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These contracts also include language whereby the provideragrees to accept the amount paid by Capital, minus any cost-sharing amountdue from the member, as payment in full.

For Example: The billed charge for an office visit is set by the doctor to be $100. Capital’s allowable amount

for this service is $60. If the doctor is a participating providerwho has agreed to accept the allowable amount, minus any cost-sharing amountfrom the member, as payment in full, $60 is the maximum dollar amount the

providerwill be reimbursed for this service; and the memberwill not be billed for the additional $40.

For Example: The billed charge for a prescription drugis set by the pharmacyto be $100. Capital’s allowable amountfor this prescription drugis $60. If the pharmacyis a participating pharmacywho has agreed to accept the allowable amount, minus any cost-sharing amountfrom the member, as payment in full, $60 is the

maximum dollar amount the pharmacywill be reimbursed for this prescription drug; and the memberwill not be billed for the additional $40.

 For non-participating providers, the allowable amountfor a benefitdetermines the maximum amount Capital

will pay a memberfor benefits. Since the non-participating providerdoes not have a contract with Capitalor with Capital’s PBM, the providerhas not agreed to accept Capital’spayment, minus any cost-sharing amount

due from the member,as payment in full. The allowable amountin these situations can be less than the

provider’scharge. Therefore, the memberis also responsible for paying the difference between the provider’s

billed charge and the allowable amountin addition to any applicable cost-sharing amount. Unless otherwise agreed to by Capital, all payment for services performed by a non-participating providerwill be made to the

member.

For Example: The billed charge for an office visit is set by the doctor to be $100. Capital’s allowable amount

for this service is $60. Since the non-participating providerdoes not have a contract with Capitaltheprovider

can ask the memberto pay the full $100 charge. However, the maximum payment Capital will make to the

memberis the allowable amountof $60. The remaining $40 is the member’sexpense.

For Example: The billed charge for a prescription drugis set by the pharmacy to be $100. Capital’s allowable amountfor this prescription drugis $60. Since the non-participating pharmacydoes not have a contract to provide prescription drugsor services to Capital members, the memberis responsible for paying the full $100 charge. However, the membercan file a claim for reimbursement. The maximum payment Capital will make to the subscriberis the allowable amountof $60 minus any applicable cost-sharing amounts. Assuming the

memberhas no other cost-sharing amountobligations, the remaining $40 is the member’sexpense (in addition to the member’s applicable copaymentor coinsurance).

Subject to the definitions in this Certificate of Coverageand in the group contract, and the terms, conditions, and exclusions specified in this Certificate of Coverageand subject to the payment by membersof the applicable cost- sharing amounts, if any, membersshall be entitled to receive the coveragefor the benefits listed below. Services will be covered by Capital: a) only if they are medically necessary;and b) in the case of health care services, only if they are preauthorized (as applicable) by Capitaland/or its designee; and c) in the case of prescription drugs, only if they are prior authorized (as applicable) by Capitaland/or its designee; and d) only if the memberis actively enrolled at the time of the service.

It is important to refer to the Summary of Cost-Sharing and Benefits section of this Certificate of Coverage to determine whether a health care service, a prescription drug, and/or a therapeutic class of prescription drugsdescribed in this section is a covered benefit, to determine the amounts membersare responsible for paying to providersor pharmacies, and to determine whether any benefitlimitations/maximums apply to this coverage.

Certain health care services require preauthorizationby Capitalor its designee. Please consult the Preauthorization Programattachment to determine which services require preauthorization. Certain

prescription drugs require prior authorizationor enhanced prior authorization or are limited to specific quantities by Capitalor its designee.

A

C

H

R

& B

A

C

Benefits for room and board in an acute care hospital include bed, board and general nursing services when a

memberoccupies:

 A semi-private room (two or more beds);  A bed in a special accommodations unit; or

 A private room, if medically necessaryor if no semi-private accommodations are available. A private room is not medically necessarywhen used solely for the comfort and/or convenience of the member. When a private room is selected at the member’soption, themember is responsible for paying ten percent (10%) of the

hospital’s private room charge.

Benefits for associated services include, but are not limited to:  Drugs and medicines provided for use while an inpatient;  Use of operating or treatment rooms and equipment;  Oxygen and administration of oxygen; and

 Medical and surgical dressings, casts and splints. Long-Term Acute Care Hospital

Benefits for long-term acute care hospitalsinclude services provided when a member is acutely ill and would otherwise require an extended stay in an acute care setting.