Common use of Paying for Covered Services Clause in Contracts

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed Charges. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; • Charges over the Allowed Charges; and • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for: • Your Cost Share; and • Charges for by capitation paymentsservices above any maximum Benefit allowance. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for: • Your Cost Share; • All charges over the Allowable Amount; and • Charges for services above any maximum Benefit allowance. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for: • An individual Member and an entire Family; and • Participating Providers and Non-Participating Providers. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for: • An individual Member and one for the an entire Family; • Participating Providers and Non-Participating Providers; and • Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; • Charges over the Allowed ChargesAllowable Amount; and • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recapEXAMPLE Cost to visit the doctor Now that you know the basics, you are responsible for all costs for Covered Services until you reach here is an example of how your DeductibleCost Share works. Once you reach your DeductiblePlease note, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described aboveDOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed Charges. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer ServiceShield Concierge. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; • Charges over the Allowed Charges; and • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: •  Deductible; •  Copayment amount; and •  Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for:  Your Cost Share; and  Charges for by capitation paymentsservices above any maximum Benefit allowance. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for:  Your Cost Share;  All charges over the Allowable Amount; and  Charges for services above any maximum Benefit allowance. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for:  An individual Member and an entire Family;  Participating Providers and Non-Participating Providers; and  Medical and pharmacy Benefits. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: •  You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; •  You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or •  You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for:  An individual Member and one for the an entire Family;  Participating Providers and Non-Participating Providers; and  Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: •  Charges for services that are not covered; •  Charges over the Allowed ChargesAllowable Amount; and •  Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for: • Your Cost Share; and • Charges for by capitation paymentsservices above any maximum Benefit allowance. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for: • Your Cost Share; • All charges over the Allowable Amount; and • Charges for services above any maximum Benefit allowance. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for: • An individual Member and an entire Family; • Participating Providers and Non-Participating Providers; and • Medical and pharmacy Benefits. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for: • An individual Member and one for the an entire Family; • Participating Providers and Non-Participating Providers; and • Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; • Charges over the Allowed ChargesAllowable Amount; and • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recapEXAMPLE Cost to visit the doctor Now that you know the basics, you are responsible for all costs for Covered Services until you reach here is an example of how your DeductibleCost Share works. Once you reach your DeductiblePlease note, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described aboveDOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for by capitation paymentsyour Cost Share. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for: • Your Cost Share; and • All charges over the Allowable Amount. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for: • An individual Member and an entire Family; • Participating Providers and Non-Participating Providers; and • Medical and pharmacy Benefits. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; • Charges over the Allowed Charges; and • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for by capitation paymentsyour Cost Share. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for: • Your Cost Share; and • All charges over the Allowable Amount. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for: • An individual Member and an entire Family; and • Participating Providers and Non-Participating Providers. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for: • An individual Member and one for the an entire Family; • Participating Providers and Non-Participating Providers; and • Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; and • Charges over the Allowed Charges; and • Charges for services over any Benefit maximumAllowable Amount. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recapEXAMPLE Cost to visit the doctor Now that you know the basics, you are responsible for all costs for Covered Services until you reach here is an example of how your DeductibleCost Share works. Once you reach your DeductiblePlease note, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described aboveDOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: •  Deductible; •  Copayment amount; and •  Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for:  Your Cost Share; and  Charges for by capitation paymentsservices above any maximum Benefit allowance. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for:  Your Cost Share;  All charges over the Allowable Amount; and  Charges for services above any maximum Benefit allowance. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for:  An individual Member and an entire Family; and  Participating Providers and Non-Participating Providers. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: •  You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; •  You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or •  You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for:  An individual Member and one for the an entire Family;  Participating Providers and Non-Participating Providers; and  Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: •  Charges for services that are not covered; •  Charges over the Allowed ChargesAllowable Amount; and •  Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.

Paying for Covered Services. Your Cost Share is the amount you pay for Covered Services. It is your portion of the Blue Shield Allowed ChargesAllowable Amount. Your Cost Share includes any: • Deductible; • Copayment amount; and • Coinsurance amount. See the Summary of Benefits section for your Cost Share for Covered Services. Allowed Charges Allowable Amount The Allowable Amount is the maximum amount Blue Shield will pay for Covered Services, or the provider’s billed charge for those Covered Services, whichever is less. Blue Shield’s payment to the provider is the difference between the Allowable Amount and capitation your Cost Share. Participating Providers agree to accept the Allowed Charges Allowable Amount as payment in full for Covered Services provided or arranged by Blue ShieldServices, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group When you see a Participating Provider, you are paid responsible for by capitation paymentsyour Cost Share. Every monthGenerally, Blue Shield pays a set dollar amount to will pay its portion of the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when Allowable Amount and you need themwill pay your Cost Share. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed ChargesAllowable Amount. You are only required to pay your Cost Share for those services. Non-Participating Providers do not agree to accept the Allowable Amount as payment in full for Covered Services. When you see a Non-Participating Provider, you are responsible for your for: • Your Cost Share; and • All charges over the Allowable Amount. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an for: • An individual Member and an entire Family; • Participating Providers and Non-Participating Providers; and • Medical and pharmacy Benefits. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges Allowable Amount you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges Allowable Amount until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, Coinsurance and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges Allowable Amount for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will Some plans may have a separate Out-of-Pocket Maximum for each for: • An individual Member and one for the an entire Family; • Participating Providers and Non-Participating Providers; and • Participating Providers and combined Participating and Non-Participating Providers. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum: • Charges for services that are not covered; and • Charges over the Allowed Charges; and • Charges for services over any Benefit maximumAllowable Amount. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Cost Share concepts in action To recapEXAMPLE Cost to visit the doctor Now that you know the basics, you are responsible for all costs for Covered Services until you reach here is an example of how your DeductibleCost Share works. Once you reach your DeductiblePlease note, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described aboveDOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.