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SECTION 4 - SCHEDULE OF BENEFITS

            What this section includes:

               ·   How Do You Access benefits?
               ·   Prior Authorization requirements;
               ·   Benefits;
               ·   Annual deductible;
               ·   Deductible carryover from prior carrier
               ·   Out-of-pocket limit;
               ·   Covered Health Care Services and;
               ·   Provider network.

            How Do You Access Benefits?


            You can choose to receive Network Benefits or Out-of-Network Benefits.
            Network Benefits apply to Covered Health Care Services that are provided by a Network Physician or other
            Network provider. For facility services, these are Benefits for Covered Health Care Services that are provided at a
            Network facility under the direction of either a Network or Out-of-Network Physician or other provider. Network
            Benefits include Physician services provided in a Network facility by a Network or an Out-of-Network
            anesthesiologist, assistant surgeon, hospitalist, pathologist and radiologist, subject to our reimbursement policy.
            Emergency services received at an Out-of-Network Hospital are covered at the Network level, subject to our
            reimbursement policy.
            Emergency Health Care Services are always paid as Network Benefits. Emergency Health Care Services and
            Emergency ambulance transportation provided by an out-of-Network provider will be reimbursed as set forth
            under Allowed Amounts as described in the Summary Plan Description. As a result, you will responsible for
            the difference between the amount billed by the out-of-Network provider and the amount we determine to
            be the Allowed Amount for reimbursement. The payments you make to out-of-Network providers for
            charges above the Allowed Amount do not apply towards any applicable Out-of-Pocket limit.

            Covered Health Care Services that are provided at a Network facility by an out-of-Network facility based
            Physician, when not Emergency Health Care Services, will be reimbursed as set forth under Allowed Amounts as
            described in the Summary Plan Description. As a result, you will be responsible for the difference between
            the amount billed by the out-of-Network facility based Physician and the amount we determine to be the
            Allowed Amount for reimbursement. The payments you make to out-of-Network facility based Physicians
            for charges above the Allowed Amount do not apply towards any applicable Out-of-Pocket Limit.

            Out-of-Network Benefits apply to Covered Health Care Services that are provided by an out-of-Network
            Physician or other out-of-Network provider, or Covered Health Care Services that are provided at an out-of-
            Network facility.
            Depending on the geographic area and the service you receive, you may have access through our Shared
            Savings Program to Out-of-Network providers who have agreed to discount their billed charges for Covered
            Health Care Services. Refer to the definition of Shared Savings Program in Section 15: Glossary for details about
            how the Shared Savings Program applies.

            You must show your identification card (ID card) every time you request health care services from a Network
            provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under
            this plan. As a result, they may bill you for the entire cost of the services you receive.

            If there is a conflict between this Schedule of Benefits and any summaries provided to you by the QUEEN CITY
            SKILLED CARE LLC, this Schedule of Benefits will control.

            Additional information about the Network of providers and how your Benefits may be affected appears at the end
            of this Schedule of Benefits.
            Prior Authorization Requirements
            We require prior authorization for certain covered expenses. In general, when services or supplies are received
            from a network provider, the network provider is responsible for obtaining the prior authorization. You may want
            to contact us to verify that the Hospital, Physician and other providers have obtained the required prior
            authorization.



            Page 8                                                                     Section 4 - Schedule of Benefits
                                                                                                     HSA - 2017
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