Common use of Covered Benefits and Services Clause in Contracts

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network Providers, a second for services provided by PHCS Network Providers, and a third for services provided by Out-of-Network Providers. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Non- Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICESSERVICE CATEGORIES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Plan creates three benefit payment levels: ; one for services provided by AvMed Participating (In-Network Network) Providers, a second for services provided by PHCS Network Providers, and a third for services provided by Out-of-Network Providers. The Benefit Level this Group Plan will pay depends on the Health Professional and/or or facility you select to provide covered Health Care ServicesServices and where the services are received. i. If the Health Professional or facility used is part of the AvMed Choice Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. iii. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating Provider low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. b. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing OutNon-of-Network Participating Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Plan creates three two benefit payment levels: one for services provided by AvMed Participating In-Network ProvidersProviders within the Service Area, or provided by PHCS Network Providers located outside the Service Area; and a second for services provided by PHCS Network Providers, and a third for services provided by Out-of-Network Providers. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Providers. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. i. If the Health Professional or facility is part of the AvMed Choice Plan Network inside the Service Area, or the Health Professional or facility is part of the PHCS Network and is outside the Service Area, benefits for Covered Services are payable at the high Benefit Level shown in your Schedule of Benefits. NOTE: Covered Services from PHCS Providers are only payable at the high Benefit Level when the PHCS Provider is located outside the Service Area. ii. If the Health Professional or facility is an Out-of-Network Provider, or is a PHCS Provider located inside the Service Area, benefits for Covered Services are payable at the low Benefit Level shown in your Schedule of Benefits. c. Members choosing AvMed Choice In-Plan Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers Providers, or PHCS while inside the Service Area, will have to pay the highest higher Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED C OVERED MEDICAL SERVICES, Part P art X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS E XCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, L IMITATIONS AND EXCLUSIONS, P art XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Empower Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network Tier A Providers, a second for services provided by PHCS In-Network Tier B Providers, and a third for services provided by Out-of-Network Providers. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Tier A Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Tier B Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. iii. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated herein. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Empower Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network Tier A Providers, a second for services provided by PHCS In-Network Tier B Providers, and a third for services provided by Out-of-Network Providers. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Tier A Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Tier B Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. iii. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED C OVERED MEDICAL SERVICES, Part P art X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS E XCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, L IMITATIONS AND EXCLUSIONS, P art XVIII. PEDIATRIC DENTAL COVERAGE, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by reference is incorporated hereinmade a part of this Contract. a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Elite Choice™ Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network ProvidersProviders within the Service Area, a second for services provided by PHCS Network ProvidersProviders when you travel outside the State of Florida, and a third for services provided by Out-of-Network Non- Participating Providers. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of a Participating Provider within the AvMed Choice NetworkService Area, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part a PHCS provider and you receive the services while outside the State of the PHCS NetworkFlorida, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. iii. If the Health Professional or facility used is an Outa Non-of-Network ProviderParticipating Provider inside the Service Area, outside the Service Area but within the State of Florida, or outside the State of Florida, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.

Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only as specified herein, appropriately prescribed or directed by Participating Physicians and Providers or Non-Participating Physicians and Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of BenefitsPart XVIII. PEDIATRIC DENTAL COVERAGE, which by reference is incorporated herein.LIMITATIONS AND a. If a Member does not follow the access rules described herein, he risks having the services and supplies received not covered under this Contract. In such a circumstance, any payment that AvMed may make will not exceed the Maximum Allowable Payment and the Member will be responsible for reimbursing AvMed for the services and supplies received. b. The AvMed Choice Empower Plan creates three benefit payment levels: one for services provided by AvMed Participating In-Network Tier A Providers, a second for services provided by PHCS In-Network Tier B Providers, and a third for services provided by Out-of-Network Providers. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. The Benefit Level this Plan will pay depends on the Health Professional and/or facility you select to provide covered Health Care Services. i. If the Health Professional or facility used is part of the AvMed Choice Tier A Network, benefits for Covered Services are payable at the Participating Provider high Benefit Level shown in your Schedule of Benefits. ii. If the Health Professional or facility used is part of the PHCS Tier B Network, benefits for Covered Services are payable at the Participating Provider middle Benefit Level shown in your Schedule of Benefits. NOTE: PHCS Network Providers are not available within the AvMed Service Area. c. iii. If the Health Professional or facility used is an Out-of-Network Provider, benefits for Covered Services are payable at the Non-Participating low Benefit Level shown in your Schedule of Benefits. d. Your choice of Health Professional or facility, and wise use of these benefits, can save you money. Members choosing AvMed Choice In-Network Providers while inside the Service Area, or PHCS Network Providers when outside the Service Area, will be responsible for paying lower Deductibles, Copayment and Coinsurance amounts. Members choosing Out-of-Network Providers will have to pay the highest Deductibles and Coinsurance, and will also be at risk for provider fees that are in excess of allowable charges.