Common use of Copayments Clause in Contracts

Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONS; and • may require Prior Authorization.

Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONSLimitations and Exclusions; and • may require Prior Authorization.

Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONSLimitations and Exclusions; and • may require Prior AuthorizationPreauthorization.

Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered DrugsServices. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity a dental Riderplan associated with this Certificate. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONSLimitations and Exclusions; and • may require Prior AuthorizationPreauthorization.

Copayments. You are liable for certain Copayments to Participating Providers, which are due at the time of service. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom You have made payments for Covered Services and for Covered Drugs. Out-of-pocket maximums will include Copayments for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. If You have several covered Dependents, all charges used to apply toward an individual out-of-pocket maximum will be applied towards the family out-of-pocket maximum amount shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits. When the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITSSchedule of Copayments and Benefit Limits; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONSLimitations and Exclusions; and • may require Prior AuthorizationPreauthorization.

Copayments. Except where stated otherwise, after You have satisfied the Deductible as described above, You must pay the Copayments, or fixed amounts, in the Schedule of Benefits for Covered Services. However, when the Allowed Amount for a service is less than the Copayment, You are liable responsible for certain Copayments the lesser amount. Except where stated otherwise, after You have satisfied the Deductible described above, You must pay a percentage of the Allowed Amount for Covered Services. We will pay the remaining percentage of the Allowed Amount as Your benefit as shown in the Schedule of Benefits. Your Coinsurance does not apply to Participating Providers, charges for services which are due at the time not covered and will not be reduced by refunds, rebates or any other form of servicenegotiated post-payment adjustments. The Copayment due for specific Covered Services, benefit limitations and out-of-pocket maximums can be found in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. The Copayment amount shall not exceed 50% of the total cost of the services provided. Copayments paid by You or on Your behalf in a Calendar Year shall not exceed 200% of the total annual Premium. HMO will determine when maximums have been reached for Covered Services and for Covered Drugs based on information provided to HMO by You and Participating Providers to whom When You have made payments for Covered Services and for Covered Drugs. met Your Out-of-pocket maximums Pocket Limit in payment of Copayments, Deductibles and Coinsurance for a Benefit Period in the Schedule of Benefits, We will include Copayments provide coverage for 100% of the Allowed Amount for Covered Services and any eligible dental expenses payment obligations from the indemnity dental Rider. Once You reach the out-of-pocket maximum, You are not required to make additional payments for Covered Services or Covered Drugs for the remainder of the Calendar Yearthat Benefit Period. If You have several covered Dependentsother than individual coverage, all charges used to apply toward an once a person within a family meets the individual outOut-of-pocket maximum Pocket Limit in the Schedule of Benefits, We will be applied towards provide coverage for 100% of the Allowed Amount for the rest of that Benefit Period for that person. If other than individual coverage applies, when persons in the same family covered under this Certificate have collectively met the family out-Out- of-pocket maximum amount shown Pocket Limit in payment of Copayments, Deductibles and Coinsurance for a Benefit Period in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS. When Schedule of Benefits, We will provide coverage for 100% of the family out-of-pocket maximum amount is reached, You are not required to make additional payments for Covered Services or Covered Drugs Allowed Amount for the remainder rest of that Benefit Period for the Calendar Year. All Covered Services, unless otherwise specifically described: • must be Medically Necessary; • must be performed, prescribed, directed or authorized in advance by the PCP and/or the HMO; • must be rendered by a Participating Provider; • are subject to the Copayment shown in the SCHEDULE OF COPAYMENTS AND BENEFIT LIMITS; • may have limitations, restrictions or exclusions described in LIMITATIONS AND EXCLUSIONS; and • may require Prior Authorizationentire family.