Common use of UNDERSTANDING THE BASICS OF YOUR COVERAGE Clause in Contracts

UNDERSTANDING THE BASICS OF YOUR COVERAGE. THIS IS A LIMITED BENEFIT POLICY PROVIDING COVERAGE FOR NEEDLE STICKS ONLY. PLEASE READ CAREFULLY. Blue Cross and Blue Shield of Louisiana issues this Student Group Health Insurance Limited Benefit Plan to the University shown in the Schedule of Benefits. A copy of this Benefit Plan provided to a Subscriber serves as the Subscriber’s certificate of coverage. As of the Benefit Plan Date shown in the University’s Schedule of Benefits, We agree to provide the Benefits specified herein for Subscribers of the University. This Benefit Plan replaces any others previously issued to the University as of the Benefit Plan Date or amended Benefit Plan Date. This Plan describes Your Benefits, as well as Your rights and responsibilities under the Plan. We encourage You to read this Benefit Plan carefully. You should call Us if You have questions about Your coverage or any limits to the coverage available to You. Many of the sections of this Benefit Plan are related to other sections of this Plan. You may not have all of the information You need by reading just one section. Please be aware that Your Physician does not have a copy of Your Benefit Plan, and is not responsible for knowing or communicating Your Benefits. Except for necessary technical terms, We use common words to describe the benefits provided under this Benefit Plan. “We,” “Us” and “Our” means BLUE CROSS AND BLUE SHIELD OF LOUISIANA. Capitalized words are defined terms in Article II - “Definitions.” A word used in the masculine gender applies also in the feminine gender, except where otherwise stated. FACTS ABOUT THIS STUDENT GROUP HEALTH INSURANCE LIMITED NEEDLE STICK BENEFIT PLAN This Benefit Plan is a limited benefit blanket group health insurance plan written by Blue Cross and Blue Shield of Louisiana and issued to the University. It is a student health insurance policy intended to cover University’s Eligible Students as defined in the Benefit Plan. This Plan provides student coverage for Needle Sticks only. It is not a comprehensive medical plan. In order to maximize Your student health service benefits, You may wish to initially visit LOUISIANA STATE UNIVERSITY HEALTH SCIENCE CENTERS STUDENT HEALTH SERVICE (LSUHSC) for Your Medical care. Some medical services for students are provided as part of Your student health fee. If You require health services not available at LSUHSC, You may want to seek care from a Preferred Care (PCare) PPO Network Provider because Your cost will generally be lower than seeing a Non-Network Provider. OUR PROVIDER NETWORK This is a network policy. Subscribers have the right to use Providers of their choice. The Subscriber’s choice of Provider will impact whether the Subscriber must pay anything toward Covered Services. When You receive Covered Services from Your student health center or a Provider in Our PPO Network, You will owe nothing for care covered under this policy. Our Preferred Care PPO (or PCare) Network consists of a select group of Physicians, Hospitals and other Allied Health Professionals who have contracted with Us to participate in the Blue Cross and Blue Shield of Louisiana PPO Provider Network and render services to Our Members. We call these Providers "PPO Providers," "Preferred Providers," or "Network Providers." Subscribers should know that care received from a Non-Network physician, facility or other healthcare professional means a cost to the Subscriber. We pay a Non-Network Provider the amount a Network Provider would accept for the same service. It is the Subscriber’s responsibility to pay the remainder of a Non-Network Provider’s bill up to the billed charge. To obtain the highest level of Benefits available, the Member should always verify that a Provider is a current Blue Cross and Blue Shield of Louisiana Preferred Care Provider before the service is rendered. Members may review a current paper Provider directory, check on-line at xxx.xxxxxx.xxx, or contact Our Customer Service Department at the number listed on their identification (ID) card. A Provider’s status may change from time to time. Members should always verify the Network status of a Provider before obtaining services. NOTICE: THE SUBSCRIBER’S SHARE OF THE PAYMENT FOR HEALTHCARE SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN THE SUBSCRIBER’S HEALTH PLAN AND THE SUBSCRIBER’S PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW THE SUBSCRIBER’S PROVIDER TO BILL THE SUBSCRIBER FOR AMOUNTS UP TO THE PROVIDER'S REGULAR BILLED CHARGES. NOTE: When a Subscriber receives Covered Services from a Non-Participating Hospital, the Benefits that the Company will pay under this Benefit Plan will be reduced by thirty percent (30%).

UNDERSTANDING THE BASICS OF YOUR COVERAGE. THIS IS A LIMITED BENEFIT POLICY PROVIDING COVERAGE FOR NEEDLE STICKS ONLY. PLEASE READ CAREFULLY. Blue Cross and Blue Shield of Louisiana (Company) issues this Student Group Health Insurance Limited Benefit Plan to the University Group/Policyholder, as shown in the Schedule of Vision Benefits. A copy of this Benefit Plan provided to a Subscriber Subscribers serves as the Subscriber’s certificate of coverage. The vision Benefits available under this Benefit Plan are described in Article IV. The Schedule of Vision Benefits controls in regards to the Benefits covered, the frequency with which they are covered, and the cost sharing applicable to each Benefit, among other things. A Subscriber must meet the employer’s Eligibility Waiting Period before coverage is effective on this Benefit Plan. The Group may apply to the Company to change the covered Benefits on the Group's anniversary date. Benefits offered may be limited. As of the later of the Original Effective Date or the Amended Effective Date of the Benefit Plan Date shown in the UniversityGroup’s Schedule of Vision Benefits, We agree to provide the vision Benefits specified herein for Subscribers of the UniversityGroup and their enrolled Dependents. This Benefit Plan replaces any others previously issued to the University as of the Benefit Plan Date or amended Benefit Plan DateGroup/Policyholder. This Plan describes Your Benefits, as well as Your rights and responsibilities under the Plan. We encourage You to read this Benefit Plan carefully. You should call Us if You have questions about Your coverage or any limits to the coverage available to You. Many of the sections of this Benefit Plan are related to other sections of this Plan. You may not have all of the information You need by reading just one section. Please be aware that Your Physician does not have a copy of Your Benefit Plan, and is not responsible for knowing or communicating Your Benefits. Except for necessary technical terms, We use common words to describe the benefits provided under this Benefit Plan. “We,” “Us” and “Our” means BLUE CROSS AND BLUE SHIELD OF LOUISIANA. Capitalized words are defined terms in Article II - “Definitions.” A word used in the masculine gender applies also in the feminine gender, except where otherwise stated. FACTS ABOUT THIS STUDENT GROUP HEALTH INSURANCE LIMITED NEEDLE STICK BENEFIT PLAN This Except for necessary technical terms, We use common words to describe the Benefits provided under this Benefit Plan is a limited benefit blanket group health insurance plan written by Plan. “We”, “Us” and “Our” means Blue Cross and Blue Shield of Louisiana Louisiana. Capitalized words are defined terms in Article II “Definitions.” THE XXXXX VISION NETWORK Xxxxx Vision, Inc. (hereinafter, “Xxxxx Vision) is the Company’s network and issued claims administrator for this Benefit Plan, and is in charge of managing the Xxxxx Vision Network, handling and paying claims, and providing customer services to the University. It is a student health insurance policy intended Members eligible to cover University’s Eligible Students as defined in the receive coverage under this Benefit Plan. This Plan provides student coverage for Needle Sticks only. It is not a comprehensive medical plan. In order to maximize Your student health service benefits, You may wish to initially visit LOUISIANA STATE UNIVERSITY HEALTH SCIENCE CENTERS STUDENT HEALTH SERVICE (LSUHSC) for Your Medical care. Some medical services for students are provided as part of Your student health fee. If You require health services not available at LSUHSC, You may want to seek care from a Preferred Care (PCare) PPO Network Provider because Your cost will generally be lower than seeing a Non-Network Provider. OUR PROVIDER NETWORK This is a network policy. Subscribers have the right to use Providers of their choice. The Subscriber’s choice of Provider will impact whether the Subscriber must pay anything toward Covered Services. When You receive Covered Services from Your student health center or a Provider in Our PPO Network, You will owe nothing for care covered under this policy. Our Preferred Care PPO (or PCare) Xxxxx Vision Network consists of a select group of Physicians, Hospitals and other Allied Health Professionals Providers who have contracted with Us Xxxxx Vision to participate in the Blue Cross and Blue Shield of Louisiana PPO Provider Network and render services to Our MembersMembers for discounted fees. We call these All other Providers "PPO Providers," "Preferred Providers," or "Network Providers." Subscribers should know that care received from a are considered Non-Network physician, facility or other healthcare professional means a cost Participating. THIS BENEFIT PLAN COVERS SERVICES OR MATERIALS RECEIVED FROM NON-PARTICIPATING PROVIDERS AT THE REDUCED BENEFITS SPECIFIED IN THE SCHEDULE OF VISION BENEFITS. In order to receive the Subscriber. We pay a Non-Network Provider the amount a Network Provider would accept for the same service. It is the Subscriber’s responsibility to pay the remainder of a Non-Network Provider’s bill up to the billed charge. To obtain the highest level of Benefits availablefull benefits under this section, the Member should always verify that a Provider is a current Blue Cross and Blue Shield of Louisiana Preferred Care Xxxxx Vision Network Participating Provider before the any service is rendered. Members may review To locate a current paper Participating Provider directory, check on-line at xxx.xxxxxx.xxxand verify their continued participation in the Xxxxx Vision Network, or to ask any questions related to Benefits or claims, please visit the website at [xxx.xxxxxx.xxx] or contact Our Customer Service Department a customer service representative at [0-000-000-0000]. HOW THE COMPANY DETERMINES WHAT IT PAYS FOR COVERED SERVICES The Company bases its payment of Benefits for a Member’s Covered Services on an amount known as the number listed “Allowable Charge.” The Allowable Charge is determined according to Xxxxx Vision’s fee schedule for each covered Benefit. If the amount that is billed for Covered Services by the Member’s Provider is less than the amount that Xxxxx Vision has set for the Covered Service, the billed amount is the Allowable Charge and the Company’s payment will be based on their identification (ID) card. A Provider’s status may change from time to time. Members should always verify the Network status of a Provider before obtaining servicesbilled amount. NOTICE: THE SUBSCRIBERMEMBER’S SHARE OF THE PAYMENT FOR HEALTHCARE COVERED SERVICES MAY BE BASED ON THE AGREEMENT BETWEEN THE SUBSCRIBERMEMBER’S HEALTH PLAN AND THE SUBSCRIBERMEMBER’S PROVIDER. UNDER CERTAIN CIRCUMSTANCES, THIS AGREEMENT MAY ALLOW THE SUBSCRIBERMEMBER’S PROVIDER TO BILL THE SUBSCRIBER MEMBER FOR AMOUNTS UP TO THE PROVIDER'S ’S REGULAR BILLED CHARGES. NOTE: When a Subscriber receives Covered Services from a Non-Participating Hospital, the Benefits that the Company will pay under this Benefit Plan will be reduced by thirty percent (30%).