Common use of Copayments Clause in Contracts

Copayments. Providers will use this information to determine the copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference:  PCP $$ -- PCP office visit copayment  SPC $$ -- specialist office visit copayment  ER $$ -- emergency room visit copayment  UC $$ -- urgent care visit copayment AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain information regarding coverage for dental, vision, and prescription drug benefits. Preauthorization: The term preauthorization alerts providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on:  Preauthorization instructions and toll-free telephone number.  General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact Keystone’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card:  Check the information on the ID Card for completeness and accuracy.  Check that one ID Card is received for each enrolled family Member.  Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the ID Card for each family Member to be sure the information on it is accurate.  Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card.  Carry the ID Card at all times. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.

Copayments. Providers will use this information to determine the copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference:  • PCP $$ -- PCP office visit copayment  • SPC $$ -- specialist office visit copayment  • ER $$ -- emergency room visit copayment  • UC $$ -- urgent care visit copayment AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain information regarding coverage for dental, vision, and prescription drug benefits. Preauthorization: The term preauthorization alerts providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on:  • Preauthorization instructions and toll-free telephone number.  • General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact KeystoneXxxxxxxx’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card:  • Check the information on the ID Card for completeness and accuracy.  • Check that one ID Card is received for each enrolled family Member.  • Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the ID Card for each family Member to be sure the information on it is accurate.  • Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card.  • Carry the ID Card at all times. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.. SECTION DE - DEFINITIONS‌ For the purposes of this Agreement, the terms below have the following meaning: ADVERSE BENEFIT DETERMINATION – any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Investigational or not Medically Necessary. AGREEMENT RENEWAL DATE – January 1st of each calendar year. AGREEMENT YEAR – the twelve (12) month period beginning on January 1st of each calendar year. ALLOWABLE AMOUNT – the payment level that Keystone reimburses for benefits provided to a Member under the Member’s coverage. For Participating Providers, the allowable amount is the amount provided for in the contract between the Provider and Keystone, unless otherwise specified in this Agreement. AMBULATORY SURGICAL FACILITY – A facility provider licensed and approved by the state in which it provides covered health care services or as otherwise approved by Keystone Health Plan Central and which: • has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis; • provides treatment by or under the supervision of physicians whenever the patient is in the facility; • does not provide inpatient accommodations; and • is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician. ANESTHESIA – consists of the administration of regional anesthetic or the administration of a drug or other anesthetic agent by injection or inhalation, the purpose and effect of which is to obtain muscular relaxation, loss of sensation or loss of consciousness. ANNUAL ENROLLMENT PERIOD – Annual enrollment means the period each year during which a Qualified Individual may enroll or change coverage in a QHP through the Marketplace. APPLICATION – the written request of the Applicant for coverage, set forth in a format approved by the Marketplace. APPLICATION/CHANGE FORM – the properly completed written request for enrollment for HMO Membership submitted in a format provided by the Marketplace, together with any amendments or modifications thereof. APPROVED CLINICAL TRIAL – A phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to prevention, detection, or treatment of cancer or other life threatening disease or condition and is described below:

Copayments. Providers will use this information to determine the copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference:  • PCP $$ -- PCP office visit copayment  • SPC $$ -- specialist office visit copayment  • ER $$ -- emergency room visit copayment  • UC $$ -- urgent care visit copayment AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain information regarding coverage for dental, vision, and prescription drug benefits. Preauthorization: The term preauthorization alerts providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on:  • Preauthorization instructions and toll-free telephone number.  • General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact KeystoneXxxxxxxx’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card:  • Check the information on the ID Card for completeness and accuracy.  • Check that one ID Card is received for each enrolled family Member.  • Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the pl ease c heck t he ID Card C ard for each eac h family Member to be sure s ure the information i nformation on it i t is accurate.  • Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card.  • Carry the ID Card at all timest xxxx. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.. SECTION DE - DEFINITIONS‌ For the purposes of this Agreement, the terms below have the following meaning: ADVERSE BENEFIT DETERMINATION – any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Investigational or not Medically Necessary. AGREEMENT RENEWAL DATE – January 1st of each calendar year. AGREEMENT YEAR – the twelve (12) month period beginning on January 1st of each calendar year. ALLOWABLE AMOUNT – the payment level that Keystone reimburses for benefits provided to a Member under the Member’s coverage. For Participating Providers, the allowable amount is the amount provided for in the contract between the Provider and Keystone, unless otherwise specified in this Agreement. AMBULATORY SURGICAL FACILITY – A facility provider licensed and approved by the state in which it provides covered health care services or as otherwise approved by Keystone Health Plan Central and which: • has permanent facilities and equipment for the primary purpose of performing surgical procedures on an outpatient basis; • provides treatment by or under the supervision of physicians whenever the patient is in the facility; • does not provide inpatient accommodations; and • is not, other than incidentally, a facility used as an office or clinic for the private practice of a physician. ANESTHESIA – consists of the administration of regional anesthetic or the administration of a drug or other anesthetic agent by injection or inhalation, the purpose and effect of which is to obtain muscular relaxation, loss of sensation or loss of consciousness. ANNUAL ENROLLMENT PERIOD – Annual enrollment means the period each year during which an Individual may enroll or change coverage. APPLICATION – the written request of the Applicant for coverage, set forth in a format approved by the HMO. APPLICATION/CHANGE FORM – the properly completed written request for enrollment for HMO Membership submitted in a format provided by the HMO, together with any amendments or modifications thereof. APPROVED CLINICAL TRIAL – A phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to prevention, detection, or treatment of cancer or other life threatening disease or condition and is described below:

Copayments. Providers will use this information to determine the copayment Copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference:  PCP $$ -- PCP office visit copayment  SPC $$ -- specialist office visit copayment  ER $$ -- emergency room visit copayment  UC $$ -- urgent care visit copayment  AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain contains information regarding coverage for dental, vision, and prescription drug benefits. The words “BlueCross Dental” and “BlueCross Vision” on the front of the ID card provides that the Member has pediatric dental and pediatric vision coverage with Capital. Preauthorization: The term preauthorization Preauthorization alerts providers Providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on:  Preauthorization instructions and toll-free telephone number.  BlueCross Dental and BlueCross Vision telephone numbers.  General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact KeystoneXxxxxxxx’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card:  Check the information on the ID Card for completeness and accuracy.  Check that one ID Card is received for each enrolled family Member.  Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the ID Card for each family Member to be sure the information on it is accurate.  Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card.  Carry the ID Card at all times. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.

Copayments. Providers will use this information to determine the copayment they may collect from Members at the time a service is rendered. Members should use the following list as a reference:  PCP $$ -- PCP office visit copayment  SPC $$ -- specialist office visit copayment  ER $$ -- emergency room visit copayment  UC $$ -- urgent care visit copayment AH $$ -- after normal business hours PCP office visit copayment (This copayment is in addition to the PCP office visit copayment) The Member’s ID card may also contain information regarding coverage for dental, vision, and prescription drug benefits. Preauthorization: The term preauthorization alerts providers that this element of a Member’s coverage is present. Members should refer to the Preauthorization Program attachment to this Agreement for more information. On the back of the ID card, members can find important additional information on:  Preauthorization instructions and toll-free telephone number.  General instructions for filing claims. Members should remember to destroy old ID cards and use only their latest ID card. Members should also contact KeystoneXxxxxxxx’s Customer Service if any information on their ID card is incorrect or if they have questions. Listed below are some important things to do and to remember about a Member ID Card:  Check the information on the ID Card for completeness and accuracy.  Check that one ID Card is received for each enrolled family Member.  Check that the name of the Primary Care Physician (or office) that was selected is shown on the ID Card. Also, please check the ID Card for each family Member to be sure the information on it is accurate.  Call Keystone’s Customer Service Department if the ID Card is lost or there is an error on the card.  Carry the ID Card at all times. Members must present an ID Card whenever they receive Medical Care. On the reverse side of the ID Card, Members will find information about medical services. There is even a toll-free number for use by Hospitals if they have questions about a Member’s coverage.