Common use of COVERED SERVICES EXPENSE LIMITATION Clause in Contracts

COVERED SERVICES EXPENSE LIMITATION. If, during any calendar year, you have paid Copayments, deductibles and/or any Coinsurance amount for Covered Services under this Certificate the total amount of which equals $1,500 per enrollee or $3,000 per family, your benefits for any additional Covered Services that you may receive during that calendar year, in­ cluding any Copayment, deductible and/or Coinsurance amounts, will be reimbursed by the Plan. Should the federal government adjust the deductible and/ or out‐of‐pocket limit amount(s) for high deductible health plans, the deductible and/or the out‐of‐pocket expense limit amount(s) in this Certificate will be adjus­ xxx accordingly. In the event your Physician or the Hospital requires you to pay any additional Co­ payments, deductible and/or Coinsurance amounts after you have met the above provision, upon receipt of properly authenticated documentation, the Plan will re­ imburse to you, the amount of those Copayments, deductibles and/or Coinsurance amounts. Copayments and deductibles required under this Certificate are not to exceed 50% of the usual and customary fee for any single service. The above Covered Services expense provisions are not applicable to the benefits described in the following sections of this Certificate: Supplemental Benefits. YOUR PROVIDER RELATIONSHIPS The choice of a Hospital, Participating IPA, Participating Medical Group, Prima­ ry Care Physician or any other Provider is solely your choice and the Plan will not interfere with your relationship with any Provider. The Plan does not itself undertake to provide health care services, but solely to arrange for the provision of health care services and to make payments to Provid­ ers for the Covered Services received by you. The Plan is not in any event liable for any act or omission of any Provider or the agent or employee of such Provider, including, but not limited to, the failure or refusal to render services to you. Pro­ fessional services which can only be legally performed by a Provider are not provided by the Plan. Any contractual relationship between a Physician and a Hospital or other Provider should not be construed to mean that the Plan is pro­ viding professional service. Each Provider provides Covered Services only to Covered Persons and does not deal with or provide any services to any Group (other than as an individual Cov­ ered Person) or any Group's ERISA Health Benefit Program. FAILURE OF YOUR PARTICIPATING IPA OR PARTICIPATING MEDICAL GROUP TO PERFORM UNDER ITS CONTRACT Should your Participating IPA or Participating Medical Group fail to perform un­ der the terms of its contract with the Plan or fail to renew such contract, the benefits of this Certificate will be provided for you for Covered Services received from other Providers limited to Covered Services received during a thirty day pe­ riod beginning on the date of the Participating IPA's/Participating Medical Group's failure to perform or failure to renew its contract with the Plan. During this thirty day period, you will have the choice of transferring your enrollment to another Participating IPA or Participating Medical Group or of transferring your coverage to any other health care coverage then being offered by your Group to its members. Your transferred enrollment or coverage will be effective thirty‐one days from the date your Participating IPA or Participating Medical Group failed to perform or failed to renew its contract with the Plan. ENTIRE POLICY The Group Policy, including the Certificate, any Addenda and/or Riders, the Benefit Program Application of the Group for the Policy and the individual ap­ plications, if any, of the Enrollees constitutes the entire contract of coverage between the Group and the Plan. AGENCY RELATIONSHIPS Your Group is your agent under this Certificate. Your Group is not the agent of the Plan.

COVERED SERVICES EXPENSE LIMITATION. If, If you have Individual Coverage and during any one calendar year, you have paid the total amount of any Copayments, deductibles and/or any Coinsurance amount amounts for Covered Cov­ ered Services under this Certificate the total amount of which equals $1,500 per enrollee or $3,000 per family1,500, your benefits for then any additional Covered Services that you may receive during that calendar year, in­ cluding any Copayment, deductible and/or Coinsurance amounts, amount that you pay towards Covered Services will be reimbursed by the Plan. Should the federal government adjust the deductible and/ or out‐of‐pocket limit amount(s) for high deductible health plansIf you have Family Coverage and during any one calendar year, the total amount of any Copayments, deductibles and/or Coinsurance amounts that your family pays towards Covered Services equals $3,000, then any additional Copayment, deductible and/or Coinsurance amount that your family pays towards Covered Services will be reimbursed by the out‐of‐pocket Plan. A family member may not apply more than the individual expense limit amount(s) in this Certificate will be adjus­ xxx accordinglyas described above towards the family expense limit. In the event your Physician or the Hospital requires you to pay any additional Co­ payments, deductible and/or Coinsurance amounts after you have met the above provision, upon receipt of properly authenticated documentation, the Plan will re­ imburse to you, the amount of those Copayments, deductibles and/or Coinsurance amounts. Copayments and deductibles required under this Certificate are not to exceed 50% of the usual and customary fee for any single service. The above This Covered Services expense provisions are limitation does not applicable to the benefits described in the following sections of include: • Services, supplies or charges excluded under this Certificate: Supplemental Benefits. Certificate YOUR PROVIDER RELATIONSHIPS The choice of a Hospital, Participating IPA, Participating Medical Group, Prima­ ry Care Physician or any other Provider is solely your choice and the Plan will not interfere with your relationship with any Provider. The Plan does not itself undertake to provide health care services, but solely to arrange for the provision of health care services and to make payments to Provid­ ers for the Covered Services received by you. The Plan is not in any event liable for any act or omission of any Provider or the agent or employee of such Provider, including, but not limited to, the failure or refusal to render services to you. Pro­ fessional services which can only be legally performed by a Provider are not provided by the Plan. Any contractual relationship between a Physician and a Hospital or other Provider should not be construed to mean that the Plan is pro­ viding professional service. Each Provider provides Covered Services only to Covered Persons and does not deal with or provide any services to any Group (other than as an individual Cov­ ered Person) or any Group's ERISA Health Benefit Program. FAILURE OF YOUR PARTICIPATING IPA OR PARTICIPATING MEDICAL GROUP TO PERFORM UNDER ITS CONTRACT Should your Participating IPA or Participating Medical Group fail to perform un­ der the terms of its contract with the Plan or fail to renew such contract, the benefits of this Certificate will be provided for you for Covered Services received from other Providers limited to Covered Services received during a thirty day pe­ riod beginning on the date of the Participating IPA's/Participating Medical Group's failure to perform or failure to renew its contract with the Plan. During this thirty day period, you will have the choice of transferring your enrollment to another Participating IPA or Participating Medical Group or of transferring your coverage to any other health care coverage then being offered by your Group to its members. Your transferred enrollment or coverage will be effective thirty‐one days from the date your Participating IPA or Participating Medical Group failed to perform or failed to renew its contract with the Plan. ENTIRE POLICY The Group Policy, including the Certificate, any Addenda and/or Riders, the Benefit Program Application of the Group for the Policy and the individual ap­ plications, if any, of the Enrollees constitutes the entire contract of coverage between the Group and the Plan. AGENCY RELATIONSHIPS Your Group is your agent under this Certificate. Your Group is not the agent of the Plan.

COVERED SERVICES EXPENSE LIMITATION. If, during any calendar year, you have paid Copayments, deductibles and/or any Coinsurance amount for Covered Services under this Certificate the total amount of which equals $1,500 per enrollee or $3,000 3,000[1,000-13,700] per family, your benefits for any additional Covered Services that you may receive during that calendar cal­ endar year, in­ cluding including any Copayment, deductible and/or Coinsurance amounts, will be reimbursed by the Plan. Should the federal government adjust the deductible and/ or deduct­ ible and/or out‐of‐pocket limit amount(s) for high deductible health plans, the deductible and/or the out‐of‐pocket expense limit amount(s) in this Certificate will be adjus­ xxx adjusted accordingly. In the event your Physician or the Hospital requires you to pay any additional Co­ payments, deductible and/or Coinsurance amounts after you have met the above provision, upon receipt of properly authenticated documentation, the Plan will re­ imburse to you, the amount of those Copayments, deductibles and/or Coinsurance amounts. Copayments and deductibles required under this Certificate are not to exceed 50% of the usual and customary fee for any single service. The above Covered Services expense provisions are not applicable to the benefits described in the following sections of this Certificate: Supplemental Benefits; Outpatient Prescription Drug Program Benefits. YOUR PROVIDER RELATIONSHIPS The choice of a Hospital, Participating IPA, Participating Medical Group, Prima­ ry Care Physician or any other Provider is solely your choice and the Plan will not interfere with your relationship with any Provider. The Plan does not itself undertake to provide health care services, but solely to arrange for the provision of health care services and to make payments to Provid­ ers for the Covered Services received by you. The Plan is not in any event liable for any act or omission of any Provider or the agent or employee of such Provider, including, but not limited to, the failure or refusal to render services to you. Pro­ fessional services which can only be legally performed by a Provider are not provided by the Plan. Any contractual relationship between a Physician and a Hospital or other Provider should not be construed to mean that the Plan is pro­ viding professional service. Each Provider provides Covered Services only to Covered Persons and does not deal with or provide any services to any Group (other than as an individual Cov­ ered Person) or any Group's ERISA Health Benefit Program. FAILURE OF YOUR PARTICIPATING IPA OR PARTICIPATING MEDICAL GROUP TO PERFORM UNDER ITS CONTRACT Should your Participating IPA or Participating Medical Group fail to perform un­ der the terms of its contract with the Plan or fail to renew such contract, the benefits of this Certificate will be provided for you for Covered Services received from other Providers limited to Covered Services received during a thirty day pe­ riod beginning on the date of the Participating IPA's/Participating Medical Group's failure to perform or failure to renew its contract with the Plan. During this thirty day period, you will have the choice of transferring your enrollment to another Participating IPA or Participating Medical Group or of transferring your coverage to any other health care coverage then being offered by your Group to its members. Your transferred enrollment or coverage will be effective thirty‐one days from the date your Participating IPA or Participating Medical Group failed to perform or failed to renew its contract with the Plan. ENTIRE POLICY The Group Policy, including the Certificate, any Addenda and/or Riders, the Benefit Program Application of the Group for the Policy and the individual ap­ plications, if any, of the Enrollees constitutes the entire contract of coverage between the Group and the Plan. AGENCY RELATIONSHIPS Your Group is your agent under this Certificate. Your Group is not the agent of the Plan.