Common use of SUMMARY OF MEDICAL BENEFITS Clause in Contracts

SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue SelectRI This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: • Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; • Covered Health Care Services - Section 3; • Health Care Services Not Covered Under This Agreement – Section 4; • Glossary – Section 8, for definitions of italicized words or phrases used throughout this *Preauthorization is recommended for services marked with an asterisk (*). Please see IMPORTANT NOTE: All of our payments at the benefit levels noted below are based upon a fee schedule called our allowance. If you receive services from a network provider, the provider has agreed to accept our allowance as payment in full for covered health care services, excluding your copayments, deductible (if any), and the difference between the maximum benefit and our allowance, if any. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit, less any copayments and deductibles (if any), if any. The deductible (if any) and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated in this agreement.

SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue SelectRI This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: •  Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; •  Covered Health Care Services - Section 3; •  Health Care Services Not Covered Under This Agreement – Section 4; •  Glossary – Section 8, for definitions of italicized words or phrases used throughout this *Preauthorization is recommended for services marked with an asterisk (*). Please see IMPORTANT NOTE: All of our payments at the benefit levels noted below are based upon a fee schedule called our allowance. If you receive services from a network provider, the provider has agreed to accept our allowance as payment in full for covered health care services, excluding your copayments, deductible (if any), and the difference between the maximum benefit and our allowance, if any. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit, less any copayments and deductibles (if any), if any. The deductible (if any) and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated in this agreement.

SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue SelectRI This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: • Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; • Covered Health Care Services - Section 3; • Health Care Services Not Covered Under This Agreement – Section 4; • Glossary – Section 8, for definitions of italicized words or phrases used throughout this agreement. *Preauthorization is recommended for services marked with an asterisk (*). Please see IMPORTANT NOTEPreauthorization in Section 1 and Section 8 for more information. COORDINATED CARE: All of our payments at Your primary care physician will coordinate your health care and refer you to other BlueCHiP providers when necessary. Only your primary care physician may refer you to other BlueCHiP providers. For example if your primary care physician refers you to a specialist, that specialist may not refer you to another specialist. In that case you would have to get a referral to the benefit levels noted below are based upon a fee schedule called our allowancesecond specialist from your primary care physician. If you receive services from a network provider, You may self-refer to the provider has agreed to accept our allowance as payment in full following BlueCHiP providers for covered health care services: • Behavioral Health Services; • Early Intervention Services*; • Emergency Care (Emergency Room Services, excluding your copayments, deductible (if any)Ambulance Services, and the difference between the maximum benefit free-standing Emergency Medical Centers); • Hair Prosthetics (Wigs)*; • Hearing Aids*; • Obstetricians and our allowance, if any. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit, less any copayments and deductibles (if any), if any. The deductible (if any) and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated in this agreement.Gynecologists;