners/Providers. When you receive services from Out-of-network Practitioners/Providers, the Coinsurance you pay is higher and the Coinsurance will be applied to the Usual, Customary and Reasonable Medicare Allowable or billed charges, whichever is less, that we allow or the particular procedure. The Out-of-network Practitioner/Provider may bill xxxx you for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply to the In- In-network Coinsurance limits and do not apply to the Out-of-network Coinsurance limits shown in the Summary of Benefits and Coverage. Covered charges or for Out-of-network Practitioner and Provider services only apply to the Out- ofOut-of- network Coinsurance limits and do not apply to the In-network Coinsurance limits shown in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary Practitioners/Providers. by type of service and by In-network and Out-of-network Practitioners/Providers. Annual Out-of-pocket Maximum This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of-pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain  Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of- Important Information Covered Services. After you have met your Annual Out-Out- of-pocket Maximum in a Contract Year, we pay 100% of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits andand Coverage for the Plan Annual Out-of- pocket Maximum. For single coverage, the Out-of-pocket Maximum requirement is fulfilled when one Member meets the Individual Out-of-pocket Maximum listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family Out-of- pocket Maximum must be met before benefits will be paid at 100%. However, if one (family) Member reaches the Individual Out-of-pocket maximum amount before the Family has met the Family Out-of-pocket maximum benefits will be paid at 100% for that Member who has met the Individual Out-of-pocket maximum. The Family and Individual Out-of-pocket maximums amounts are listed in the Summary of Benefits and Coverage. You will pay less out of your pocket (Cost Sharing) to meet your Annual Out-of-pocket Maximum when you visit an In-network Practitioner/Provider. Covered charges for In-network Practitioner and Provider services only apply to the In-network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum shown on the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioner and Provider services only apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the In-network Limits shown on the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Plan Annual Out-of-pocket Maximum. To inquire about the status of your specific Annual Out-of-pocket Maximum, you may call our Presbyterian Customer Service Center, 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 line at 711. Office Visit Copayment If your Plan has an Office Visit Copayment, this is the amount of Cost Sharing you must pay each time you have an office visit with an In-network Practitioner/Provider. This Copayment is for the office visit only. All other services provided during the visit are subject to other Cost Sharing (Deductible and Coinsurance). Refer to your Summary of Benefits and Coverage for all Cost Sharing Copayment, Deductible and Coinsurance amounts. Utilization Management and Quality We may review medical records, claims, and requests for Covered Services to establish that the services are/were Medically Necessary, delivered in the appropriate setting, consistent with the condition reported and with generally accepted standards of medical and surgical practice in the area where performed and according to the findings and opinions of our professional medical consultants. Utilization management decisions are based only on appropriateness of care and service. We do not reward Practitioners or other Health Care Professionals conducting Utilization Review for denying coverage or services and we do not offer incentives to encourage underutilization.

Benefits and Coverage. You will pay a lower percentage (Coinsurance) of Covered charges when you visit our In- network Practitioners/Providers. When you receive services from Out-of-network Practitioners/Providers, the Coinsurance you pay is higher and the Coinsurance will be applied to the Usual, Customary and Reasonable Medicare Allowable or billed charges, whichever is less, that we allow or the particular procedure. The Out-of-network Practitioner/Provider may bill xxxx you for any amounts over the billed charges we allow and this amount does not apply to your Annual Contract Year Deductible or your Coinsurance. Covered charges for In-network Practitioner and Provider services only apply to the In- In-network Coinsurance limits and do not apply to the Out-of-network Coinsurance limits shown in the Summary of Benefits and Coverage. Covered charges or for Out-of-network Practitioner and Provider services only apply to the Out- ofOut-of- network Coinsurance limits and do not apply to the In-network Coinsurance limits shown in the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Coinsurance Amounts. Coinsurance Amounts vary Practitioners/Providers. by type of service and by In-network and Out-of-network Practitioners/Providers. Annual Out-of-pocket Maximum This Plan includes an Annual Out-of-pocket Maximum amount to help protect you and your Covered Dependents from high-cost catastrophic healthcare expenses. The Annual Out-of-pocket Maximum is the most you will pay in Cost Sharing in a Contract Year for certain  Covered Dependents from high-cost catastrophic health care expenses. The Annual Out-of- Important Information Covered Services. After you have met your Annual Out-Out- of-pocket Maximum in a Contract Year, we pay 100 percent (100% %) of the cost for Covered Services, for the remainder of that Contract Year, up to the maximum benefit amount, if any. Refer to your Summary of Benefits andand Coverage for the Plan Annual Out-of-pocket Maximum. For single coverage, the Out-of-pocket Maximum requirement is fulfilled when one Member meets the Individual Out-of-pocket Maximum listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family Out-of- pocket Maximum must be met before benefits will be paid at 100 percent (100%). However, if one (family) Member reaches the Individual Out-of-pocket maximum amount before the Family has met the Family Out-of-pocket maximum benefits will be paid at 100 percent (100%) for that Member who has met the Individual Out-of-pocket maximum. The Family and Individual Out- of-pocket maximums amounts are listed in the Summary of Benefits and Coverage.‌ You will pay less out of your pocket (Cost Sharing) to meet your Annual Out-of-pocket Maximum when you visit an In-network Practitioner/Provider. Covered charges for In-network Practitioner and Provider services only apply to the In-network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum shown on the Summary of Benefits and Coverage. Covered charges for Out-of-network Practitioner and Provider services only apply to the Out-of- network Coinsurance and Annual Out-of-pocket Maximum limits and do not apply to the In-network Limits shown on the Summary of Benefits and Coverage. Refer to your Summary of Benefits and Coverage for the Plan Annual Out-of-pocket Maximum. To inquire about the status of your specific Annual Out-of-pocket Maximum, you may call our Presbyterian Customer Service Center, 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 TTY 711. Office Visit Copayment If your Plan has an Office Visit Copayment, this is the amount of Cost Sharing you must pay each time you have an office visit with an In-network Practitioner/Provider. This Copayment is for the office visit only. All other services provided during the visit are subject to other Cost Sharing (Deductible and Coinsurance). Refer to your Summary of Benefits and Coverage for all Cost Sharing Copayment, Deductible and Coinsurance amounts. Specialist Care As our Member, you must carefully follow all procedures and conditions for obtaining care from In-network specialists and/or Out-of-network Practitioners/Providers. We no longer require a paper referral from your Primary Care Provider (PCP) for your visits to specialists. However, it is important to your healthcare that your PCP is included in the decisions about the specialists that you visit. Your PCP continues to be your partner for good health and is the best person to help you determine your needs for specialty care. Effective communication about your medical history and treatment between your PCP and the specialists that provide care for you is very important so that the best decisions can be made about your medical care. We recommend that you contact your PCP’s office regarding your desire to visit a specialist. Please note that some specialists may require written referral even though we do not. Certain procedures require Prior Authorization. Your In-network Practitioner/Provider must obtain this Prior Authorization before providing these services to you. Please refer to the Prior Authorization Section of this Agreement.‌‌ Obtaining Care after Normal Provider Office Hours Most Providers offer an after-hours answering service. For non-emergency situations, you should phone your PCP. If needed, you can find your PCP’s phone number in the Provider Directory. If Emergency Healthcare Services are needed, you should call 911, or seek treatment at an emergency room. If in need of Urgent Care, you may seek treatment at an Urgent Care Center that is available and open for business. Please note that some Urgent Care Centers are not open after 8 p.m. In such circumstances, it may be necessary to use an emergency room for care that is needed on an urgent basis. Please refer to the Benefits Section, Accidental Injury / Urgent Care / Emergency Health Services / Observation /Trauma Services Benefits Section of this Agreement for a detailed description of Coverage for Urgent and Emergency Healthcare Services. Utilization Management and Quality We may review medical records, claims, and requests for Covered Services to establish that the services are/were Medically Necessary, delivered in the appropriate setting, consistent with the condition reported and with generally accepted standards of medical and surgical practice in the area where performed and according to the findings and opinions of our professional medical consultants. Utilization management decisions are based only on appropriateness of care and service. We do not reward Practitioners or other Healthcare Professionals conducting Utilization Review for denying coverage or services and we do not offer incentives to encourage underutilization. Members may seek a second opinion when questions arise as to the medical appropriateness of a diagnosis or the appropriateness of medical and/or surgical services. Members may seek the second opinion from any provider in or out-of-network. Typical cost-sharing will apply. Technology Assessment Committee We have a process to continuously evaluate evolving medical technologies, which include medical procedures, drugs and devices. In-network Practitioners from our PPO Network and the community along with other clinical staff are responsible for this process and are known as the Technology Assessment Committee. The Technology Assessment Committee evaluates new technologies and/or new applications of existing technologies, determines the value of the new technology, and recommends whether the technology should be a specified Covered Benefit of your Plan. Factors to be considered include safety, comparison to existing drugs, procedures and technology, cost and effectiveness of the new technology, and clinical skills and training of those proposing to provide the new technology.‌ Transition of Care If we terminate or suspend any contract with an In-network Practitioner/Provider from which you are currently receiving care, we will notify you, in writing, within 30 days. We will assist you in locating and transferring to another similarly qualified In-network Practitioner/Provider, if available, for continued In-network benefits. You may elect to continue to receive care from this Out-of-network Practitioner/Provider; however, we will only reimburse for such services in accordance with applicable Out-of-network benefit level, if any, and then subject to Medicare Allowable Charges except when you wish to continue an ongoing course of treatment with the provider for a transitional period. This period shall continue for a time that is sufficient to permit coordinated transition planning consistent with your condition and needs relating to the continuity of the case and will not be less than 30 days. If you are in your third trimester of pregnancy at the time of the provider’s disaffiliation, your transitional period will last through the delivery and will allow for post-partum care. These transitional periods with your provider will not be allowed if the provider’s disaffiliation was for reasons related to medical competence or professional behavior. For transitional periods exceeding 30 days, continued care will be provided only if the provider agrees to accept reimbursement from Presbyterian at the rates applicable prior to the start of the transitional period as payment in full. Additionally, the provider must also agree to adhere to Presbyterian’s quality assurance requirements, to provide necessary medical information related to such care, and to follow Presbyterian’s policies and procedures, including but not limited to procedures regarding referrals, pre-authorization and treatment planning approved by Presbyterian. Advance Directives An advance directive is a legal document about your healthcare decisions. It is only used when you are unable to make your wishes known and includes information about the person you want to make healthcare decisions on your behalf as well as medical services you do and do not want. These are documents you complete in advance and can share with your provider or person who will speak on your behalf. Sharing your advance directives with your healthcare team helps make your wishes clear. Prior Authorization‌‌