Common use of Important Information Clause in Contracts

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following limited circumstances: • emergency care (emergency room services and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non- network provider at a network facility outside of your control as described in Section 5; • otherwise, as required by law. In these limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. The reimbursement is based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated. You may be responsible up to the provider’s charge. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider.

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plandirectly with us. Services received from a non-network provider are not covered except in the following limited circumstances: • emergency care (emergency room services and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non- network provider at a network facility outside of your control as described in Section 5; • otherwise, as required by law. In these limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. The reimbursement is based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated. You may be responsible up to the provider’s charge. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider.

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following limited circumstances: • emergency care (emergency room services and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non- network provider at a network facility outside of your control as described in Section 5; • otherwise, as required by law. In these limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. The reimbursement is based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated. You may be responsible up to the provider’s charge. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider. Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to both the network and limited non-network services combined. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits.

Important Information. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plandirectly with us. Services received from a non-network provider are not covered except in the following limited circumstances: •  emergency care (emergency room services and ambulance services); •  we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; •  covered healthcare services are rendered by a non- network provider at a network facility outside of your control as described in Section 5; •  otherwise, as required by law. In these limited circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. The reimbursement is based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit, less any copayments and deductibles. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated. You may be responsible up to the provider’s charge. If you are traveling outside our service area and need emergency care, call the number provided for BlueCard Access listed in the Contact Information section. You may also visit our website and use the “Find A Doctor” feature to find a BlueCard provider.