BENEFIT PAYMENT FOR PHYSICIAN SERVICES

The benefits provided by Blue Cross and Blue Shield and the expenses that are your responsibility for your Covered Services will depend on whether you re­

ceive services from a Community, Participating or Non‐Participating Professional Provider.

Community Provider

When you receive any of the Covered Services described in this Physician Benefit Section from a Community Provider, benefits will be provided at after you have met your program deductible.

When you receive Covered Services in your Physician's office, benefits for of­

fice visits are subject to a Copayment of $20 per visit. Benefits for office visits will then be provided at 100% of the Maximum Allowance. Your program de­

ductible will not apply.

Your benefits for Outpatient Diagnostic Services and mammograms (other than routine mammograms) will not be subject to the program deductible. Benefits for routine mammograms will be provided at the benefit payment level de­

scribed in the SPECIAL CONDITIONS AND PAYMENTS section of this Certificate.

For Physician Covered Services you receive from a Provider other than a Com­

munity Provider, benefit payment will be as described below.

Participating Provider

When you receive any of the Covered Services described in this Physician Benefit Section from a Participating Provider or from a Dentist, benefits will be provided at 80% of the Maximum Allowance after you have met your program deductible, unless otherwise specified in this Certificate. Although Dentists are not Participating Providers they will be treated as such for purposes of benefit payment made under this Certificate and may bill you for the difference be­

tween the Blue Cross and Blue Shield benefit payment and the Provider's charge to you.

When you receive Covered Services in a Participating Provider's office, bene­

fits for office visits are subject to a Copayment of $20 per visit. Benefits for office visits will then be provided at 80% of the Maximum Allowance. Your program deductible will not apply.

Benefits for Outpatient Diagnostic Service and mammograms (other than rou­

tine mammograms) will be provided at 80% of the Maximum Allowance from a Participating Provider and will not be subject to the program deductible.

Benefits for routine mammograms will be provided at the benefit payment level described in the SPECIAL CONDITIONS AND PAYMENTS section of this Certificate.

Non‐Participating Provider

When you receive any of the Covered Services described in this Physician

60% of the Maximum Allowance after you have met your program deductible, unless otherwise specified in this Certificate.

When you receive Covered Services, from a Participating Hospital or from a Plan Ambulatory Surgical Facility and, due to any reason, Covered Services for anesthesiology, pathology, radiology, neonatology or emergency room are un­

available from a Participating Provider and Covered Services are provided by a Non‐Participating Provider, you will incur no greater out‐of‐pocket costs than you would have incurred if the Covered Services were provided by a Participat­

ing Provider.

However, in the event that you willfully choose to receive Covered Services from a Non‐Participating Provider when a Participating Professional Provider is available, or you or the Non‐Participating Provider reject the assignment of benefits, the above provision will not apply to you.

Benefits for Outpatient Diagnostic Service and mammograms (other than rou­

tine mammograms) will be provided at 60% of the Maximum Allowance from a Non‐Participating Provider and will not be subject to the program deductible.

Benefits for routine mammograms will be provided at the benefit payment level described in the SPECIAL CONDITIONS AND PAYMENTS section of this Certificate.

Emergency Care

Benefits for Emergency Accident Care will be provided at 90% of the Maxi­

mum Allowance when rendered by either a Community, Participating or Non‐Participating Provider. Your program deductible will not apply.

Benefits for Emergency Medical Care will be provided at 90% of the Maximum Allowance when rendered by either a Community, Participating or Non‐Partici­

pating Provider. Your program deductible will not apply.

However, Covered Services for Emergency Accident Care and Emergency Medical Care resulting from a criminal sexual assault or abuse will be paid at 100% of the Maximum Allowance whether or not you have met your program deductible. The office visit Copayment will not apply.

Community Providers and Participating Providers are:

S Physicians S Podiatrists S Psychologists

S Certified Clinical Nurse Specialists S Certified Nurse‐Midwives

S Certified Nurse Practitioners

S Certified Registered Nurse Anesthetists S Chiropractors

S Clinical Laboratories

S Clinical Professional Counselors S Clinical Social Workers

S Durable Medical Equipment Providers S Home Infusion Therapy Providers S Marriage and Family Therapists S Occupational Therapists S Optometrists

S Orthotic Providers S Physical Therapists S Prosthetic Providers

S Registered Surgical Assistants S Retail Health Clinics

S Speech Therapists

who have signed an Agreement with Blue Cross and Blue Shield to accept the Maximum Allowance as payment in full. Such Community Providers and Par­

ticipating Providers have agreed not to bill you for Covered Services amounts in excess of the Maximum Allowance. Therefore, you will be responsible only for the difference between the Blue Cross and Blue Shield benefit payment and the Maximum Allowance for the particular Covered Service — that is, your pro­

gram deductible, Copayment and Coinsurance amounts.

Non‐Participating Providers are:

S Physicians S Podiatrists S Psychologists S Dentists

S Certified Nurse‐Midwives S Certified Nurse Practitioners S Certified Clinical Nurse Specialists S Certified Registered Nurse Anesthetists S Chiropractors

S Clinical Social Workers

S Clinical Professional Counselors S Clinical Laboratories

S Durable Medical Equipment Providers S Home Infusion Therapy Providers

S Marriage and Family Therapists S Occupational Therapists S Optometrists

S Orthotic Providers S Physical Therapists S Prosthetic Providers

S Registered Surgical Assistants S Retail Health Clinics

S Speech Therapists

S other Professional Providers

who have not signed an agreement with Blue Cross and Blue Shield to accept the Maximum Allowance as payment in full. Therefore, you are responsible to these Providers for the difference between the Blue Cross and Blue Shield bene­

fit payment and such Provider's charge to you.

Should you wish to know the Maximum Allowance for a particular procedure or whether a particular Provider is a Participating Provider, contact your Group Administrator, your Professional Provider or Blue Cross and Blue Shield.