Common use of NOTICE OF RIGHT TO EXAMINE CONTRACT Clause in Contracts

NOTICE OF RIGHT TO EXAMINE CONTRACT. Within 30 days after delivery of this Contract to You, You may return it to Us for a full refund of any premium paid, less the cost for services provided. The Contract will be deemed void from the beginning. [EFFECTIVE DATE OF CONTRACT: [January 1, 2014 ]] [Note to Carriers: Omit Effective date here if included below] Renewal Provision. Subject to all Contract terms and provisions, including those describing Termination of the Contract, You may renew and keep this Contract in force by paying the premiums as they become due. We agree to arrange or provide services under the terms and provisions of this Contract. In consideration of the application for this Contract and the payment of premiums as stated herein, We agree to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in New Jersey and is governed by the laws thereof. This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions. [Secretary President] [[Member]: Xxxx Xxx Identification Number: 125689 Effective Date: January 1, 2015 [Product Name: XXXX]] [Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members] 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 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 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 PHYSICIAN [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.] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [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. [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 means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services 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 and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [$6,600 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments, 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.

NOTICE OF RIGHT TO EXAMINE CONTRACT. Within 30 days after delivery of this Contract to You, You may return it to Us for a full refund of any premium Premium paid, less the cost for services provided. The Contract will be deemed void from the beginning. [EFFECTIVE DATE OF CONTRACT: [January September 1, 2014 ]] [Note to Carriers: Omit Effective date here if included below2012 ] Renewal Provision. Subject to all Contract terms and provisions, including those describing Termination of the Contract, You may renew and keep this Contract in force by paying the premiums as they become due. We agree to arrange or provide services under the terms and provisions of this Contract. In consideration of the application for this Contract and the payment of premiums as stated herein, We agree to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in New Jersey and is governed by the laws thereof. This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions. [Secretary President] [[Member]: Xxxx Xxx Identification Number: 125689 Effective Date: January 1, 2015 [Product Name: XXXX]] [Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members] 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 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 sheetare: Single Coverage Only $ Two Adults $ Adult and Child(ren) Coverage $ Family Coverage. $ ] 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 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 150, $300, $400, $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [ dollar amount equal to 10 times the per day copayment]/Calendar [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)$15, $30, $40, $50] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $[0] 0 Copayment OUTPATIENT VISIT amount consistent with N.J.A.C. 11:22-5.5(a)][$15, $30, $40, $50] 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)]$15, $30, $40, $50] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]$30, $60, $80, $100]] [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)]SURGERY:[$15, $30, $40, $50]] [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]0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) NONE [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT [$15, $30, $40, $50] Copayment/visit maximum 20 visits/Calendar Year. INPATIENT [$150, $300, $400, $500] Copayment/day for a maximum of 5 days per admission. Maximum Copayment: [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Maximum of 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. PRESCRIPTION DRUGS [50% Coinsurance] [copays consistent with N.J.A.C. 11:22-5.5(a) may be substituted for coinsurance] Coinsurance PRIMARY CARE PHYSICIAN [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. [OR CARE MANAGER] 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)]$15, $30, $40, $50] 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)]$30, $50, $60, $70] Copayment/visit] [Note to carriers: Use this item if the specialist copay exceeds the PCP copay.] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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$0 Copayment. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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)]15, $30, $40, $50] Copayment/visit MAXIMUM OUT SCHEDULE OF POCKET SERVICES AND SUPPLIES [Note to Carriers: This schedule illustrates the $30 copayment plan that must be offered by HMO carriers.] 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 $300 Copayment/day for a maximum of 5 days/admission. Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Copayment $3,000/Calendar Year. All amounts paid as Unlimited days. OUTPATIENT $30 Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT $30 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, Deductible and Coinsurance shall count toward if any. PRACTITIONER CHARGES FOR SURGERY: INPATIENT $0 Copayment OUTPATIENT $30 Copayment/visit FACILITY CHARGES FOR OUTPATIENT SURGERY:$15 HOME HEALTH CARE Unlimited days, if Pre-Approved; $0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) [at 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 and Supplies for the remainder option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES $30 Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT $30 Copayment/visit maximum 20 visits/Calendar Year. The INPATIENT $300 Copayment/day for a maximum of 5 days per admission. Maximum Out Copayment: $3,000/Calendar Year. Maximum of Pocket 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for this Contract is as follows: Per Member per additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION $30 Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING $30 Copayment/visit. PRESCRIPTION DRUGS- 50% Coinsurance PRIMARY CARE PHYSICIAN $30 Copayment/visit. [OR CARE MANAGER] SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if services are Preventive Care services. SPECIALIST SERVICES $6,600 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount30 Copayment/visit.] Note: REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Maximum Out of Pocket canCopayment does not be met with Nonapply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION $30 Copayment/visit. SKILLED NURSING FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Covered Services and SuppliesApproved; $0 Copayment. THERAPY SERVICES $30 Copayment/visit. DIAGNOSTIC SERVICES INPATIENT $0 Copayment (OUTPATIENT) $30 Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments, 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 For Primary Care Physician but not for Preventive Care Visits [ $15, $30, $40, $50] per visit For Preventive Care NONE Maternity (pre-natal care) [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment/initial visit. For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR For Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. for all other Covered Services and Supplies Per Member [$1,000, $2,500]  Per Covered Family [$2,000, $5,000.] COINSURANCE For Prescription Drugs 50% For Preventive Care: NONE For all services and supplies to which a Copayment does not apply [10% - 50%, in 10% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT $100 Copayment/visit/Member (waived if admitted within 24 hours ).

NOTICE OF RIGHT TO EXAMINE CONTRACT. Within 30 days after delivery of this Contract to You, You may return it to Us for a full refund of any premium Premium paid, less the cost for services provided. The Contract will be deemed void from the beginning. [EFFECTIVE DATE OF CONTRACT: [January 1September 23, 2014 ]] [Note to Carriers: Omit Effective date here if included below2010 ] Renewal Provision. Subject to all Contract terms and provisions, including those describing Termination of the Contract, You may renew and keep this Contract in force by paying the premiums as they become due. We agree to arrange or provide services under the terms and provisions of this Contract. In consideration of the application for this Contract and the payment of premiums as stated herein, We agree to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in New Jersey and is governed by the laws thereof. This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions. [Secretary President] [[Member]: Xxxx Xxx Identification Number: 125689 Effective Date: January 1, 2015 [Product Name: XXXX]] [Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members] 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 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 sheetare: Single Coverage Only $ Two Adults $ Adult and Child(ren) Coverage $ Family Coverage. $ ] 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 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 150, $300, $400, $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [ dollar amount equal to 10 times the per day copayment]/Calendar [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)$15, $30, $40, $50] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $[0] 0 Copayment OUTPATIENT VISIT amount consistent with N.J.A.C. 11:22-5.5(a)][$15, $30, $40, $50] 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)]$15, $30, $40, $50] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]$30, $60, $80, $100]] [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)]SURGERY:[$15, $30, $40, $50]] [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]0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) NONE [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT [$15, $30, $40, $50] Copayment/visit maximum 20 visits/Calendar Year. INPATIENT [$150, $300, $400, $500] Copayment/day for a maximum of 5 days per admission. Maximum Copayment: [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Maximum of 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. PRESCRIPTION DRUGS [DRUG 50% Coinsurance] [copays consistent with N.J.A.C. 11:22-5.5(a) may be substituted for coinsurance] Coinsurance PRIMARY CARE PHYSICIAN [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. [OR CARE MANAGER] 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)]$15, $30, $40, $50] 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)]$30, $50, $60, $70] Copayment/visit] [Note to carriers: Use this item if the specialist copay exceeds the PCP copay.] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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$0 Copayment. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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)]15, $30, $40, $50] Copayment/visit MAXIMUM OUT SCHEDULE OF POCKET SERVICES AND SUPPLIES [Note to Carriers: This schedule illustrates the $30 copayment plan that must be offered by HMO carriers.] 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 $300 Copayment/day for a maximum of 5 days/admission. Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Copayment $3,000/Calendar Year. All amounts paid as Unlimited days. OUTPATIENT $30 Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT $30 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, Deductible and Coinsurance shall count toward if any. PRACTITIONER CHARGES FOR SURGERY: INPATIENT $0 Copayment OUTPATIENT $30 Copayment/visit FACILITY CHARGES FOR OUTPATIENT SURGERY:$15 HOME HEALTH CARE Unlimited days, if Pre-Approved; $0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) [at 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 and Supplies for the remainder option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES $30 Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT $30 Copayment/visit maximum 20 visits/Calendar Year. The INPATIENT $300 Copayment/day for a maximum of 5 days per admission. Maximum Out Copayment: $3,000/Calendar Year. Maximum of Pocket 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for this Contract is as follows: Per Member per additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION $30 Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING $30 Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance PRIMARY CARE PHYSICIAN $30 Copayment/visit. [OR CARE MANAGER] SERVICES (OUTSIDE HOSPITAL) Copayment does not apply if services are Preventive Care services. SPECIALIST SERVICES $6,600 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount30 Copayment/visit.] Note: REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Maximum Out of Pocket canCopayment does not be met with Nonapply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION $30 Copayment/visit. SKILLED NURSING FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Covered Services and SuppliesApproved; $0 Copayment. THERAPY SERVICES $30 Copayment/visit. DIAGNOSTIC SERVICES INPATIENT $0 Copayment (OUTPATIENT) $30 Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments, 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 For Primary Care Physician but not for Preventive Care Visits [ $15, $30, $40, $50] per visit For Preventive Care NONE Maternity (pre-natal care) [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment/initial visit. For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR For Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. for all other Covered Services and Supplies Per Member [$1,000, $2,500]  Per Covered Family [$2,000, $5,000.] COINSURANCE PRESCRIPTION DRUG 50% Coinsurance For Preventive Care: NONE For all services and supplies to which a Copayment does not apply [10% - 50%, in 10% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT $100 Copayment/visit/Member (waived if admitted within 24 hours ).

NOTICE OF RIGHT TO EXAMINE CONTRACT. Within 30 days after delivery of this Contract to You, You may return it to Us for a full refund of any premium Premium paid, less the cost for services provided. The Contract will be deemed void from the beginning. [EFFECTIVE DATE OF CONTRACT: [January 1, 2014 ]] [Note to Carriers: Omit Effective date here if included below2009 ] Renewal Provision. Subject to all Contract terms and provisions, including those describing Termination of the Contract, You may renew and keep this Contract in force by paying the premiums as they become due. We agree to arrange or provide services under the terms and provisions of this Contract. In consideration of the application for this Contract and the payment of premiums as stated herein, We agree to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in New Jersey and is governed by the laws thereof. This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions. [Secretary President] [[Member]: Xxxx Xxx Identification Number: 125689 Effective Date: January 1, 2015 [Product Name: XXXX]] [Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members] 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 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 sheetare: Single Coverage Only $ Two Adults $ Adult and Child(ren) Coverage $ Family Coverage. $ ] 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 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 150, $300, $400, $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [ dollar amount equal to 10 times the per day copayment]/Calendar [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Unlimited days. OUTPATIENT [amount consistent with N.J.A.C. 11:22-5.5(a)$15, $30, $40, $50] Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $[0] 0 Copayment OUTPATIENT VISIT amount consistent with N.J.A.C. 11:22-5.5(a)][$15, $30, $40, $50] 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)]$15, $30, $40, $50] Copayment/visit [FACILITY CHARGES FOR OUTPATIENT SURGERY: AMBULATORY SURGERY CENTER [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] HOSPITAL OUTPATIENT DEPARTMENT [amount consistent with N.J.A.C. 11:22-5.5(a)]$30, $60, $80, $100]] [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)]SURGERY:[$15, $30, $40, $50]] [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]0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) NONE [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT [$15, $30, $40, $50] Copayment/visit maximum 20 visits/Calendar Year. INPATIENT [$150, $300, $400, $500] Copayment/day for a maximum of 5 days per admission. Maximum Copayment: [$1,500, $3,000, $4,000, $5,000]/Calendar Year. Maximum of 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. PRESCRIPTION DRUGS [DRUG 50% Coinsurance] [copays consistent with N.J.A.C. 11:22-5.5(a) may be substituted for coinsurance] Coinsurance PRIMARY CARE PHYSICIAN [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] Copayment/visit. [OR CARE MANAGER] 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)]$15, $30, $40, $50] 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)]$30, $50, $60, $70] Copayment/visit] [Note to carriers: Use this item if the specialist copay exceeds the PCP copay.] REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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$0 Copayment. THERAPY SERVICES [amount consistent with N.J.A.C. 11:22-5.5(a)]$15, $30, $40, $50] 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)]15, $30, $40, $50] Copayment/visit MAXIMUM OUT SCHEDULE OF POCKET SERVICES AND SUPPLIES [Note to Carriers: This schedule illustrates the $30 copayment plan that must be offered by HMO carriers.] 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 $300 Copayment/day for a maximum of 5 days/admission. Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Copayment $3,000/Calendar Year. All amounts paid as Unlimited days. OUTPATIENT $30 Copayment/visit PRACTITIONER SERVICES RECEIVED AT A HOSPITAL: INPATIENT VISIT $0 Copayment OUTPATIENT VISIT $30 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, Deductible and Coinsurance shall count toward if any. PRACTITIONER CHARGES FOR SURGERY: INPATIENT $0 Copayment OUTPATIENT $30 Copayment/visit FACILITY CHARGES FOR OUTPATIENT SURGERY:$15 HOME HEALTH CARE Unlimited days, if Pre-Approved; $0 Copayment. HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment. MATERNITY (PRE-NATAL CARE) [at 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 and Supplies for the remainder option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter. BIRTHING CENTER SERVICES $30 Copayment/visit NON-BIOLOGICALLY BASED MENTAL ILLNESS AND SUBSTANCE ABUSE: OUTPATIENT $30 Copayment/visit maximum 20 visits/Calendar Year. The INPATIENT $300 Copayment/day for a maximum of 5 days per admission. Maximum Out Copayment: $3,000/Calendar Year. Maximum of Pocket 30 days inpatient care/Calendar Year. Subject to Pre-Approval, unused Inpatient days may be exchanged for this Contract is as follows: Per Member per additional Outpatient visits, where each Inpatient day may be exchanged for two Outpatient visits. THERAPEUTIC MANIPULATION $30 Copayment/visit; maximum 30 visits/Calendar Year PRE-ADMISSION TESTING $30 Copayment/visit. PRESCRIPTION DRUG 50% Coinsurance PRIMARY CARE PHYSICIAN $30 Copayment/visit. [OR CARE MANAGER] SERVICES (OUTSIDE HOSPITAL) SPECIALIST SERVICES $6,600 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount30 Copayment/visit.] Note: REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Maximum Out of Pocket canCopayment does not be met with Nonapply if Admission is immediately preceded by a Hospital Inpatient Stay. SECOND SURGICAL OPINION $30 Copayment/visit. SKILLED NURSING FACILITY/ EXTENDED CARE CENTER Unlimited days, if Pre-Covered Services and SuppliesApproved; $0 Copayment. THERAPY SERVICES $30 Copayment/visit. DIAGNOSTIC SERVICES INPATIENT $0 Copayment (OUTPATIENT) $30 Copayment/visit SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments, 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 For Primary Care Physician and Preventive Care Visits [ $15, $30, $40, $50] per visit Maternity (pre-natal care) [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment/initial visit. For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections DEDUCTIBLE PER CALENDAR YEAR For Preventive Care and immunizations and lead screening for children NONE Maternity (pre-natal care) NONE. for all other Covered Services and Supplies Per Member [$1,000, $2,500]  Per Covered Family [$2,000, $5,000.] COINSURANCE PRESCRIPTION DRUG 50% Coinsurance For all services and supplies to which a Copayment does not apply [10% - 50%, in 10% increments] For all services and supplies to which a Copayment applies None EMERGENCY ROOM COPAYMENT $100 Copayment/visit/Member (waived if admitted within 24 hours ).

NOTICE OF RIGHT TO EXAMINE CONTRACT. Within 30 days after delivery of this Contract to You, You may return it to Us for a full refund of any premium paid, less the cost for services provided. The Contract will be deemed void from the beginning. [EFFECTIVE DATE OF CONTRACT: [January 1, 2014 2016 ]] [Note to Carriers: Omit Effective date here if included below] Renewal Provision. Subject to all Contract terms and provisions, including those describing Termination of the Contract, You may renew and keep this Contract in force by paying the premiums as they become due. We agree to arrange or provide services under the terms and provisions of this Contract. In consideration of the application for this Contract and the payment of premiums as stated herein, We agree to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in New Jersey and is governed by the laws thereof. This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions. [Secretary President] [[Member]: Xxxx Xxx Identification Number: 125689 Effective Date: January 1, 2015 2016 [Product Name: XXXX]] [Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members] 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 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 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 PHYSICIAN 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 Hospital Inpatient Stay. SECOND SURGICAL OPINION [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. [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 means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services 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 and Supplies for the remainder of the Calendar Year. The Maximum Out of Pocket for this Contract is as follows: Per Member per Calendar Year [$6,600 6,850 or amount permitted by 45 C.F.R. 156.130] Per Family per Calendar Year [$2X per member amount.] Note: The Maximum Out of Pocket cannot be met with Non-Covered Services and Supplies. SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance] The services or supplies covered under this Contract are subject to the Copayments, 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.