Common use of Copayments Clause in Contracts

Copayments. A copayment is typically a fixed dollar amount due at the time of service. Members may be required to pay copayments to a provider each time services are performed that require a copayment. Copayments, as shown in the Schedule of Benefits, are due at the time of service. Payment of a copayment does not exclude the possibility of a provider billing you for any non-covered services. Copayments do not count or apply toward the deductible amount, but do apply toward your maximum out-of-pocket amount. Coinsurance Amount A coinsurance amount is your share of the cost of a service. Members may be required to pay a coinsurance in addition to any applicable deductible amount(s) due for a covered service or supply. Payment of a coinsurance amount does not exclude the possibility of a provider billing you for any non-covered services. Coinsurance amounts do not apply toward the deductible, but do apply toward your maximum out-of-pocket amount. When the annual maximum out-of-pocket amount has been met, additional covered service expenses will be provided at 100 percent. Deductible The deductible amount means the amount of covered service expenses that must be paid by each/all members before any benefits are provided or payable. The deductible amount does not include any copayment amount or coinsurance amount. Not all covered service expenses are subject to the deductible amount. See your Schedule of Benefits for more details. Maximum Out-of-Pocket Amount You must pay any required copayments or coinsurance amounts required until you reach the maximum out-of- pocket amount shown on your Schedule of Benefits. After the maximum out-of-pocket amount is met for an individual, we will pay 100 percent of the cost for covered services. The family maximum out-of-pocket amount is two times the individual maximum out-of-pocket amount. For the family maximum out-of-pocket amount, once a member has met the individual maximum out-of-pocket amount, the remainder of the family maximum out-of- pocket amount can be met with the combination of any one or more members’ eligible expenses. After the maximum out-of-pocket amount is met for an individual, Ambetter pays 100 percent of eligible expenses for that individual. The family maximum out-of-pocket amount is two times the individual maximum out-of- pocket amount. Both the individual and the family maximum out-of-pocket amounts are shown in the Schedule of Benefits. For family coverage, the family maximum out-of-pocket amount can be met with the combination of any one or more covered persons’ eligible expenses. A covered person’s maximum out-of-pocket will not exceed the individual maximum out-of-pocket amount. If you are a covered member in a family of two or more members, you will satisfy your maximum out-of-pocket when:

Copayments. A copayment is typically a fixed dollar amount due at the time of service. Members may be required You are liable for certain Copayments to pay copayments to a provider each time services are performed that require a copayment. CopaymentsParticipating Providers, as shown in the Schedule of Benefits, which are due at the time of service. Payment of a copayment does not exclude the possibility of a provider billing you The Copayment due for any non-covered services. Copayments do not count or apply toward the deductible amountspecific Covered Services, but do apply toward your maximum benefit limitations and out-of-pocket amountmaximums can be found in the Schedule of Copayments and Benefit Limits. Coinsurance Amount A coinsurance The Copayment amount is your share shall not exceed 50% of the total cost of the services provided. Out-of-Pocket Maximums Copayments paid by You or on Your behalf in a serviceCalendar Year shall not exceed 200% of the total annual Premium. Members may be required HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to pay a coinsurance in addition HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any applicable deductible amount(s) due for a covered service or supplyeligible dental expenses payment obligations from the indemnity dental Rider. Payment of a coinsurance amount does not exclude Once You reach the possibility of a provider billing you for any non-covered services. Coinsurance amounts do not apply toward the deductible, but do apply toward your maximum out-of-pocket amountmaximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. When the annual maximum If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket amount has been met, additional covered service expenses maximum will be provided at 100 percent. Deductible The deductible amount means applied towards the amount of covered service expenses that must be paid by each/all members before any benefits are provided or payable. The deductible amount does not include any copayment amount or coinsurance amount. Not all covered service expenses are subject to the deductible amount. See your Schedule of Benefits for more details. Maximum Out-of-Pocket Amount You must pay any required copayments or coinsurance amounts required until you reach the maximum out-of- pocket amount shown on your Schedule of Benefits. After the maximum family out-of-pocket maximum amount is met for an individual, we will pay 100 percent shown in the Schedule of Copayments and Benefit Limits. When the cost for covered services. The family maximum out-of-pocket maximum amount is two times the individual maximum out-of-pocket amount. For the family maximum out-of-pocket amountreached, once a member has met the individual maximum out-of-pocket amount, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the family maximum out-of- pocket amount can Calendar Year. Requirements All Covered Services, unless otherwise specifically described: • must be met with Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the combination of any one or more members’ eligible expenses. After PCP and/or the maximum out-of-pocket amount is met for an individual, Ambetter pays 100 percent of eligible expenses for that individual. The family maximum out-of-pocket amount is two times HMO; • must be rendered by a Participating Provider; • are subject to the individual maximum out-of- pocket amount. Both the individual and the family maximum out-of-pocket amounts are Copayment shown in the Schedule of Benefits. For family coverageSCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; • may have limitations, the family maximum out-of-pocket amount can be met with the combination of any one restrictions or more covered persons’ eligible expenses. A covered person’s maximum out-of-pocket will not exceed the individual maximum out-of-pocket amount. If you are a covered member exclusions described in a family of two or more members, you will satisfy your maximum out-of-pocket when:Limitations and Exclusions; and • may require Prior Authorization.

Copayments. A copayment is typically a fixed dollar amount due at the time of service. Members may be required to pay copayments to a provider each time services are performed that require a copayment. Copayments, as shown in the Schedule of Benefits, are due at the time of service. Payment of a copayment does not exclude the possibility of a provider billing you for any non-non- covered services. Copayments do not count or apply toward the deductible amount, but do apply toward your maximum out-of-pocket amount. Coinsurance Amount A coinsurance amount is your share of the cost of a service. Members may be required to pay a provider a coinsurance in addition to any applicable deductible amount(s) due for a covered service or supply. Payment of a coinsurance amount does not exclude the possibility of a provider billing you for any non-covered services. Coinsurance amounts do not apply toward the deductible, but do apply toward your maximum out-of-pocket amount. When the annual maximum out-of-of- pocket amount has been met, additional covered service expenses services will be provided at 100 percent. Deductible The deductible amount means the amount of covered service expenses services that must be paid to a provider by each/all members before any benefits are provided or payable. The deductible amount does not include any copayment amount or coinsurance amount. Not all covered service expenses services are subject to the deductible amount. See your Schedule of Benefits for more details. Maximum Out-of-Pocket Amount You must pay a provider any required copayments or coinsurance amounts required until you reach the maximum out-of- of-pocket amount shown on your Schedule of Benefits. After the maximum out-of-pocket amount is met for an individual, we will pay 100 percent of the cost for covered services. The family maximum out-of-pocket amount is two times the individual maximum out-of-of- pocket amount. For the family maximum out-of-pocket amount, once a member has met the individual maximum out-of-pocket amount, the remainder of the family maximum out-of- of-pocket amount can be met with the combination of any one or more members’ eligible expenses. After the maximum out-of-pocket amount is met for an individual, Ambetter pays 100 percent of eligible expenses for that individual. The family maximum out-of-pocket amount is two times the individual maximum out-of- of-pocket amount. Both the individual and the family maximum out-of-of- pocket amounts are shown in the Schedule of Benefits. For family coverage, the family maximum out-of-pocket amount can be met with the combination of any one or more covered persons’ eligible expenses. A covered person’s maximum out-of-pocket will not exceed the individual maximum out-of-pocket amount. If you are a covered member in a family of two or more members, you will satisfy your maximum out-of-pocket when: