Common use of COVERED SERVICES AND BENEFITS Clause in Contracts

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for various reasons as permitted by applicable law. O u t - o f - P o c k e t M a x i m u m s P e r C a l e n d a r Y e a r i n c l u d i n g P h a r m a c y B e n e f i t s Per Individual Member $9,100 Per Family $18,200 P r o f e s s i onal Se r v i c e s Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $45 Copay $80 Copay

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments shown below indicate the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-of-pocket maximums may be adjusted for various reasons as permitted by applicable law. O u t Out - o f - P o c k e ocke t M a x i Maxi m u m s ums P e r C a l Cal e n d a r ndar Y e a r i n c l u d i n g ncl udi ng P h a r m a c harm ac y B e n e ene f i t s Per Individual Member $9,100 Per Family $18,200 P r o f e s s i onal Se r v i c e s Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $45 35 Copay $80 70 Copay

COVERED SERVICES AND BENEFITS. All Covered Services (except in emergencies) must be provided by or through Your Participating Primary Care Physician/Practitioner, who may refer You for further treatment by Providers in the applicable network of Participating Specialists and Hospitals. Urgent Care, Retail Health Clinics, Clinics and Virtual Visits do not require Primary Care Physician/Practitioner Referral. Some services may require Prior Authorization Preauthorization by HMO. A Copayment for Covered Services shall not exceed fifty percent (50%) of the total cost of the services provided. Out-of-pocket maximums paid by You or on Your behalf in a Calendar Year for Covered Services shall not exceed two hundred percent (200%) of the total annual Premium. HMO will determine when maximums have been reached based on information provided to HMO by You and Participating Providers to whom You have made Copayments. Once You reach the maximum, You are not required to make additional Copayments for Covered Services or Covered Drugs for the remainder of the Calendar Year. IMPORTANT NOTE: Copayments Copayment shown below indicate indicates the amount You are required to pay, are expressed as either a fixed dollar amount or a percentage of the Allowable Amount and will be applied for each occurrence unless otherwise indicated. Copayments and out-out- of-pocket maximums may be adjusted for various reasons as permitted by applicable law. O u t Out - o f - P o c k e ocke t M a x i Maxi m u m s ums P e r C a l Cal e n d a r ndar Y e a r i n c l u d i n g ncl udi ng P h a r m a c harm ac y B e n e ene f i t s Per Individual Member $9,100 8,550 Per Family $18,200 17,100 P r o f e s s i onal Se r v i c e s Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $45 25 Copay $80 45 Copay