Common use of Care Management Clause in Contracts

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  • Before you receive certain medical services and drugs, or prescription drugs  • Before you schedule a planned admission to certain inpatient facilities  • When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect Your PCP or referred Heritage Signature providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect Heritage Signature network. If there is not a LifeWise Connect Heritage Signature provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect Your PCP or referred Heritage Signature providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect Heritage Signature network. If there is not a LifeWise Connect Heritage Signature provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. There may be additional services that are available to you, such as disease management programs, discharge planning, health education, and patient advocacy. When you seek prior authorization for a Covered Health Care Management Service as required or are otherwise identified as meeting eligibility requirements for a care management program, we will work with you to engage in the care management process and to provide you with information about these additional services. We require prior authorization for certain Covered Health Care Services. Your Primary Care Physician and other Network providers are responsible for obtaining prior authorization before they provide these services work to help ensure you. We recommend that you receive appropriate and cost-effective medical careconfirm with us that all Covered Health Care Services have been prior authorized as required. Your role in the Care Management process is simpleBefore receiving these services from a Network provider, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you may want to call Customer Service us to verify that you meet the Hospital, Physician and other providers are Network providers and that they have obtained the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary Network facilities and eligible for coverage under this plan. We will let Network providers cannot bill you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have they do not prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for youauthorize as required. You should verify with can call us at the telephone number on your provider that a prior authorization request has been approved in writing before you receive servicesID card. Generally this plan does not cover services from providers not Benefits for Covered Health Care Services are described in the LifeWise Connect networktables below. If there is not Annual Deductibles are calculated on a LifeWise Connect provider that can provide the service needed, see Services from calendar year basis. Out-of-Network Providers Pocket Limits are calculated on a calendar year basis. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. The amount you pay for more informationCovered Health Care Services per year before you are eligible to receive Benefits. We will respond The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section, the Pediatric Vision Care Services Section and the Pediatric Dental Care Services Section. Benefits for outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a request visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. $7,850 per Covered Person, not to exceed $15,700 for prior authorization within 5 calendar days all Covered Persons in a family. The maximum you pay per year for the Annual Deductible, Co- payments or Co-insurance. Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of receipt Allowed Amounts during the rest of all information necessary that year. The Out-of-Pocket Limit applies to make a decisionCovered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. If your situation is clinically urgent (meaning that your life or health would be put The Out-of-Pocket Limit applies to Covered Health Care Services under the Policy as indicated in serious jeopardy if you did this Schedule of Benefits including the Pediatric Dental Care Services Section and the Pediatric Vision Care Services Section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not receive treatment right away)include any of the following and, once the Out-of-Pocket Limit has been reached, you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations still will be valid required to pay the following: • Any charges for 30 calendar daysnon-Covered Health Care Services. This 30• Charges that exceed Allowed Amounts, when applicable. $9,450 per Covered Person, not to exceed $18,900 for all Covered Persons in a family. The Out-day period of-Pocket Limit includes the Annual Deductible. Co-payment is subject the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Co-payments apply, the amount is listed on the following pages next to your continued coverage under the plandescription for each Covered Health Care Service. If you do not receive the services within Please note that timefor Covered Health Care Services, you will have to ask us are responsible for another prior authorizationpaying the lesser of: • The applicable Co-payment. Providers that have contracts with us will get SAMPLE • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive servicescertain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

Care Management. SAMPLE There may be additional services that are available to you, such as disease management programs, discharge planning, health education, and patient advocacy. When you seek prior authorization for a Covered Health Care Management Service as required or are otherwise identified as meeting eligibility requirements for a care management program, we will work with you to engage in the care management process and to provide you with information about these additional services. We require prior authorization for certain Covered Health Care Services. Your Primary Care Physician and other Network providers are responsible for obtaining prior authorization before they provide these services work to help ensure you. We recommend that you receive appropriate and cost-effective medical careconfirm with us that all Covered Health Care Services have been prior authorized as required. Your role in the Care Management process is simpleBefore receiving these services from a Network provider, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you may want to call Customer Service us to verify that you meet the Hospital, Physician and other providers are Network providers and that they have obtained the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary Network facilities and eligible for coverage under this plan. We will let Network providers cannot bill you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have they do not prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for youauthorize as required. You should verify with can call us at the telephone number on your provider that a prior authorization request has been approved in writing before you receive servicesID card. Generally this plan does not cover services from providers not Benefits for Covered Health Care Services are described in the LifeWise Connect networktables below. If there is not Annual Deductibles are calculated on a LifeWise Connect provider that can provide the service needed, see Services from calendar year basis. Out-of-Network Providers Pocket Limits are calculated on a calendar year basis. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. The amount you pay for more informationCovered Health Care Services per year before you are eligible to receive Benefits. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services section and the Pediatric Dental Care Services section. Benefits for outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Coupons: We will respond may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible. Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a request visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. $3,250 per Covered Person, not to exceed $6,500 for prior authorization within 5 calendar days all Covered Persons in a family. The maximum you pay per year for the Annual Deductible, Co- payments or Co-insurance. Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of receipt Allowed Amounts during the rest of all information necessary that year. The Out-of-Pocket Limit applies to make a decisionCovered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. If your situation is clinically urgent (meaning that your life or health would be put The Out-of-Pocket Limit applies to Covered Health Care Services under the Policy as indicated in serious jeopardy if you did this Schedule of Benefits including the Pediatric Dental Care Services section and the Pediatric Vision Care Services section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not receive treatment right away)include any of the following and, once the Out-of-Pocket Limit has been reached, you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations still will be valid required to pay the following: • Any charges for 30 calendar daysnon-Covered Health Care Services. This 30-day period is subject • Charges that exceed Allowed Amounts, when applicable. Coupons: We may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your continued coverage under Out-of-Pocket Limit. $9,450 per Covered Person, not to exceed $18,900 for all Covered Persons in a family. The Out-of-Pocket Limit includes the planAnnual Deductible. If SAMPLE Co-payment is the amount you do not pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Co-payments apply, the services within amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that timefor Covered Health Care Services, you will have to ask us are responsible for another prior authorizationpaying the lesser of: • The applicable Co-payment. Providers that have contracts with us will get • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive servicescertain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  • Before you receive certain medical services and drugs, or prescription drugs  • Before you schedule a planned admission to certain inpatient facilities  • When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. There may be additional services that are available to you, such as disease management programs, discharge planning, health education, and patient advocacy. When you seek prior authorization for a Covered Health Care Management Service as required or are otherwise identified as meeting eligibility requirements for a care management program, we will work with you to engage in the care management process and to provide you with information about these additional services. We require prior authorization for certain Covered Health Care Services. Your Primary Care Physician and other Network providers are responsible for obtaining prior authorization before they provide these services work to help ensure you. We recommend that you receive appropriate and cost-effective medical careconfirm with us that all Covered Health Care Services have been prior authorized as required. Your role in the Care Management process is simpleBefore receiving these services from a Network provider, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you may want to call Customer Service us to verify that you meet the Hospital, Physician and other providers are Network providers and that they have obtained the required criteria for claims payment and to help us identify admissions that might benefit from case management. Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary Network facilities and eligible for coverage under this plan. We will let Network providers cannot bill you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider The plan has a specific list of services that must have they do not prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for youauthorize as required. You should verify with can call us at the telephone number on your provider that a prior authorization request has been approved in writing before you receive servicesID card. Generally this plan does not cover services from providers not Benefits for Covered Health Care Services are described in the LifeWise Connect networktables below. If there is not Annual Deductibles are calculated on a LifeWise Connect provider that can provide the service needed, see Services from calendar year basis. Out-of-Network Providers Pocket Limits are calculated on a calendar year basis. Benefit limits are calculated on a calendar year basis unless otherwise specifically stated. NOTE: When Covered Health Care Services are provided by an Indian Health Service provider, your cost share may be reduced. The amount you pay for more informationCovered Health Care Services per year before you are eligible to receive Benefits. We will respond The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services section and the Pediatric Dental Care Services section. Benefits for outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a request visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. The amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. $8,500 per Covered Person, not to exceed $17,000 for prior authorization within 5 calendar days all Covered Persons in a family. The maximum you pay per year for the Annual Deductible, Co- payments or Co-insurance. Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of receipt Allowed Amounts during the rest of all information necessary that year. The Out-of-Pocket Limit applies to make a decisionCovered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. If your situation is clinically urgent (meaning that your life or health would be put The Out-of-Pocket Limit applies to Covered Health Care Services under the Policy as indicated in serious jeopardy if you did this Schedule of Benefits including the Pediatric Dental Care Services section and the Pediatric Vision Care Services section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not receive treatment right away)include any of the following and, once the Out-of-Pocket Limit has been reached, you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations still will be valid required to pay the following: • Any charges for 30 calendar daysnon-Covered Health Care Services. This 30• Charges that exceed Allowed Amounts, when applicable. $9,200 per Covered Person, not to exceed $18,400 for all Covered Persons in a family. The Out-day period of-Pocket Limit includes the Annual Deductible. Co-payment is subject the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Co-payments apply, the amount is listed on the following pages next to your continued coverage under the plandescription for each Covered Health Care Service. If you do not receive the services within Please note that timefor Covered Health Care Services, you will have to ask us are responsible for another prior authorizationpaying the lesser of: SAMPLE • The applicable Co-payment. Providers that have contracts with us will get • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive servicescertain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.