Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866) 403-2785 for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider and Out-of-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866) 403-2785 for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES PROVIDER NETWORK STATUS The MAC for out-of-network emergency medical services allowed amount may vary depending upon whether the Provider is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower outor an Out-of-pocket costs to Youof- Network Provider. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866at (▇▇▇) 403▇▇▇-2785 ▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our our networks are Out-of- Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our out-of-network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or an amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only ifsuch charges are less than the MACcalculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the non participating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non emergency medical services from an out-of- network provider, and You did NOT actively choose the out-of-network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the out-of-network provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum may vary depending on whether You received services from an In-Network or Out-of-Network Provider. Specifically, You may be required to pay higher cost sharing amounts or may have limits on Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances, You may only be asked to pay the lower In- Network cost sharing amount when You use an Out-of-Network Provider. For example, if You go to an In-Network Hospital or facility and receive Covered Services from an Out-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, You will pay the in-network cost share amounts for those Covered Services. However, You also may be liable for the difference between the MAC and the Out-of-Network Provider’s charge. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES PROVIDER NETWORK STATUS The MAC for out-of-network emergency medical services allowed amount may vary depending upon whether the Provider is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower outor an Out-of-pocket costs to Youof- Network Provider. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866at (▇▇▇) 403▇▇▇-2785 ▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or an amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only ifsuch charges are less than the MACcalculated by using one of the methods described above. The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the non-participating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non emergency medical services from an Out-of- Network ProvidersProvider, and You did NOT actively choose the Out-of-Network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-Network Provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum may vary depending on whether You received services from an In-Network or Out-of-Network Provider. Specifically, You may be required to pay higher cost sharing amounts or may have limits on Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for nonNon-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances, You may only be asked to pay the lower In- Network cost sharing amount when You use an Out-of-Network Provider. For example, if You go to an In-Network Hospital or facility and receive Covered Services from an Out-of- Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, You will pay the In-Network cost share amounts for those Covered Services. However, You also may be liable for the difference between the MAC and the Out-of-Network Provider’s charge. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the inIn-network Network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the inIn-network Network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the inIn-network Network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your Inin-Network network Coinsurance amount and Inin-Network network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider and Out-of-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor or have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare another health care professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or incidentalor inclusive. EMERGENCY SERVICES The allowed amount may vary depending upon whether the Provider is an In-Network or an Out-of-Network Provider. For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a Copayment or Coinsurance. Please call Customer Service at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For Covered Services You choose to receive from Out-of-Network Providers (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-Of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for outOut-of-network Network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for nonemergency medical services from an Out-of-Network provider, and You did NOT actively choose the Out-of-Network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-Network provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services Customer Service at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866) 403-2785 for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, ,We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866) 403-2785 for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the in-network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the in-network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Network Provider’s charge. Please contact Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES PROVIDER NETWORK STATUS The MAC for out-of-network emergency medical services allowed amount may vary depending upon whether the Provider is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower outor an Out-of-pocket costs to Youof- Network Provider. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866at (▇▇▇) 403▇▇▇-2785 ▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or an amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third-party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only ifsuch charges are less than the MACcalculated by using one of the methods described above. The MAC for Out-of-Network emergency medical services received in the state of Georgia is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4, the Surprise Billing and Consumer Protection Act; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the non-participating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. For Out-of-Network emergency services received outside the state of Georgia, the MAC or QPA (Qualifying Payment Amount) is calculated as described in the federal No Surprises Act; with respect to emergency services, We will calculate the QPA using the lesser of billed charges or: • The median contracted rate in 2019 for the same or similar service in the same geographic region, adjusted for inflation; or if not available, • The amount listed in an applicable State All-Payer Claims Database (APCD) or other eligible database, such as Fair Health; or if not available, • A derived amount for the purposes of submitting data in accordance with 45 CFR 153.710(c). The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non emergency medical services from an Out-of- Network ProvidersProvider, and You did NOT actively choose the Out-of-Network Provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-Network Provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower Out-of-Pocket costs to You. Please call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum may vary depending on whether You received services from an In-Network or Out-of-Network Provider. Specifically, You may be required to pay higher cost sharing amounts or may have limits on Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for nonNon-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances where Surprise Billing protections apply, You may only be asked to pay the lower In-Network cost sharing amount when You use an Out-of- Network Provider. If You actively choose to see an Out-of-Network Provider, Your cost share may include Your Out- of-Network Deductible, Copayments, or Coinsurance up to and including the Provider’s full billed charges. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the inIn-network Network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the inIn-network Network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-of- Network Provider’s charge. Please contact Client Services at (▇▇▇)) ▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. WHAT YOUR PLAN PAYS‌ In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES The MAC for out-of-network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866at (▇▇▇) 403▇▇▇-2785 ▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. The MAC for Out-of-Network emergency medical services is calculated as described in Federal No Surprises Act as the greater of: • The median contracted rate on 1/31/2019 for the same or similar service, in the same geographic area, adjusted for inflation. • The amount prescribed by an All-Payer Claims Database (APCD) in the state where the services are performed or a similar eligible third-party database. • An alternate derived amount assigned by the insurer for the item or service for the purpose of internal accounting or submission of data in accordance with 45 CFR 153.710(c). The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. Alliant will not provide any reimbursement for nonNon-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the inIn-network Network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the inIn-network Network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Out- of- Network Provider’s charge. Please contact Client Services at (▇▇▇)) ▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.

Benefits and Coverage. After You reach Your Out-of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for the remainder of the calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your In-Network Coinsurance amount and In-Network Out-of-Pocket Maximum. ANNUAL AND LIFETIME LIMITS There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network and Out-of-Network Provider contained in the Definitions section of this booklet. MAXIMUM ALLOWED COST (MAC) This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by Out-of-Network Providers is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not met Your Deductible nor have a Copayment or Coinsurance. In addition, when You receive Covered Services from an Out-of-Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, We may reduce the MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive. EMERGENCY SERVICES PROVIDER NETWORK STATUS The MAC for out-of-network emergency medical services allowed amount may vary depending upon whether the Provider is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was an In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. an Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policyProvider. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇)▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. PROVIDER NETWORK STATUS For Covered Services performed by an In-Network Provider, the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a copayment or Coinsurance. Please call Client Services at(866at (▇▇▇) 403▇▇▇-2785 ▇▇▇▇ for help in finding an In-Network Provider or visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of- Network Providers. For Covered Services You choose to receive from Out-of-Network Providers, the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third-party vendor which has been agreed to by the Provider. This may include rates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for Out-of-Network emergency medical services is calculated as described in Federal No Surprises Act as the greater of: • The median contracted rate on 1/31/2019 for the same or similar service, in the same geographic area, adjusted for inflation. • The amount prescribed by an All-Payer Claims Database (APCD) in the state where the services are performed or a similar eligible third-party database. • An alternate derived amount assigned by the insurer for the item or service for the purpose of internal accounting or submission of data in accordance with 45 CFR 153.710(c). The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for non-emergency medical services from an out- of- network provider, and You did NOT actively choose the Out-of-Network provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-Network provider to confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in lower out-of-pocket costs to You. Please call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ for help in finding an In-Network Provider or visit Our website at ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. MEMBER COST SHARE For certain Covered Services and depending on Your plan design, You may be required to pay a part of the MAC as Your cost share amount (e.g., Deductible, copayment, and/ or Coinsurance). Your cost share amount and Out-of-Pocket Maximum may vary depending on whether You received services from an In-Network or Out-of-Network Provider. Specifically, You may be required to pay higher cost sharing amounts or may have limits on Your benefits when using Out-of-Network Providers. Please see the Summary of Benefits and Coverage for Your cost share responsibilities and limitations or call Client Services at (▇▇▇) ▇▇▇-▇▇▇▇ to learn how Your plan’s benefits or cost share amounts may vary by the type of Provider You use. use Alliant will not provide any reimbursement for non-Covered Services. You will be responsible for the total amount billed by Your Provider for Non-Covered Services, regardless of whether such services are performed by an In-Network or Out-of-Network Provider. Both services specifically excluded by the terms of Your policy/plan and those received after benefits have been exhausted are Non-Covered Services. Benefits may be exhausted by exceeding, for example, calendar year day/visit limits. In some instances, You may only be asked to pay the lower In- Network cost sharing amount when You use an Out-of-Network Provider. For example, if You go to an In-Network Hospital or facility and receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or facility, You will pay the In-Network cost share amounts for those Covered Services. AUTHORIZED SERVICES In some circumstances, such as where there is no In-Network Provider available for the Covered Service, We may authorize the inIn-network Network cost share amounts (Deductible, Copayment, and/ or Coinsurance) to apply to a claim for a Covered Service You receive from an Out-of-Network Provider. In such circumstance, You must contact Us in advance of obtaining the Covered Service. We also may authorize the in-network cost share amounts to apply to a claim for Covered Services if You receive Emergency Services from an Out-of-Network Provider and are not able to contact Us until after the Covered Service is rendered. If We authorize a Covered Service so that You are responsible for the inIn-network Network cost share amounts, You may still be liable for the difference between the MAC and the Out-of-Out- of- Network Provider’s charge. Please contact Client Services at (▇▇▇)) ▇▇▇-▇▇▇▇ for Authorized Services information or to request authorization.