PROVIDER NETWORK The word "Network" means an organization that has contracted with various providers to provide health care services to Covered Persons at a Negotiated Rate. Providers who participate in a Network have agreed to accept the negotiated fees as payment in full, including any portion of the fees that the Covered Person must pay due to the Deductible, Plan Participation amounts, or other out-of-pocket expenses. The allowable charges used in the calculation of the payable benefit to participating providers will be determined by the Negotiated Rates in the network contract. A provider who does not participate in a Network may bill Covered Persons for additional fees over and above what the Plan pays. Knowing to which Network a provider belongs will help a Covered Person determine how much he or she will need to pay for certain services. To obtain the highest level of benefits under this Plan, Covered Persons should receive services from In-Network providers. However, this Plan does not limit a Covered Person's right to choose his or her own provider of medical care at his or her own expense if a medical expense is not a Covered Expense under this Plan, or is subject to a limitation or exclusion. To find out to which Network a provider belongs, please refer to the Provider Directory, or call the toll-free number that is listed on the back of the Plan’s identification card. The participation status of providers may change from time to time. • If a provider belongs to one of the following Networks, claims for Covered Expenses will normally be processed in accordance with the In-Network benefit levels that are listed on the Schedule of Benefits: UnitedHealthcare Choice Plus • For services received from any other provider, claims for Covered Expenses will normally be processed in accordance with the Out-of-Network benefit levels that are listed on the Schedule of Benefits. EXCEPTIONS TO THE PROVIDER NETWORK BENEFITS In addition to services required to be covered as specified under the Protection from Balance Billing section of this SPD, some benefits may be processed at In-Network benefit levels when provided by Out- of-Network providers. When Out-of-Network charges are covered in accordance with Network benefits, the charges may be subject to the Usual and Customary charge limitations. The following exceptions may apply: • Non-air Ambulance Transportation services will be payable at the In-Network level of benefits when provided by an Out-of-Network provider. • Covered services provided by a Physician during an Inpatient stay will be payable at the In-Network level of benefits when provided at an In-Network Hospital. • If there is no In-Network provider, or no In-Network provider is willing or able to provide the necessary service(s) to the Covered Person within a 30-mile radius of the Covered Person’s residence, the Covered Person may be eligible to receive In-Network benefits from an Out-of- Network provider. In this situation, Your In-Network Physician will notify the claims administrator, who will work with You and Your In-Network Physician to coordinate care through an Out-of- Network provider. • Wigs, toupees, and hairpieces will be payable at the In-Network level of benefits when provided by an Out-of-Network provider, -55- 7670-00-413597