Common use of Note to carriers Clause in Contracts

Note to carriers. Use the above text for other than single coverage for a plan that is a high deductible health plan that could be used in conjunction with an HSA. Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year. Once Members in a family meet the family Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. [Tier 1] and [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) [[Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.) [Maximum Out of Pocket: The Per Covered Person and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Covered Person, the Maximum Out of Pocket is the annual maximum dollar amount that a Covered Person must pay as per Covered Person Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Person Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance will be required for such Covered Person for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for members of the covered family for the rest of the Calendar Year.] [Note to carriers: Use the above text if the plan is issued as a high deductible health plan that could be used in conjunction with an HSA.] COVERED SERVICES & SUPPLIES [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the applicable Schedule of Services and Supplies and subject to the terms, conditions and limitations of this Contract. Read the entire Contract to determine what treatment, services and supplies are limited or excluded.

Note to carriers. Use Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES AND CLASSIFICATION SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES GENERAL PROVISIONS CONTINUATION RIGHTS MEDICARE AS SECONDARY PAYOR SCHEDULE OF PREMIUM RATES AND CLASSIFICATION [The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate quote] for this Contract for the effective date shown on the face page of the Contract. We have the right to prospectively change any Premium rate(s) set forth above text at the times and in the manner established by the provision of this Contract entitled " General Provisions." This Contract’s classifications, and the coverages and amounts which apply to each class are shown below: CLASS(ES) [All eligible employees] SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER [CALENDAR] [PLAN] YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS[/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [dollar amount equal to 10 times the per day copayment ]/[Calendar] [Plan] Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] ] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] SURGERY:. INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit HOME HEALTH CARE 60 visits, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per [day] [visit]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) $0 Copayment THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit; maximum 30 visits/[Calendar] [Plan] Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance [May be substituted by [Other than contraceptives] Carrier with Copayments consistent [including network contraceptives not with N.J.A.C. 11:22-5.5(a).] [0% for covered under the Contraceptives provision] contraceptives] PRIMARY CARE PROVIDER For services other than single coverage for Preventive Care [amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit. [ SERVICES (OUTSIDE HOSPITAL) PREVENTIVE CARE $0 copayment CONTRACEPTIVES: $0 copayment [included under the contraceptives provision] BREASTFEEDING SUPPORT: $0 copayment REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a plan that is a high deductible health plan that could be used in conjunction Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with an HSAN.J.A.C. 11:22- 5.5(a)] Copayment/visit. SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit. SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; amount consistent with N.J.A.C. 11:22-5.5(a)Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit. Speech and Cognitive Therapy (Combined), Maximum Out 30 visits per [Calendar] [Plan] Year Note: the limit does not apply to speech therapy covered under the Diagnosis and Treatment of Pocket Maximum out Autism and Other Developmental Disabilities Provision Physical and Occupational Therapy (Combined), maximum 30 visits per [Calendar] [Plan] Year Note: The limit does not apply to physical or occupational therapy covered under the Diagnosis and Treatment of pocket means Autism and Other Developmental Disabilities Provision [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22- 5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES . INPATIENT $0 Copayment (OUTPATIENT) amount consistent with N.J.A.C. 11:22- 5.5(a)] Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the annual maximum dollar amount that a Member must pay as Copayment, Copayments Deductible and Coinsurance set forth below and are determined per [Calendar] [Plan] Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Preventive Care NONE All other Primary Care Provider Visits [amount consistent with N.J.A.C. 11:22- 5.5(a)] per visit Maternity (pre-natal care) NONE Contraceptives [included under the contraceptives provision] NONE Breastfeeding Support NONE Prescription Drugs [Other than contraceptives] [including network contraceptives not covered under the Contraceptives provision] [Copayments consistent with N.J.A.C. 11:22- 5.5] [0% for all Covered Services or Supplies in a Calendar Year. contraceptives] [subject to the Prescription Drug Cost Sharing Limit]‌ All amounts paid as Copayment, other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance shall count toward sections DEDUCTIBLE PER [CALENDAR] [PLAN] YEAR • Primary Care Provider Visits including Preventive Care and immunizations and lead screening for children NONE •Maternity (pre-natal care) NONE. •Contraceptives [included under the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year. Once Members in a family meet the family Maximum Out of Pocket, no contraceptives provision] NONE •Breastfeeding Support NONE •Second Surgical Opinion NONE •All other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. •Per Covered Person Dollar amount not to exceed deductible permitted by 45 CFR 156.130(b)] • [Tier 1] and Per Covered Family [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar Dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to which is two times the individual Deductible.] COINSURANCE Preventive Care 0% Prescription Drugs [Tier 1Other than contraceptives] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance [including contraceptives not Included under the contraceptives provisions]50% [0% for contraceptives] Contraceptives [Tier 1included under the contraceptives provision] Network NONE Breastfeeding Support NONE [Vision Benefits (for Covered Services and Supplies for Persons through the remainder end of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies month in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, which the Member has no further obligation to pay any amounts as Copayment, Deductible turns age 19) V2500 – V2599 Contact Lenses [50%] Optional lenses and Coinsurance treatments [50%]] [Dental Benefits (for [Tier 2] Network Covered Services and Supplies for Persons through the remainder end of the Calendar Year. Once any combination of Members month in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) [[Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, which the Member has no further obligation to pay any amounts as Copaymentturns age 19) Preventive, Deductible Diagnostic and Coinsurance for Restorative services 0% Endodontic, Periodontal, Prosthodontic and Oral and Maxillofacial Surgical Services [Tier 120%] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the Orthodontic Treatment [Tier 150%]] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.) [Maximum Out of Pocket: The Per Covered Person and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Covered Person, the Maximum Out of Pocket is the annual maximum dollar amount that a Covered Person must pay as per Covered Person Cash Deductible plus Coinsurance and Copayments for all covered other services and supplies to which a Copayment does not apply [10% - 50%, in a Calendar Year. Once the Per Covered Person Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance will be required for such Covered Person for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance for all covered 5% increments] All services and supplies in to which a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Copayment applies None [[Outpatient Surgery (facility charges)] Coinsurance or Copayments will be required for members of the covered family for the rest of the Calendar Year.Limit: $[500] per [surgery]] Note to carriers: Use Outpatient surgery may be replaced with any other service or supply for which coinsurance is required. EMERGENCY ROOM COPAYMENT [amount consistent with N.J.A.C. 11:22-5.5] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the above text if result of the plan is issued as a high deductible health plan that could be used in conjunction with an HSAemergency).] COVERED SERVICES & SUPPLIES [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the applicable Schedule of Services and Supplies and subject to the terms, conditions and limitations of this Contract. Read the entire Contract to determine what treatment, services and supplies are limited or excluded.

Note to carriers. Use Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS SCHEDULE OF PREMIUM RATES The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate sheet] for this Contract for the effective date shown on the first page of this Contract. We have the right to prospectively change any Premium rate(s) set forth above text for other than single coverage at the times and in the manner established by the provision of this Contract entitled "General Provisions." SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS [/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a plan that maximum of 5 days/admission. Maximum Copayment [ dollar amount equal to 10 times the per day copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $[0] Copayment OUTPATIENT VISIT amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM $100 Copayment/visit/Member (waived if admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY: INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22- 5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22- 5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [visit] [day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION DRUGS [50% Coinsurance] [copays consistent with N.J.A.C. 11:22-5.5(a) may be substituted for coinsurance] PRIMARY CARE PROVIDER [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [Note to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit] [Note to carriers: Use this item if the specialist copay exceeds the PCP copay.] [TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a high deductible health plan that could be used in conjunction Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with an HSAN.J.A.C. 11:22-5.5(a)]] Copayment/visit. SKILLED NURSING FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit MAXIMUM OUT OF POCKET Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year. Once Members in a family meet the family Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. [Tier 1] and [Tier 2] The Maximum Out of Pocket for this Contract is as follows: •Per Member per Calendar Year [Please note$6,850 or amount permitted by 45 C.F.R. 156.130] •Per Family per Calendar Year [$2X per member amount.] Note: There are separate The Maximum Out of Pocket amounts for cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Tier 1Example Using Deductible, Coinsurance] and [Tier 2] as shown on The services or supplies covered under this Contract are subject to the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as CopaymentCopayments, Deductible and Coinsurance set forth below and are determined per Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Primary Care Provider but not for all Preventive Care Visits [Tier 1amount consistent with N.J.A.C. 11:22-5.5(a)]] Network per visit Preventive Care NONE Maternity (pre-natal care) NONE Prescription Drugs Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR • Preventive Care and immunizations and lead screening for children NONE •Maternity (pre-natal care) NONE. •Second Surgical Opinion •All other Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward •Per Member [dollar amount not to exceed the [Tier 1amount permitted by N.J.A.C. 11:20-3.1(b)3i] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network • Per Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an Family amount equal to two 2 times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Yearper member amount.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) COINSURANCE [[Tier 1Prescription Drugs 50% ] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. Preventive Care: NONE All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.) [Maximum Out of Pocket: The Per Covered Person and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Covered Person, the Maximum Out of Pocket is the annual maximum dollar amount that a Covered Person must pay as per Covered Person Cash Deductible plus Coinsurance and Copayments for all covered services and supplies to which a Copayment does not apply [10% - 50%, in a Calendar Year. Once the Per Covered Person Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance will be required for such Covered Person for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance for all covered 10% increments] All services and supplies in to which a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for members of the covered family for the rest of the Calendar YearCopayment applies None EMERGENCY ROOM COPAYMENT $100 Copayment/visit/Member (waived if admitted within 24 hours ).] [Note to carriers: Use the above text if the plan is issued as a high deductible health plan that could be used in conjunction with an HSA.] COVERED SERVICES & SUPPLIES [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the applicable Schedule of Services and Supplies and subject to the terms, conditions and limitations of this Contract. Read the entire Contract to determine what treatment, services and supplies are limited or excluded.

Note to carriers. Use Carriers may place the taglines in the location the carrier believes most appropriate. TABLE OF CONTENTS Section Page SCHEDULE OF PREMIUM RATES SCHEDULE OF SERVICES AND SUPPLIES DEFINITIONS ELIGIBILITY [MEMBER] PROVISIONS [COVERAGE PROVISION] COVERED SERVICES AND SUPPLIES NON-COVERED SERVICES AND SUPPLIES COORDINATION OF BENEFITS AND SERVICES SERVICES FOR AUTOMOBILE RELATED INJURIES GENERAL PROVISIONS SCHEDULE OF PREMIUM RATES The initial monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are set forth on the [rate sheet] for this Contract for the effective date shown on the first page of this Contract. We have the right to prospectively change any Premium rate(s) set forth above text for other than single coverage at the times and in the manner established by the provision of this Contract entitled "General Provisions." SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment] THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED. [SERVICES COPAYMENTS [/COINSURANCE]: HOSPITAL SERVICES: INPATIENT [$100 to $500] Copayment/day for a plan that maximum of 5 days/admission. Maximum Copayment [ dollar amount equal to 10 times the per day copayment]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $[0] Copayment OUTPATIENT VISIT amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; no Copayment if any other Copayment applies. EMERGENCY ROOM $100 Copayment/visit/Member (waived if admitted within 24 hours) Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any. [URGENT CARE [amount consistent with N.J.A.C. 11:22-5.5(a)]] PRACTITIONER CHARGES FOR SURGERY: INPATIENT $0 Copayment OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay differs based on the setting.] [FACILITY CHARGES FOR OUTPATIENT SURGERY:[amount consistent with N.J.A.C. 11:22-5.5(a)]]] [Note to carriers: Use this text if the copay is the same regardless of the setting.] HOME HEALTH CARE Unlimited days, if Pre-Approved; $[amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment per [visit] [day]. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) NONE BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. PRESCRIPTION DRUGS [50% Coinsurance] [copays consistent with N.J.A.C. 11:22-5.5(a) may be substituted for coinsurance] PRIMARY CARE PROVIDER [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if the services are Preventive Care services. [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit.] [Note to carriers: Use this text if the specialist copay and the PCP copay are the same.] [SPECIALIST SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit] [Note to carriers: Use this item if the specialist copay exceeds the PCP copay.] [TELEMEDICINE VISITS [dollar amount not to exceed $50]] [E-VISITS [dollar amount not to exceed $50]] [VIRTUAL VISITS [dollar amount not to exceed $50]] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a high deductible health plan that could be used in conjunction Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with an HSAN.J.A.C. 11:22-5.5(a)]] Copayment/visit. SKILLED NURSING FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Approved; [amount consistent with N.J.A.C. 11:22-5.5(a)] Copayment per day. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit. [COMPLEX IMAGING SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]] [ALL OTHER] DIAGNOSTIC SERVICES INPATIENT $0 Copayment (OUTPATIENT) [$amount consistent with N.J.A.C. 11:22-5.5(a)]] Copayment/visit MAXIMUM OUT OF POCKET Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year. Once Members in a family meet the family Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year. [Tier 1] and [Tier 2] The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [Please note$6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount.] Note: There are separate The Maximum Out of Pocket amounts for cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Tier 1Example Using Deductible, Coinsurance] and [Tier 2] as shown on The services or supplies covered under this Contract are subject to the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as CopaymentCopayments, Deductible and Coinsurance set forth below and are determined per Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT Primary Care Provider but not for all Preventive Care Visits [Tier 1amount consistent with N.J.A.C. 11:22-5.5(a)]] Network per visit Preventive Care NONE Maternity (pre-natal care) NONE Prescription Drugs Copayments consistent with N.J.A.C. 11:22-5.5] All other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR  Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. Second Surgical Opinion All other Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward Per Member [dollar amount not to exceed the [Tier 1amount permitted by N.J.A.C. 11:20-3.1(b)3i] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network  Per Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an Family amount equal to two 2 times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Yearper member amount.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) COINSURANCE [[Tier 1Prescription Drugs 50% ] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. Preventive Care: NONE All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.) [Maximum Out of Pocket: The Per Covered Person and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Covered Person, the Maximum Out of Pocket is the annual maximum dollar amount that a Covered Person must pay as per Covered Person Cash Deductible plus Coinsurance and Copayments for all covered services and supplies to which a Copayment does not apply [10% - 50%, in a Calendar Year. Once the Per Covered Person Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance will be required for such Covered Person for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance for all covered 10% increments] All services and supplies in to which a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for members of the covered family for the rest of the Calendar YearCopayment applies None EMERGENCY ROOM COPAYMENT $100 Copayment/visit/Member (waived if admitted within 24 hours ).] [Note to carriers: Use the above text if the plan is issued as a high deductible health plan that could be used in conjunction with an HSA.] COVERED SERVICES & SUPPLIES [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the applicable Schedule of Services and Supplies and subject to the terms, conditions and limitations of this Contract. Read the entire Contract to determine what treatment, services and supplies are limited or excluded.