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The benefits provided by the Claim Administrator and the expenses that are your responsibility for your Covered Services will depend on whether you re­ ceive services from a Participating or Non‐Participating Professional Provider.

Tier 1 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 100% of the Maximum Allowance after you have met your pro­gram deductible, unless otherwise specified in this benefit booklet. Although Dentists are not Participating Providers they will be treated as such for pur­poses of benefit payment made under this benefit booklet and may bill you forthe difference between the Claim Administrator's benefit payment and the Provider's charge to you.

When you receive Covered Services in a Participating Provider's office (other than a specialist's office), benefits for office visits are subject to a Copayment of $10 per visit. Benefits for office visits will then be provided at 100% of the Maximum Allowance. Your program deductible will not apply.

When you receive Covered Services in a Participating Provider specialist's of­ fice, benefits for office visits are subject to a Copayment of $20 per visit. A specialist is a Professional Provider who is not a Behavioral Health Practition­ er or a Physician in general practice, family practice, internal medicine, psychiatry, obstetrics, gynecology or pediatrics. Benefits for office visits will then be provided at 100% of the Maximum Allowance. Your program deduct­ ible will not apply.

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 100% of the Maximum Allowance after you have met your pro­ gram deductible, unless otherwise specified in this benefit booklet. Although Dentists are not Participating Providers they will be treated as such for pur­ poses of benefit payment made under this benefit booklet and may bill you for the difference between the Claim Administrator's benefit payment and the Provider's charge to you.

When you receive Covered Services in a Participating Provider's office (other than a specialist's office), benefits for office visits are subject to a Copayment of $25 per visit. Benefits for office visits will then be provided at 100% of the Maximum Allowance. Your program deductible will not apply.

When you receive Covered Services in a Participating Provider specialist's of­ fice, benefits for office visits are subject to a Copayment of $35 per visit. A specialist is a Professional Provider who is not a Behavioral Health Practition­ er or a Physician in general practice, family practice, internal medicine, psychiatry, obstetrics, gynecology or pediatrics. Benefits for office visits will then be provided at 100% of the Maximum Allowance. Your program deduct­ ible will not apply.

Non‐Participating Provider

When you receive any of the Covered Services described in this Physician Benefit Section from a Non‐Participating Provider, benefits will be provided at 60% of the Maximum Allowance after you have met your program deduct­ ible.

When you receive Covered Services from a Non-Participating Provider psy­ chiatrist, benefits will be provided at 100% of the Maximum Allowance after you have met your program deductible.

Emergency Care

Benefits for Emergency Accident Care will be provided at 100% of the Maxi­ mum Allowance when rendered by either a Participating or Non‐Participating Provider. Your program deductible will not apply. Benefits for surgical proce­ dures, such as stitching, gluing and casting are not provided at the Emergency Accident Care payment level. Such services will be provided at the benefit payment level for Surgery described in this benefit booklet.

Benefits for Emergency Medical Care will be provided at 100% of the Maxi­ mum Allowance when rendered by either a Participating or Non‐Participating 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.

Notwithstanding anything in this benefit booklet to the contrary, the method used to determine the Maximum Allowance for Emergency care services will be equal to the greatest of the following three possible amounts:

1. the amount negotiated with Participating Providers for emergency care benefits furnished; or

2. the amount for the emergency care service calculated using the same method the Participating Providers generally uses to determine pay­ ments for Non‐Participating Provider services but substituting the Participating cost sharing provisions for the Non‐Participating Pro­ vider cost‐sharing provisions; or

3. the amount that would be paid under Medicare for the emergency care service.

Each of these three amounts is calculated excluding any Non‐Participating Provider Copayment or Coinsurance imposed with respect to the covered per­ son.

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 Speech Therapists

who have signed an Agreement with the Claim Administrator to accept the Maximum Allowance as payment in full. Such Participating Providers have agreed not to bill you for Covered Services amounts in excess of the Maxi­ mum Allowance. Therefore, you will be responsible only for the difference between the Claim Administrator's benefit payment and the Maximum Al­ lowance for the particular Covered Service — that is, your program 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 the Claim Administrator to accept the Maximum Allowance as payment in full. Therefore, you are responsible to

these Providers for the difference between the Claim Administrator's benefit 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 Em­ ployer, your Professional Provider or the Claim Administrator.