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. Per Individual Member Per Family $8,700 $17,400 Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 Copay $60 Copay Inpatient Hospital Services, for each admission $150 Copay Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other X-Ray Services Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services, Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.

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. Per Individual Member Per Family $8,700 7,350 $17,400 14,700 Primary Care Physician/Practitioner (“PCP”) Office or Home Visit Participating Specialist Physician (“Specialist”) Office or Home Visit $30 25 Copay $60 45 Copay Inpatient Hospital Services, for each admission $150 Copay Outpatient Surgery $100 Copay -Radiation Therapy -Dialysis No Copay Routine Maintenance Drug – Hospital Setting $500 Copay Routine Maintenance Drug – Home, Office, Infusion Suite Setting $50 Copay Non-Maintenance Drug No Copay Chemotherapy No Copay Computerized Tomography (CT Scan), Computerized Tomography Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET Scan), SPECT/Nuclear Cardiology studies, per procedure Other -Other X-Ray Services Outpatient -Outpatient Lab $200 Copay $100 Copay $100 Copay Rehabilitation Services, Therapies, per visit Habilitation Services, and Therapies, per visit $100 Copay; unless otherwise covered under Inpatient Hospital Services.