32 • By counting any cost sharing payments made by the participant or beneficiary toward any in-network deductible and in-network out-of-pocket maximums applied under the Plan (and the in-network deductible and out-of-pocket maximums must be applied) in the same manner as if such cost sharing payments were made with respect to items and services furnished by a PPO Provider. • Non-emergency items or services performed by a Non-PPO Provider at a PPO facility will be covered based on your out-of-network coverage if: – At least 72 hours before the day of the appointment (or three (3) hours in advance of services rendered in the case of a same-day appointment), the participant or dependent is supplied with a written notice, as required by federal law, that the provider is a Non-PPO Provider with respect to the Plan, of the estimated charges for your treatment and any advance limitations that the Plan may put on your treatment, of the names of any PPO Providers at the facility who are able to treat you, and that you may elect to be referred to one of the PPO Providers listed; and – The participant or dependent gives informed consent to continued treatment by the Non-PPO Provider, acknowledging that the participant or beneficiary understands that continued treatment by the Non-PPO Provider may result in greater cost to the participant or beneficiary. • The notice and consent exception does not apply to Ancillary Services and items, or services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the Non-PPO Provider satisfied the notice and consent criteria, and therefore these services will be covered: – With a cost sharing requirement that is no greater than the cost sharing requirement that would apply if a PPO Provider had furnished the items or services, – With cost sharing requirements calculated as if the total amount charged for the items and services were equal to the recognized amount for the items and services, and – With cost sharing counted toward any in-network deductible and in-network out-of-pocket maximums, as if such cost sharing payments were with respect to items and services furnished by a PPO Provider. Your cost sharing amount for Non-Emergency Services at PPO Facilities by Non-PPO Providers will be based on the lesser of billed charges from the provider or the QPA. Air Ambulance Services If you receive Air Ambulance Services that are otherwise covered by the Plan from a Non-PPO Provider, the Plan will cover those services as follows: • The Air Ambulance Services received from a Non-PPO Provider will be covered with a cost sharing requirement that is no greater than the cost sharing requirement that would apply if a PPO Provider had furnished the services. • In general, you cannot be balance billed for these items or services. Your cost sharing will be calculated as if the total amount that would have been charged for the services by a PPO Provider of Air Ambulance Services were equal to the lesser of the QPA or the billed amount for the services. • Any cost sharing payments you make with respect to covered Air Ambulance Services will count toward your Network (PPO) deductible and Network (PPO) out-of-pocket maximum in the same manner as those received from a PPO Provider. Payments to Non-PPO Providers and Facilities