How Your Plan Works Introduction Your Plan is a Point of Service (POS) plan. The Plan has two sets of benefits: In-Network and Out-of- Network. If you choose an In-Network Provider, you will pay less in Out-of-Pocket costs, such as Copayments, Deductibles, and Coinsurance. If you use an Out-of-Network Provider, you will have to pay more Out-of-Pocket costs. To find an In-Network Provider for this Plan, please see “How to Find a Provider in the Network,” later in this section. In-Network Services When you use an In-Network Provider or get care as part of an Authorized Service, Covered Services will be covered at the In-Network level. If you receive Covered Services from an Out-of-Network Provider after we failed to provide you with accurate information in our Provider Directory, or after we failed to respond to your telephone or web- based inquiry within the time required by federal law, your cost share for Covered Services will be based on the In-Network level. Regardless of Medical Necessity, benefits will be denied for care that is not a Covered Service. We, on behalf of the Employer, have final authority to decide the Medical Necessity of the service. This Plan includes three (3) levels of coverage: • Tier 1 Network Providers contract with the Plan and charge a lower Copayment / Coinsurance on many services than other In-Network Providers. • Tier 2 All other Network Providers are also In-Network but may require a higher Copayment/Coinsurance on many services than Tier 1 In-Network Provider. • Out-of-Network Providers are not in the Plan’s Network and require the highest Copayment / Coinsurance in this Benefit Booklet. For services from In-Network Providers: 1. You will not need to file claims. In-Network Providers will file claims for Covered Services for you. (You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be billed by your In-Network Provider(s) for any non-Covered Services you get or when you have not followed the terms of this Booklet. 2. Precertification will be done by the In-Network Provider. (See the “Getting Approval for Benefits” section for further details.) Please read the “ 33