Common use of PRIMARY AND SECONDARY PLAN Clause in Contracts

PRIMARY AND SECONDARY PLAN. We consider each plan separately when coordinating payments. For the purpose of coordinating benefits with this individual contract, Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan is always the Primary Plan and this Contract is always the Secondary Plan. Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan pays or provides services or supplies first, without taking into consideration the existence of this Contract. This Contract takes into consideration the benefits provided by Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan. During each Claim Determination Period, this Contract will pay up to the remaining unpaid allowable expenses, but this Contract will not pay more than it would have paid if it had been the Primary Plan. The method this Contract uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. This Contract shall not reduce Allowable Expenses for Medically Necessary and Appropriate services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the Member may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an allowed charge is called an “AC Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the Member may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” An HMO and Exclusive Provider Organization (EPO) are examples of network only plans that could use a fee schedule. If the Member uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Payment to the provider may be based on a “capitation”. This means that then HMO or other plans pays the provider a fixed amount per Member. The Member is liable only for the applicable deductible, coinsurance or copayment. If the Member uses the services of a non-network provider, the HMO, EPO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan, and “EPO” refers to Exclusive Provider Organization. Primary Plan is AC Plan and Secondary Plan is AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the Member shall not exceed the fee schedule of the Primary Plan. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The Member shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the Member has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or AC Plan If Member receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan If the Member receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The Member shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. [Primary Plan is an HMO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.] [Note to carriers: This paragraph should only be included in plans issued as HMO or EPO coverage.] SERVICES FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a [Member’s] coverage under this Contract when services are provided as a result of an automobile related Injury.

PRIMARY AND SECONDARY PLAN. We consider each plan separately when coordinating payments. For the purpose of coordinating benefits with this individual contract, Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan is always the Primary Plan and this Contract is always the Secondary Plan. Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan pays or provides services or supplies first, without taking into consideration the existence of this Contract. This Contract takes into consideration the benefits provided by Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan. During each Claim Determination Period, this Contract will pay up to the remaining unpaid allowable expenses, but this Contract will not pay more than it would have paid if it had been the Primary Plan. The method this Contract uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. This Contract shall not reduce Allowable Expenses for Medically Necessary medically necessary and Appropriate appropriate services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the Member may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an allowed charge is called an “AC PlanACPlan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the Member may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” An HMO and Exclusive Provider Organization (EPO) are examples of network only plans that could use a fee schedule. If the Member uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Payment to the provider may be based on a “capitation”. This means that then HMO or other plans pays the provider a fixed amount per Member. The Member is liable only for the applicable deductible, coinsurance or copayment. If the Member uses the services of a non-network provider, the HMO, EPO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan, and “EPO” refers to Exclusive Provider Organization. Primary Plan is AC Plan and Secondary Plan is AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the Member shall not exceed the fee schedule of the Primary Plan. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The Member shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the Member has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or AC Plan If Member receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan If the Member receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The Member shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. [Primary Plan is an HMO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.] [Note to carriers: This paragraph should only be included in plans issued as HMO or EPO coverage.] SERVICES FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a [Member’s] coverage under this Contract when services are provided as a result of an automobile related Injury.

PRIMARY AND SECONDARY PLAN. We consider each plan separately when coordinating payments. For the purpose of coordinating benefits with this individual contract, Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan is always the Primary Plan and this Contract is always the Secondary Plan. Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan pays or provides services or supplies first, without taking into consideration the existence of this Contract. This Contract takes into consideration the benefits provided by Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan. During each Claim Determination Period, this Contract will pay up to the remaining unpaid allowable expenses, but this Contract will not pay more than it would have paid if it had been the Primary Plan. The method this Contract uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. This Contract shall not reduce Allowable Expenses for Medically Necessary and Appropriate services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the Member may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an allowed charge is called an “AC PlanACPlan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the Member may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” An HMO and Exclusive Provider Organization (EPO) are examples of network only plans that could use a fee schedule. If the Member uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Payment to the provider may be based on a “capitation”. This means that then HMO or other plans pays the provider a fixed amount per Member. The Member is liable only for the applicable deductible, coinsurance or copayment. If the Member uses the services of a non-network provider, the HMO, EPO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan, and “EPO” refers to Exclusive Provider Organization. Primary Plan is AC Plan and Secondary Plan is AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the Member shall not exceed the fee schedule of the Primary Plan. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The Member shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the Member has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or AC Plan If Member receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan If the Member receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The Member shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. [Primary Plan is an HMO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.] [Note to carriers: This paragraph should only be included in plans issued as HMO or EPO coverage.] SERVICES FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a [Member’s] coverage under this Contract when services are provided as a result of an automobile related Injury.

PRIMARY AND SECONDARY PLAN. We consider each plan separately when coordinating payments. For the purpose of coordinating benefits with this individual contract, Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan is always the Primary Plan and this Contract is always the Secondary Plan. Medicare or coverage Coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan pays or provides services or supplies first, without taking into consideration the existence of this Contract. This Contract takes into consideration the benefits provided by Medicare or coverage under a group Health Benefits Plan, Group Health Plan, Governmental Plan, or Church Plan. During each Claim Determination Period, this Contract will pay up to the remaining unpaid allowable expenses, but this Contract will not pay more than it would have paid if it had been the Primary Plan. The method this Contract uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. This Contract shall not reduce Allowable Expenses for Medically Necessary and Appropriate services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: the basis on which the Primary Plan and the Secondary Plan pay benefits; and whether the provider who provides or arranges the services and supplies is in the network of either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the Member may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an allowed charge is called an “AC Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the Member may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” An HMO and Exclusive Provider Organization (EPO) are examples of network only plans that could use a fee schedule. If the Member uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Payment to the provider may be based on a “capitation”. This means that then HMO or other plans pays the provider a fixed amount per Member. The Member is liable only for the applicable deductible, coinsurance or copayment. If the Member uses the services of a non-network provider, the HMO, EPO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan, and “EPO” refers to Exclusive Provider Organization. Primary Plan is AC Plan and Secondary Plan is AC Plan The Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the Member shall not exceed the fee schedule of the Primary Plan. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is AC Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: the difference between the amount of the billed charges for the Allowable Expenses and the amount paid by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. The Member shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the Member has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Fee Schedule Plan and Secondary Plan is AC Plan or Fee Schedule Plan If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or AC Plan If Member receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of: The amount of any deductible, coinsurance or copayment required by the Primary Plan; or the amount the Secondary Plan would have paid if it had been the Primary Plan. Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan If the Member receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The Member shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan. [Primary Plan is an HMO and Secondary Plan is an HMO or EPO If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.] [Note to carriers: This paragraph should only be included in plans issued as HMO or EPO coverage.] SERVICES FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a [Member’s] coverage under this Contract when services are provided as a result of an automobile related Injury.]