YOUR 2018 BENEFIT BOOKLET · 2017-11-01 · First Priority Health is a licensed affiliate of...

First Priority Health is a licensed affiliate of Highmark Blue Cross Blue Shield.

YOUR 2018 BENEFIT BOOKLET

my Priority Blue Flex HMO 6900S

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First Priority Health is a licensed affiliate of Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, all of which are independent licensees of the Blue Cross Blue Shield Association. Health care plans are subject to the terms of the benefit agreement. Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Blues On Call is a registered mark of the Blue Cross and Blue Shield Association. Visa Inc. is a global payments technology company. Visa Inc. is an independent company and is solely responsible for the goods and services it provides. Visa and the Visa logo are trademarks of VISA, Inc. Express Scripts is an independent company that administers the pharmacy benefit for your health plan.

Thank You for Choosing Our Plan Welcome to your new plan. We appreciate your choosing us for your health coverage. We recommend that you take the time to review this booklet, because it contains important information about your health insurance, including:

• How to use your member ID card • The importance of selecting a primary care provider • Getting quality care and service • Definitions of common health care insurance terms • The Agreement for your plan

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Table of Contents Your Identification Card Is Your Key to Care 1 Changes that Affect Your Premium 2 Select a Primary Care Provider 3 How to Obtain Information Regarding Your Provider 3 How to Use my Priority Blue Flex HMO 5 Preventive Schedule 7 Using Your Prescription Drug Coverage 15 Prescription Drug Management for Your Formulary 15 Get Quality Care 17 Is it Necessary and Appropriate? 17 Get Quality Service 19 How We Decide if a Technology or Drug is Experimental 19 Evaluating New Drugs 19 If you Suspect Fraud or Provider Abuse 20 Paying for Your Care 21 Paying in the Provider’s Office 21 The Explanation of Benefits 21 Filing Claims 21 How to Submit a Complaint 22 Appeal Procedure 23 Your Rights and Responsibilities 24 Your Rights 24 Your Responsibilities 24 Women’s Health and Cancer Rights Act of 1998 25 Definitions of Health Care Terms 26 How We Protect Your Right to Privacy 28 Highmark Notice of Privacy Practices 29 Agreement

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Your Identification Card Is Your Key to Care You will receive your identification (ID) card in a separate mailing. Your ID card is your key to letting providers know that you have health coverage. You should carry your card with you. You can also view and fax it to a provider by logging in to www.HighmarkBCBS.com with your web-enabled phone or with a tablet or computer with the ability to fax. Show your card to the health care provider when you need care. Use it at the pharmacy when you buy prescription drugs. You can even use your ID card nationwide for emergency and urgent care. Your ID card is your source for important information. It includes:

● Your name and/or dependent’s name (when applicable)

● Your identification number

● Your group number

● Effective date of your plan

● Pediatric vision network and pediatric dental network information

● Office visit, specialist visit, and emergency room copayment amounts (if applicable)

● Pharmacy network

● Toll-free Member Service phone number

● Member website address

● Blues On CallSM nurse line

● Toll-free phone numbers for authorizing services

● Addresses for filing claims that are out of the network or out of the coverage area. Note that only out-of-network emergency care and urgent care are covered for HMO plans.

If your ID card is lost or stolen, please contact Member Service immediately. You can order a replacement ID card on www.HighmarkBCBS.com. It’s illegal to lend your ID card to anyone who is not eligible to use your benefits.

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Changes That Affect Your Premium Here are three things that can change your premium amount that you need to report to us: 1. Changes in Membership Status

You must report when you or any of your dependents have a change that can affect your enrollment, such as:

● Marriage or divorce

● Adding or removing a domestic partner or dependent

● Termination or death of a dependent or policyholder

● Eligibility for employer group health insurance coverage*

● Eligibility for Medicare* To report a change for coverage you bought directly from us, call the Member Service number on the back of your ID card. For coverage purchased on the Health Insurance Marketplace, call 1-800-318-2596 or visit www.healthcare.gov. *These situations won’t affect your premium, but they should be reported.

2. Changes in Household Income If you bought your health coverage from the Health Insurance Marketplace, you must report changes in your household income. Increases or decreases in your income can affect your eligibility for the federal Advance Premium Tax Credit and/or cost-sharing reductions. To report changes, you must call 1-800-318-2596 or visit www.healthcare.gov. You can also check for increased or reduced premium credits or cost-sharing reductions on healthcare.gov.

3. Changes in Tobacco Use Tobacco use means that you used tobacco products on average four or more times per week within the past six months. If you indicated that you are a tobacco user when you enrolled for health coverage, your premium includes a tobacco surcharge. This means you pay a higher rate. If you are tobacco-free for six months, the new health care law no longer considers you a tobacco user. You are then eligible for an adjustment in your health insurance premium rate. After you have stopped using tobacco for six months, let us know so that we can adjust your rate. Simply call the Member Service number on the back of your ID card.

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Select a Primary Care Provider A primary care provider (PCP) is the doctor or practice that you visit for your primary and routine health care services. This could be an internal medicine physician, general practitioner, family practitioner, certified registered nurse practitioner, or pediatrician. Seeing a PCP is often your least costly option for getting care. Your PCP can deliver routine services, such as physicals and immunizations, and can recommend and help you select appropriate specialist care when you need it. PCPs, or their covering providers, are on call 24 hours a day, seven days a week. All of our plans allow you to go directly to a specialist without a referral. This includes specialists for behavioral health and preventive care. A PCP can help you to:

● Achieve health goals.

● Monitor chronic health conditions and care maintenance.

● Make sure you receive preventive services, like annual exams.

● Coordinate the care you receive from other providers, such as specialists, labs, and imaging centers. This prevents gaps or overlaps in service.

● Improve your patient experience.

NOTE: If you have an HMO, you must select a PCP, or one will be assigned to you. The PCP assigned to you will be a provider accepting new patients who is located near the address that we have on file for you.

How to Obtain Information Regarding Your Provider To learn more about a provider or to find a PCP:

1. Visit www.HighmarkBCBS.com.

a. Select Find a Doctor or Rx. b. Select Find a Doctor, Hospital or other Medical Provider. c. Enter “primary care” into the search field. Select Pick a plan and:

1) Select Click here to pick a plan from the full list to choose your plan, OR 2) Enter the first three letters of your Member ID

f. Click on the SEARCH button to locate PCPs near you who participate in your plan. g. Select See More to learn more about a specific PCP. h. Click More Details then select Physician Details to locate the PCP’s nine-digit

Physician ID number.

2. Call Member Service at the number on the back of your Member ID card to ask for help in locating a PCP with an office near you.

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When you search for a provider at www.HighmarkBCBS.com, you can view the following information:

• Location/Office Hours/Phone numbers • Whether the provider is accepting new patients • Professional qualifications • Clinical specialties • Medical school attended • Residency completion • Board certification status • Hospital affiliations • Medical group affiliations • Patient ratings • Performance in 13 categories of care • Parking and public transit nearby • Handicap accessibility • Languages spoken • Gender

You may also obtain more information on network providers by calling Member Service at the number on the back of your member ID card. Once you select your PCP, you must notify us of your selection by:

● Logging in to your account on www.HighmarkBCBS.com, selecting Your Account, selecting Account Settings, selecting Physician Information, and entering your Primary Care Physician. If you do not currently have an account, you must register for an account and then follow the instructions; OR

● Call Member Service at the number on the back of your Member ID card.

NOTE: If you selected your PCP by calling Member Service, your selection was noted during that call and no further action is needed. If you indicated your PCP selection on your application for coverage, no further action is needed.

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How to Use my Priority Blue Flex HMO my Priority Blue Flex HMO features plans that give members more value than ever before. The my Priority Blue Flex HMO plans give you two levels of in-network benefits, an Enhanced Value Level and a Standard Value Level, to let you choose the high-quality providers who give you the most for your health care dollars. The network includes PCPs, specialists, imaging centers, hospitals, and other facilities.

You must select a PCP or one will be assigned to you. The PCP assigned to you will be a provider accepting new patients who is located near the address that we have on file for you. Please see the Select a Primary Care Provider section in this booklet to learn more about selecting your PCP. With my Priority Blue Flex HMO, health care professionals and hospitals are grouped into two levels of in-network benefits. What you pay for care is based on the level of benefits you choose.

At all benefit levels, the full network of providers offers high-quality care and easy access to every kind of service. Here is how the Enhanced Value and Standard Value Levels of Benefits affect out-of-pocket costs.

Care Out of the Network Out-of-network care is only available for emergencies and urgent care. Except in certain situations, my Priority Blue Flex HMO does not pay for out-of-network health services or providers. However, if you need emergency services or urgent care, my Priority Blue Flex HMO will cover these services at the Enhanced Value Level of Benefits — both in and out of the network.

How to Use Your my Priority Blue Flex HMO Plan Check the benefit levels — and what your out-of-pocket costs will be — for your doctor or facility before you schedule an appointment. To check a provider’s participation:

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• Confirm that your providers are in-network. Search Find a Doctor on www.HighmarkBCBS.com.

• Find out at what benefit level your provider participates. Look for Enhanced Value or Standard Value Level of Benefits under the provider’s name.

• Remember your out-of-pocket costs are generally lowest when you receive care from providers participating at the Enhanced Value Level of Benefits.

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Preventive Schedule Preventive or routine care helps you to stay well or find problems early, when they are easier to treat. The preventive guidelines in the schedule on the next few pages depend upon your age, gender, health, and family history and can be an important part of your overall health and well-being. Take some time to review the preventive schedule and discuss it with your doctor. The following preventive schedule is current as of January 1, 2018. Periodic updates may be made to the schedule. Visit the member website at www.HighmarkBCBS.com to view the current schedule.

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Using Your Prescription Drug Coverage Your benefits include prescription drug coverage. You can fill prescriptions at pharmacies in your plan’s pharmacy network. To locate a network pharmacy, go to your member website, www.HighmarkBCBS.com, log in, and click the Prescriptions tab. Scroll down to Find a Pharmacy and click on Search Pharmacies. Or call Member Services at the number on the back of your ID card. You may save money on drugs you take for at least 90 days by choosing the convenient home delivery option. You can arrange for home delivery from the Express Scripts Pharmacy by calling 1-800-903-6228. For maintenance prescription drugs, you have two choices:

• Your prescriptions can be delivered to your home. • You can pick up your prescriptions at a retail pharmacy.

Express Scripts will contact you about making your choice. You can inform Express Scripts before that time by calling 1-855-686-9786. You can change your preference for retail or mail order delivery at any time by contacting Express Scripts. If, after two fills of a maintenance prescription drug at a retail pharmacy, you have not notified Express Scripts of your choice, you will pay 100 percent of the cost for future refills until you have notified Express Scripts of your choice.

Prescription Drug Management for Your Formulary Your formulary is a list of Food and Drug Administration (FDA)-approved prescription drugs. It covers products in every major treatment category. Your drug formulary may restrict use of some drugs. In many cases, a lower-cost generic drug is available and covered on your formulary. Generic drugs have the same active ingredients and healing effects as the brand-name drug. A list of drugs included on your formulary is on the member website. You can also call Member Service for more information. Please note that infrequent formulary changes may occur throughout a plan year. Your plan may impose quantity level limits on certain prescription drugs. Limits are based on the manufacturer’s recommended daily dosage and the plan’s determination. The limits control the quantity the pharmacy provider gives you for each new prescription or refill. Additional quantity level limits may be imposed for your first prescription for certain covered drugs. This means that the quantity you get will be reduced as necessary while it is established that you can tolerate the drug. Your plan may deny a prescription or refill that may exceed the manufacturer’s recommended dosage over a specified period of time. The prescribing physician may contact us if an additional quantity of the drug is medically necessary and appropriate. If the plan determines that it is medically necessary and appropriate, you will continue to receive the drug. Certain drugs that your physician may prescribe require a prior authorization from your plan. You can find out what specific drugs or drug classifications require prior authorization by

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simply calling the Member Service number on your ID card. Once the prescription is written, the provider or the member must request prior authorization from your plan. To obtain a prescription medication that is not included in the formulary, or to request prior authorization, your physician must complete the “Prescription Drug Medication Request Form” and return it using either the fax number or the address as shown on the form for clinical review. To print a copy of the “Prescription Drug Medication Request Form” for your physician to complete, log in to www.HighmarkBCBS.com, click on the Coverage tab, and then click on Prescriptions Summary. Scroll down to the Drugs & Coverage Guidelines section and then click on the Prescription Drug Medication Request link. You may also initiate this process yourself by following these steps: Log in to www.HighmarkBCBS.com, click on the Coverage tab, and then click on Prescriptions Summary. Scroll down to the Drugs & Coverage Guidelines section and then click on Medication Exception Request. Complete the form and click Submit. Once a clinical decision has been made, a decision letter will be mailed to you and your provider. If your request for an exception is not granted, you can ask for a review of our decision by making an appeal. See your Agreement for more details about your prescription drug benefits.

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Get Quality Care

Is It Necessary and Appropriate? Your plan pays for covered services, supplies, or medications that are medically necessary and appropriate. These might be to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms. They must:

• be generally accepted as standards of medical practice • be clinically appropriate in type, frequency, extent, site, and duration • be considered effective for your illness, injury, or disease • not be for your or your provider’s convenience • not be more costly than another service that may give you similar results

If your care requires prior authorization, a network provider will contact our Utilization Management (UM) team in Clinical Services to authorize your care. This includes inpatient and outpatient non-emergency care. It is their right to decide if a service, supplies, or medication is medically necessary and appropriate. They do this before your plan pays benefits. Your plan will not pay benefits if our team of doctors and nurses decides that the service, supplies, or medication is not medically necessary and appropriate.

Out-of-network services Your plan does not include out-of-network care except in the case of emergencies or urgent situations when urgent care is needed outside of the 19-county service area. If you choose to receive care from an out-of-network provider for a non-emergent or non-urgent situation, you will be responsible for all costs associated with that care, including an admission that results from an out-of-network provider as a result of an emergency department visit.

• Out-of-network emergency care services In a medical emergency when you think you need immediate treatment, go directly to a hospital emergency room or call 911. Emergency care is care needed for the treatment of serious or life-threatening medical conditions that require immediate care. Emergency care is covered. You or your designated representative should contact Highmark Member Service at the number on the back of your member ID card and your PCP after the crisis has passed. If in-patient care is required, once you are stabilized and able to be transported to an in-network facility, Highmark will work with you and your family, and the treating hospital, to arrange transfer. Please note: If you seek emergency care from an out-of-network provider, Highmark will ensure that you are not responsible for any amounts in excess of the Highmark payment, except for applicable deductible, coinsurance, and/or copayment required

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by your plan. If you should receive such a balance bill from an out-of-network provider for emergency care services, please contact Highmark immediately. Providers who are in-network may not balance bill you for covered services.

• Out-of-network urgent care services

Urgent care is care needed for an unexpected illness or injury that is not life threatening but must be treated and cannot reasonably be postponed until you return to the 19-county service area to see a participating provider. If you are within the 19-county service area and seek urgent care, you must see a participating in-network provider for those urgent care services to be covered. Out-of-network urgent care refers to urgent care provided outside of your plan’s 19-county service area. Out-of-network urgent care is covered. If you receive out-of-network urgent care services, you may be responsible for any costs above the plan allowance, as well as any applicable deductible, coinsurance, and/or copayments required by your plan.

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Get Quality Service

How We Decide if a Technology or Drug Is Experimental Medical researchers constantly experiment with new medical equipment, drugs, and other technologies. They also look for new applications for existing technologies. These could be for medical and behavioral health procedures, drugs, and devices. A panel of medical professionals must evaluate these new technologies and new applications for existing technologies for:

• Safety • Effectiveness • Product efficiency

We may recommend that the technology be considered a medical practice and a covered benefit. Or the technology may be considered “experimental or investigative.” This technology is not generally covered. We may also re-evaluate it in the future.

Evaluating New Drugs A Pharmacy and Therapeutics (P&T) Committee composed of network-employed pharmacists and physicians evaluates new drugs based on items such as:

• National and international data • Current research • Opinions from leading clinicians

The review process addresses factors such as:

• Safety • Drug effectiveness • Unique value • Patient compliance • Local physician and specialist input • Financial impact of the drug

The P&T Committee then makes a recommendation. You may decide to pursue an experimental or investigative treatment. If a service you are going to receive may be experimental or investigational, find out if it’s covered. You, the hospital, or a professional provider can call Member Service about coverage.

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If You Suspect Fraud or Provider Abuse If you think that a provider is committing fraud, please let us know. Examples of fraud include:

• Submitting claims for services that you did not get • Adding extra charges for services that you did not get • Giving you treatment for services you did not need

Please call the toll-free Fraud Hotline at 1-800-438-2478.

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Paying for Your Care

Paying in the Provider’s Office A copayment, or copay, is a fixed amount you pay for a health service, such as a doctor’s visit. If you owe a copayment, you need to pay it when you check in for your visit. Coinsurance is a percentage of the total cost of care that you also may need to pay. Network providers may have online tools to estimate your coinsurance costs. They can do this at the time of your visit. This lets you talk about costs with your provider before getting services. It also allows you to pay your share of the cost for services before leaving the office. Please note that copayments and coinsurance may not be required for some covered services.

The Explanation of Benefits Once your claim is processed, you may receive an Explanation of Benefits (EOB) from us. The EOB is not a bill. It’s a statement that gives you information about services you received. Services can be from physicians, facilities, or other professional providers. The EOB also includes costs you may owe for these services.

The EOB includes: • The provider’s charge • The allowable amount • The copayment, deductible, and coinsurance amounts, if applicable, that you’re

required to pay • The total benefits payable • The total amount you owe

You can get your EOB online by simply registering on the member website. Your EOB can also be mailed to you if that is your preference. If you do not owe a payment to the provider, you may not receive an EOB. If you are enrolled in a qualified high-deductible plan with a Health Savings Account (HSA), you will receive a Plan Activity Statement instead of an EOB. If this applies to you, please refer to the Health Savings Account section in this booklet for information about your Plan Activity Statement.

Filing Claims A claim is a request you make for payment of the charges or costs for a covered service you received. If you receive services from a network provider, you do not have to file a claim. Your network provider takes care of that for you. If you go to an out-of-network provider, you may have to file the claim yourself. It is important to note that if you have an EPO or HMO plan you only have coverage for emergency and urgent care when out-of-network.

If you have to file the claim yourself, simply follow these easy steps:

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1. Know your benefits. Review your Agreement to see if the services you received are eligible under your plan.

2. Get a detailed bill that includes:

• The name and address of the service provider • The patient’s full name • Date of service • Description of the service/supply • Amount charged • Diagnosis or nature of illness • Doctor’s certification for durable medical equipment • Nurse’s license number and shift worked for private duty nursing • Total mileage for ambulance services

Canceled checks, cash register receipts, or personal lists are not acceptable as bills.

3. Copy bills for your records. You must submit original bills. Once your claim is received, we

cannot return bills.

4. Complete a claim form. Make sure all information is completed properly. Date the form. To download claim forms, go to www.HighmarkBCBS.com, click Spending, then Forms Library. You can also get a claim form by calling Member Service.

After you complete steps 1 through 4, attach all detailed bills to the claim form. Mail the form to the address on the form. You can file multiple services for the same family member with one claim form. However, you must complete a separate claim form for each covered member. You must submit your claim no later than 15 months after the date you received services.

How to Submit a Complaint You can submit a complaint if you are not satisfied with:

• Any part of your health care benefits • A participating health care provider • Coverage • Operations • Management policies

Please contact Member Service at the number on the back of your member ID card or by mail at the address listed below. Please include your identification and group numbers as displayed on your ID card.

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Highmark Blue Cross Blue Shield P.O. Box 226 Pittsburgh, PA 15222 If this process does not meet your needs, your objection can be reviewed through an appeal process. Please refer to your Agreement in the back of this booklet for more details regarding your appeal rights. You may also call Member Service at the number on your member ID card.

Appeal Procedure If you receive notification that your coverage has been rescinded or that a claim has been denied by the plan, in whole or in part, you may appeal the decision. You can file and appeal in writing or by phone. If you file in writing, please include your identification and group numbers as displayed on your ID card. Mail your appeal to: For plans purchased on the Health Insurance Marketplace: Highmark Blue Cross Blue Shield Member Appeals Attn: Review Committee P.O. Box 1988 Parkersburg, WV 26102-1988 1-800-822-8753 For all other HMO plans: Highmark Blue Cross Blue Shield Member Appeals Attn: Review Committee P.O. Box 2717 Pittsburgh, PA 15230-2717 For all other EPO and PPO plans: Highmark Blue Cross Blue Shield P.O. Box 535095 Pittsburgh, PA 15253 - 5059 1-800-822-8753 If you decide to appeal by calling, you can call Member Service at the number on the back of your ID card. You must submit this appeal no later than 180 days from the date we notified you in order for your appeal to be reviewed. You should submit information to support your appeal. We will review your appeal. You will be notified in writing of the appeal decision. Please refer to your Agreement in the back of this booklet for more details regarding your appeal rights.

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Your Rights and Responsibilities As a plan member, you have certain rights and responsibilities as part of your membership. These rights and responsibilities can enhance your health care benefits:

Your Rights 1. You have the right to get information about the following:

• Our company, products, and services • Our doctors, facilities, and other professional providers • Your rights and responsibilities

2. You have the right to be treated with respect. You have the right to have your dignity and right to privacy recognized.

3. You have the right to make decisions about your health care with your providers. This includes identifying your problem, illness, or disease and treatment plan in words you can understand. You have the right to help make decisions about your care.

4. You have the right to openly discuss treatment decisions that are right and necessary for you. You have the right to do this without concern for cost or coverage. We do not restrict information shared between you and your providers. We have policies telling providers to openly discuss all treatment options with you.

5. You have the right to voice a complaint or appeal about your coverage or care. You have the right to get a reply in a reasonable amount of time.

6. You have the right to recommend rights and responsibilities to us.

Your Responsibilities 1. You have the responsibility to give us as much information as you can. We need this

information to make care available to you. It’s also what providers need to take care of you.

2. You have the responsibility to follow the plans and instructions for care that you agree to with your providers.

3. You have the responsibility to talk openly with the provider you choose. Ask questions. Make sure you understand explanations and instructions you get. Help develop treatment goals you agree to with your providers. Develop a trusting and cooperative relationship with your providers.

If you have any questions, please call Member Service at the number on the back of your identification card.

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Women’s Health and Cancer Rights Act of 1998 A diagnosis of breast cancer can be devastating. And while we hope you never face such a situation, we want you to know that your plan will be there if you need us. Our plans are in compliance with the Women’s Health and Cancer Rights Act of 1998. The federal act requires group plans that cover mastectomies to also cover all stages of reconstruction and surgery of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance. The act also requires such plans to offer coverage for prostheses and treatment of physical complications of a mastectomy, including lymphedema. Coverage may be subject to deductibles and coinsurance. If you have any questions, please call Member Service at the number on the back of your ID card.

Info Is a Call Away If you are facing decisions about breast cancer, you can discuss your options or concerns with a Blues On Call health coach anytime, day or night, by calling 1-888-BLUE-428.

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Definitions of Health Care Terms Definitions to explain how health care works: Allowed or allowable amount — The most a plan will pay for a health service. A health service could be a test or a procedure. Your plan’s network providers have signed a contract to provide services at a discount. They agree not to charge more than this plan allowance to members of the plan. Out-of-network providers may charge more than the plan allowance. If you see an out-of-network provider who charges more, you may have to pay the extra cost. (See balance billing.) Balance billing — When an out-of-network provider bills you for the difference between the provider’s charge and the plan allowance. For example, if the provider’s charge is $100 and the plan allowance is $70, the provider may bill you for the remaining $30. Providers who are in network may not balance bill you for covered services. Coinsurance — Your part of a medical bill that you pay after reaching your deductible. For example, if your medical bill for covered, in-network services is $100 and your coinsurance is 20 percent, you pay $20. The insurance company pays $80. (See balance billing for details on out-of-network care.) Copayment (copay) — The fixed amount you pay for a health service. This could be a PCP visit, specialist visit or urgent care. The copay may vary by plan. The copay for each service may be different. For example, a PCP visit may require a $30 copay. But a visit to a specialist may require a $50 copay. You usually have to pay the copay when you get a health care service, such as at your doctor’s office or at the drugstore. Deductible — The dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay for covered services. For example, if you have a $500 in-network deductible, that’s the amount you will pay before your insurance plan will pay for covered in-network services. Copayments are not included. Network provider — A doctor, hospital, or other provider in the plan’s network. Network providers have agreed to accept a certain rate for people with that plan. You pay less when you use a network provider instead of an out-of-network provider. Out-of-pocket maximum — The most you pay during a coverage period (usually a year) before your health insurer begins to pay 100 percent of the plan allowance. The maximum never includes your premium, balance-billed charges or payments for services your plan doesn’t cover. All of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses count toward this maximum. Out-of-network provider — A provider who does not have a contract with your health insurer to provide services to you at a discount. You will generally pay more to see an out-of-

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network provider. If you have an EPO plan, you are not covered for out-of-network services (except for emergency services). Plan allowance — The amount the insurer decides that you must pay for covered services. Plan allowance amounts are based on the type of provider who delivers services or as required by law. Premium — The dollar amount you pay each month for your health insurance or plan.

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How We Protect Your Right to Privacy We have policies and procedures to protect your privacy. This includes your Protected Health Information (PHI). PHI may be oral, written, or electronic.

• We do not discuss PHI outside of our offices. • We confirm who you are before we discuss PHI on the phone. • Our employees sign privacy agreements. • Our employees use computer passwords to limit PHI access. • We include privacy language in our provider contracts.

Notice of Privacy Practices The Notice of Privacy Practices describes:

• How your medical information may be used and disclosed • How you can get access to this information • How we collect, use, and disclose non-public personal financial information

To review our complete notice of privacy practices, please see page 27.

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29 Effective Date: September 23, 2013

Sí necesita ayuda para traducir esta información, por favor comuníquese con el departamento de Servicios a miembros de Highmark al número al réves de su tarjeta de identificación de Highmark. Estos servicios están disponibles de lunes a viernes, de 8:00 a 19:00, y los sábados de 8:00 a 17:00.

HIGHMARK INC. NOTICE OF PRIVACY PRACTICES

PART I – NOTICE OF PRIVACY PRACTICES (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE ALSO DESCRIBES HOW WE COLLECT, USE AND DISCLOSE NON-PUBLIC PERSONAL FINANCIAL INFORMATION.

Our Legal Duties

At Highmark Inc. (“Highmark”), we are committed to protecting the privacy of your “Protected Health Information” (PHI). PHI is your individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health plan, your employer, or a health care clearinghouse that relates to: (i) your past, present, or future physical or mental health or condition; (ii) the provision of health care to you; or (iii) the past, present, or future payment for the provision of health care to you.

This Notice describes our privacy practices, which include how we may use, disclose, collect, handle, and protect our members’ protected health information. We are required by applicable federal and state laws to maintain the privacy of your protected health information. We also are required by the HIPAA Privacy Rule (45 C.F.R. parts 160 and 164, as amended) to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We are also required to notify affected individuals following a breach of unsecured health information.

We will inform you of these practices the first time you become a Highmark customer. We must follow the privacy practices that are described in this Notice as long as it is in effect. This Notice becomes effective September 23, 2013, and will remain in effect unless we replace it.

On an ongoing basis, we will review and monitor our privacy practices to ensure the privacy of our members’ protected health information. Due to changing circumstances, it may become necessary to revise our privacy practices and the terms of this Notice. We reserve the right to make the changes in our privacy practices and the new terms of our Notice will become effective for all protected health information that we maintain, including protected health information we created or received before we made the changes. Before we make a material change in our privacy practices, we will change this Notice and notify all affected members in writing in advance of the change. Any change to this notice will be posted on our website and we will further notify you of any changes in our annual mailing.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

I. Uses and Disclosures of Protected Health Information In order to administer our health benefit programs effectively, we will collect, use and disclose protected health

information for certain of our activities, including payment and health care operations. A. Uses and Disclosures of Protected Health Information for Payment and Health Care Operations The following is a description of how we may use and/or disclose protected health information about you for payment

and health care operations:

Payment We may use and disclose your protected health information for all activities that are included within the definition of

“payment” as set out in 45 C.F.R. § 164.501. We have not listed in this Notice all of the activities included within the definition of “payment,” so please refer to 45 C.F.R. § 164.501 for a complete list.

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For example: We may use and disclose your protected health information to pay claims from doctors, hospitals, pharmacies and

others for services delivered to you that are covered by your health plan, to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain premiums, and/or to issue explanations of benefits/payments to the person who subscribes to the health plan in which you participate.

Health Care Operations We may use and disclose your protected health information for all activities that are included within the definition of

“health care operations” as set out in 45 C.F.R. § 164.501. We have not listed in this Notice all of the activities included within the definition of “health care operations,” so please refer to 45 C.F.R. § 164.501 for a complete list.

For example: We may use and disclose your protected health information to rate our risk and determine the premium for your health

plan, to conduct quality assessment and improvement activities, to credential health care providers, to engage in care coordination or case management, and/or to manage our business.

B. Uses and Disclosures of Protected Health Information To Other Entities We also may use and disclose protected health information to other covered entities, business associates, or other

individuals (as permitted by the HIPAA Privacy Rule) who assist us in administering our programs and delivering services to our members.

(i) Business Associates. In connection with our payment and health care operations activities, we contract with individuals and entities (called

“business associates”) to perform various functions on our behalf or to provide certain types of services (such as member service support, utilization management, subrogation, or pharmacy benefit management). To perform these functions or to provide the services, business associates will receive, create, maintain, use, or disclose protected health information, but only after we require the business associates to agree in writing to contract terms designed to appropriately safeguard your information.

(ii) Other Covered Entities. In addition, we may use or disclose your protected health information to assist health care providers in connection with

their treatment or payment activities, or to assist other covered entities in connection with certain of their health care operations. For example, we may disclose your protected health information to a health care provider when needed by the provider to render treatment to you, and we may disclose protected health information to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing or credentialing.

II. Other Possible Uses and Disclosures of Protected Health Information In addition to uses and disclosures for payment and health care operations, we may use and/or disclose your protected

health information for the following purposes.

A. To Plan Sponsors We may disclose your protected health information to the plan sponsor of your group health plan to permit the plan

sponsor to perform plan administration functions. For example, a plan sponsor may contact us regarding a member’s question, concern, issue regarding claim, benefits, service, coverage, etc. We may also disclose summary health information (this type of information is defined in the HIPAA Privacy Rule) about the enrollees in your group health plan to the plan sponsor to obtain premium bids for the health insurance coverage offered through your group health plan or to decide whether to modify, amend or terminate your group health plan.

B. Required by Law We may use or disclose your protected health information to the extent that federal or state law requires the use or

disclosure. For example, we must disclose your protected health information to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws.

C. Public Health Activities We may use or disclose your protected health information for public health activities that are permitted or required by

law. For example, we may use or disclose information for the purpose of preventing or controlling disease, injury, or disability.

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D. Health Oversight Activities We may disclose your protected health information to a health oversight agency for activities authorized by law,

such as: audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other government regulatory programs; and (iv) compliance with civil rights laws.

E. Abuse or Neglect We may disclose your protected health information to a government authority that is authorized by law to receive

reports of abuse, neglect, or domestic violence.

F. Legal Proceedings We may disclose your protected health information: (1) in the course of any judicial or administrative proceeding;

(2) in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized); and (3) in response to a subpoena, a discovery request, or other lawful process, once we have met all administrative requirements of the HIPAA Privacy Rule. For example, we may disclose your protected health information in response to a subpoena for such information.

G. Law Enforcement Under certain conditions, we also may disclose your protected health information to law enforcement officials. For

example, some of the reasons for such a disclosure may include, but not be limited to: (1) it is required by law or some other legal process; or (2) it is necessary to locate or identify a suspect, fugitive, material witness, or missing person.

H. Coroners, Medical Examiners, Funeral Directors, and Organ Donation We may disclose protected health information to a coroner or medical examiner for purposes of identifying a

deceased person, determining a cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We also may disclose, as authorized by law, information to funeral directors so that they may carry out their duties. Further, we may disclose protected health information to organizations that handle organ, eye, or tissue donation and transplantation.

I. Research We may disclose your protected health information to researchers when an institutional review board or privacy

board has: (1) reviewed the research proposal and established protocols to ensure the privacy of the information; and (2) approved the research.

J. To Prevent a Serious Threat to Health or Safety Consistent with applicable federal and state laws, we may disclose your protected health information if we believe that

the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

K. Military Activity and National Security, Protective Services Under certain conditions, we may disclose your protected health information if you are, or were, Armed Forces

personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, we may disclose, in certain circumstances, your information to the foreign military authority. We also may disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, and for the protection of the President, other authorized persons, or heads of state.

L. Inmates If you are an inmate of a correctional institution, we may disclose your protected health information to the

correctional institution or to a law enforcement official for: (1) the institution to provide health care to you; (2) your health and safety and the health and safety of others; or (3) the safety and security of the correctional institution.

M. Workers’ Compensation We may disclose your protected health information to comply with workers’ compensation laws and other similar

programs that provide benefits for work-related injuries or illnesses.

N. Others Involved in Your Health Care Unless you object, we may disclose your protected health information to a friend or family member that you have

identified as being involved in your health care. We also may disclose your information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your protected health information, then we may, using our professional judgment, determine whether the disclosure is in your best interest.

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O. Underwriting We may disclose your protected health information for underwriting purposes; however, we are prohibited from

using or disclosing your genetic information for these purposes..

P. Health Information Exchange We will participate in a Health Information Exchange (HIE). An HIE is primarily a secure electronic data sharing network. In accordance with federal and state privacy regulations, regional health care providers participate in the HIE to exchange patient information in order to facilitate health care, avoid duplication of services, such as tests, and to reduce the likelihood that medical errors will occur.

The HIE allows your health information to be shared among authorized participating healthcare providers, such as health systems, hospitals and physicians, for the purposes of Treatment, Payment or Healthcare Operations purposes. Examples of this health information may include:

• General laboratory, pathology, transcribed radiology reports and EKG Images. • Results of outpatient diagnostic testing (GI testing, cardiac testing, neurological testing, etc.) • Health Maintenance documentation/Medication • Allergy documentation/Immunization profiles • Progress notes/Urgent Care visit progress notes • Consultation notes • Inpatient operative reports • Discharge summary/Emergency room visit discharge summary notes

All participating providers who provide services to you will have the ability to access your information. Providers that do not provide services to you will not have access to your information. Information may be provided to others as necessary for referral, consultation, treatment or the provision of other healthcare services, such as pharmacy or laboratory services. All participating providers have agreed to a set of standards relating to their use and disclosure of the information available through the HIE. Your health information shall be available to all participating providers through the HIE.

You cannot choose to have only certain providers access your information. Patients who do not want their health information to be accessible through the HIE may choose not to participate or may “opt-out.”

In order to opt-out, you must complete an opt-out Form, which is available at highmark.com or by calling the customer service number located on the back of your membership card. You should be aware, if you choose to opt-out, your health care providers will not be able to access your health information through the HIE. Even if you chose to opt-out, your information will be sent to the HIE, but providers will not be able to access this information. Additionally, your opt-out does not affect the ability of participating providers to access health information entered into the HIE prior to your opt-out submission.

III. Required Disclosures of Your Protected Health Information The following is a description of disclosures that we are required by law to make:

A. Disclosures to the Secretary of the U.S. Department of Health and Human Services We are required to disclose your protected health information to the Secretary of the U.S. Department of Health and

Human Services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Rule.

B. Disclosures to You We are required to disclose to you most of your protected health information that is in a “designated record set”

(defined below) when you request access to this information. We also are required to provide, upon your request, an accounting of many disclosures of your protected health information that are for reasons other than payment and health care operations.

IV. Other Uses and Disclosures of Your Protected Health Information

Sometimes we are required to obtain your written authorization for use or disclosure of your health information. The uses and disclosures that require an authorization under 45 C.F.R. § 164.508(a) are:

1. For marketing purposes 2. If we intend to sell your PHI

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http://highmark.com/


3. For use of Psychotherapy notes, which are notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. An Authorization for use of psychotherapy notes is required unless:

a. Used by the person who created the psychotherapy note for treatment purposes, or b. Used or disclosed for the following purposes:

(i) the provider’s own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint family or individual counseling; (ii) for the provider to defend itself in a legal action or other proceeding brought by an individualthat is the subject of the notes; (iii) if required for enforcement purposes; (iv) if mandated by law; (v) if permitted for oversight of the provider that created the note, (vi) to a coroner or medical examiner for investigation of the death of any individual in certain circumstances; or (vii) if needed to avert a serious and imminent threat to health or safety.

Other uses and disclosures of your protected health information that are not described above will be made only with your written authorization. If you provide us with such an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of protected health information. However, the revocation will not be effective for information that we already have used or disclosed, relying on the authorization.

V. Your Individual Rights The following is a description of your rights with respect to your protected health information:

A. Right to Access You have the right to look at or get copies of your protected health information in a designated record set. Generally, a “designated record set” contains medical and billing records, as well as other records that are used to make decisions about your health care benefits. However, you may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set.

You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so, if you request the information in an electronic format that is not readily producible, we will provide the information in a readable electronic format as mutually agreed upon. You must make a request in writing to obtain access to your protected health information.

To inspect and/or copy your protected health information, you may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. The first request within a 12-month period will be free. If you request access to your designated record set more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. If you request an alternative format, we will charge a cost-based fee for providing your protected health information in that format. If you prefer, we will prepare a summary or an explanation of your protected health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

We may deny your request to inspect and copy your protected health information in certain limited circumstances. If you are denied access to your information, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person performing this review will not be the same one who denied your initial request. Under certain conditions, our denial will not be reviewable. If this event occurs, we will inform you in our denial that the decision is not reviewable.

B. Right to an Accounting You have a right to an accounting of certain disclosures of your protected health information that are for reasons other

than treatment, payment or health care operations. You should know that most disclosures of protected health information will be for purposes of payment or health care operations.

An accounting will include the date(s) of the disclosure, to whom we made the disclosure, a brief description of the information disclosed, and the purpose for the disclosure.

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You may request an accounting by contacting us at the Customer Service phone number on the back of your identification card, or submitting your request in writing to the Highmark Privacy Department, 120 Fifth Avenue Place 1814, Pittsburgh, PA 15222. Your request may be for disclosures made up to 6 years before the date of your request, but in no event, for disclosures made before April 14, 2003.

The first list you request within a 12-month period will be free. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

C. Right to Request a Restriction You have the right to request a restriction on the protected health information we use or disclose about you for

treatment, payment or health care operations. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement unless the information is needed to provide emergency treatment to you. Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is so memorialized in writing. We have a right to terminate this restriction, however if we do so, we must inform you of this restriction.

You may request a restriction by contacting us at the Customer Service phone number on the back of your identification card, or writing to the Highmark Privacy Department, 120 Fifth Avenue Place 1814, Pittsburgh, PA 15222. In your request tell us: (1) the information whose disclosure you want to limit; and (2) how you want to limit our use and/or disclosure of the information.

D. Right to Request Confidential Communications If you believe that a disclosure of all or part of your protected health information may endanger you, you have the right

to request that we communicate with you in confidence about your protected health information by alternative means or to an alternative location. For example, you may ask that we contact you only at your work address or via your work e-mail.

You must make your request in writing, and you must state that the information could endanger you if it is not communicated in confidence by the alternative means or to the alternative location you want. We must accommodate your request if it is reasonable, specifies the alternative means or location, and continues to permit us to collect premiums and pay claims under your health plan, including issuance of explanations of benefits/payments to the subscriber of the health plan in which you participate.

In the event that a Confidential Communication is placed against you, then you will no longer have the ability to access any of your health and/ or policy information online.

E. Right to Request Amendment If you believe that your protected health information is incorrect or incomplete, you have the right to request that we

amend your protected health information. Your request must be in writing, and it must explain why the information should be amended.

We may deny your request if we did not create the information you want amended or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

F. Right to a Paper Copy of this Notice If you receive this Notice on our web site or by electronic mail (e-mail), you are entitled to receive this Notice in written

form. Please contact us using the information listed at the end of this Notice to obtain this Notice in written form.

VI. Questions and Complaints If you want more information about our privacy policies or practices or have questions or concerns, please contact us

using the information listed below.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information or in response to a request you made to amend or restrict the use or disclosure of your protected health information or to have us communicate with you in confidence by alternative means or at an alternative location, you may complain to us using the contact information listed below.

You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

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We support your right to protect the privacy of your protected health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Office: Highmark Privacy Department Telephone: 1-866-228-9424 (toll free) Fax: 1-412-544-4320 Address: 120 Fifth Avenue Place 1814

Pittsburgh, PA 15222

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PART II – NOTICE OF PRIVACY PRACTICES (GRAMM-LEACH-BLILEY)

Highmark Inc. is committed to protecting its members’ privacy. This notice describes our policies and practices for collecting, handling and protecting personal information about our members. We will inform each group of these policies the first time the group becomes a Highmark member and will annually reaffirm our privacy policy for as long as the group remains a Highmark customer. We will continually review our privacy policy and monitor our business practices to help ensure the security of our members’ personal information. Due to changing circumstances, it may become necessary to revise our privacy policy in the future. Should such a change be required, we will notify all affected customers in writing in advance of the change.

In order to administer our health benefit programs effectively, we must collect, use and disclose non-public personal financial information. Non-public personal financial information is information that identifies an individual member of a Highmark health plan. It may include the member’s name, address, telephone number and Social Security number or it may relate to the member’s participation in the plan, the provision of health care services or the payment for health care services. Non-public personal financial information does not include publicly available information or statistical information that does not identify individual persons.

Information we collect and maintain: We collect non-public personal financial information about our members from the following sources:

• We receive information from the members themselves, either directly or through their employers or group administrators. This information includes personal data provided on applications, surveys or other forms, such as name, address, Social Security number, date of birth, marital status, dependent information and employment information. It may also include information submitted to us in writing, in person, by telephone or electronically in connection with inquiries or complaints.

• We collect and create information about our members’ transactions with Highmark, our affiliates, our agents and health care providers. Examples are: information provided on health care claims (including the name of the health care provider, a diagnosis code and the services provided), explanations of benefits/payments (including the reasons for claim decision, the amount charged by the provider and the amount we paid), payment history, utilization review, appeals and grievances.

Information we may disclose and the purpose: We do not sell any personal information about our members or former members for marketing purposes. We use and disclose the personal information we collect (as described above) only as necessary to deliver health care products and services to our members or to comply with legal requirements. Some examples are:

• We use personal information internally to manage enrollment, process claims, monitor the quality of the health services provided to our members, prevent fraud, audit our own performance or to respond to members’ requests for information, products or services. • We share personal information with our affiliated companies, health care providers, agents, other insurers, peer review organizations, auditors, attorneys or consultants who assist us in administering our programs and delivering health services to our members. Our contracts with all such service providers require them to protect the confidentiality of our members’ personal information.

• We may share personal information with other insurers that cooperate with us to jointly market or administer health insurance products or services. All contracts with other insurers for this purpose require them to protect the confidentiality of our members’ personal information.

• We may disclose information under order of a court of law in connection with a legal proceeding.

• We may disclose information to government agencies or accrediting organizations that monitor our compliance with applicable laws and standards.

We may disclose information under a subpoena or summons to government agencies that investigate fraud or other violations of law.

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How we protect information: We restrict access to our members’ non-public personal information to those employees, agents, consultants and health care providers who need to know that information to provide health products or services. We maintain physical, electronic, and procedural safeguards that comply with state and federal regulations to guard non-public personal financial information from unauthorized access, use and disclosure.

For questions about this Privacy Notice, please contact:

Contact Office: Highmark Privacy Department Telephone: 1-866-228-9424 (toll free) Fax: 1-412-544-4320 Address: 120 Fifth Avenue Place 1814 Pittsburgh, PA 15222

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FORM NO. FP-1-I-MPBF-HMO-01-1/1/18

HMO of Northeastern Pennsylvania, Inc.

d/b/a First Priority Health 19 North Main Street

Wilkes-Barre, PA 18711

MY PRIORITY BLUE FLEX HMO Member Agreement DESCRIPTION OF COVERAGE: This HMO Subscriber Agreement sets forth a comprehensive program of inpatient and outpatient health care benefits, pediatric dental and vision benefits provided with cost-sharing options such as deductibles, Coinsurance and copayments. Although referrals are not required in order to receive benefits for covered Services, members must still select a primary care provider upon enrollment. Except for Emergency Care Services, out-of-area urgent care services or when covered health care Services are not available from a Network Provider, benefits are provided only for Services performed by a First Priority Health Network Provider. Benefits for dental Services are only available through the United Concordia Advantage Plus Provider Network, and benefits for vision care Services are only available through the Davis Vision Network. Several specific Services are covered only when rendered by a primary care provider. Additionally, some covered Services require Preauthorization from First Priority Health. Marketed as my Priority Blue Flex , this Individual Managed Health Care Agreement provides Hospital, Medical-Surgical, Skilled Nursing Facility, Home Health Care and Hospice Care utilizing the First Priority Health Network to maximize benefits.

This Agreement is GUARANTEED RENEWABLE. Guaranteed Renewable/Premium Rate is subject to change on a class basis. Refer to page 2.

This A g r e e m e n t utilizes Prior Authorization procedures which must be followed in order to maximize coverage and avoid penalties. Refer to Section CC – Care Coordination for Prior Authorization requirements and procedures.

This Agreement is governed by the laws of the Commonwealth of Pennsylvania. THE M EM BER HAS THE RIGHT TO EXAMINE THIS AGREEM ENT FOR TEN DAYS. The Mem ber covered under this Agreement has a right to return this Agreement within ten days of delivery for refund of premium paid, if after examination of this Agreement the Member is not satisfied for any reason. This Agreement may be returned to: First Priority Health, 19 North Main Street, Wilkes-Barre, PA 18711. First Priority Health shall not be liable for payment of any benefits under this Agreement in such refund cases.

Plans are offered by First Priority Health, a licensed affiliate of Highmark Blue Cross Blue Shield. Highmark Blue Cross Blue Shield and First Priority Health are independent licensees of the Blue Cross Blue Shield Association.

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FORM NO. FP-1-I-MPBF-HMO-01-1/1/18 2

Discrimination is Against the Law The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual.

The Plan:

• Provides free aids and Services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

formats) • Provides free language Services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If a Member needs these Services, the Member should contact the Civil Rights Coordinator.

If a Member believes that the Plan has failed to provide these Services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, the Member can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. The Member can file a grievance in person or by mail, fax, or email. If the Member needs help filing a grievance, the Civil Rights Coordinator is available to help the Member. The Member can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at [https://ocrportal.hhs.gov/ocr/portal/lobby.jsf], or by mail or phone at:

[U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)]

Complaint forms are available at [http://www.hhs.gov/ocr/office/file/index.html].

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mailto:[email protected]


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This Agreement is provided as evidence of your coverage and sets forth a comprehensive program of inpatient and outpatient benefits. Cost-sharing options are available such as deductibles, coinsurance, copayments, and annual and lifetime maximums. Except for Emergency Care Services or when covered health care Services are not available from a network provider, benefits are provided only for Services performed by a network provider. . Additionally, certain network Services received from a network provider participating at the Enhanced Value benefit level are provided at a higher benefit level than network Services received from a provider participating at the Standard Value level of benefits. This Agreement is non-participating in any divisible surplus of premium. An Individual Managed Health Care Agreement

Identified as a

First Priority Health

Individual Managed Health Care Program

Marketed as my Priority Blue Flex HMO

In consideration for and upon payment of the appropriate premium, the person covered under the my Priority Blue Flex HMO Individual Managed Care Agreement is entitled to Hospital, Medical-Surgical, Skilled Nursing Facility, Home Health Care and Hospice Care benefits set forth herein in accordance with the terms and conditions of this Agreement.

Guaranteed Renewable/Premium Increases Annually Based Upon the Attained Age of the Member/Premium Rate Subject to Change

Within a Given Class The initial rates for this product will vary based on the age and gender of the Mem ber as well as the

benefit option selected by the Member and the Member’s tobacco use. First Priority Health reserves the right to change the premium rates for the Agreement on a class basis. Subject to the approval of the Pennsylvania Insurance Department, First Priority Health may adjust premiums. Any change in the premium shall become applicable for the M e m b e r upon thirty (30) days advance notice to the Member and at renewal, on January 1st. Premiums will be charged to Members based upon their attained age as of the Effective Date of his/her coverage under the product and the Agreement will renew every year thereafter on January 1st at the premium for the age which the Member has then attained. The Member’s class will remain constant and will not be revised in the future to reflect adverse claims/health history.

Coverage continues from the Effective Date of the Agreement through the end of the premium payment

period. Subject to the right of First Priority Health to terminate coverage and to any amendment permitted under applicable law, this Agreement will remain in effect continually until terminated by the Member or First Priority Health in accordance with Section GP – General Provis ions of this Agreement.

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PATIENT PROTECTION DISCLOSURE

The Plan generally requires the designation of a Primary Care Provider (“PCP”). Members have the right to designate any primary care Professional Provider who participates in the Network and who is available to accept Members and their family members. For children, a Member may designate a pediatrician as the child’s PCP. However, if no PCP is selected, the Member may be responsible for payment for certain Covered Services. If a Member fails to select a valid PCP within thirty (30) days of membership in this program, the Plan reserves the right to select a PCP for the Member. Members do not need prior authorization from the Plan or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a Participating Provider who specializes in obstetrics or gynecology. The Participating Provider, however, may be required to comply with certain procedures, including obtaining prior authorization for certain Services or following a pre-approved treatment plan.

For information on how to select a PCP, for a list of the primary care Professional Providers in the Network, or for a list of Professional Providers in the Network who specialize in obstetrics or gynecology, contact the Plan at the toll-free telephone number or the website appearing on the back of the Member Identification Card.

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Contents

Where to look for: Page

Section DE Definitions ........................................................................................................................................ 7

Section ER Eligibility Requirements ................................................................................................................. 24

Section CC Care Coordination .......................................................................................................................... 27

Section SB Schedule of Benefits for Covered Medical Expenses .................................................................... 37

Section PE Schedule of Benefits for Covered Pharmacy Expenses ................................................................ 55

Section DB Description of Benefits ................................................................................................................... 55

Section EX Exclusions ..................................................................................................................................... 84

Section GP General Provisions ........................................................................................................................ 91

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The following words and phrases when used in this Agreement shall have, unless the context clearly indicates otherwise, the meaning given to them below:

1. ADVANCE PAYMENT OF PREMIUM TAX CREDITS (APTCs) - tax credit payments made on behalf of the

Member to the Plan, on an advance basis and in amounts as determined by the Exchange, which are applied to the premium amounts due under this Agreement.

2. AGREEMENT – this Agreement, including the application and endorsements, if any, between the Plan and the

Subscriber, the Member’s enrollment confirmation letter, the Highmark Preventive Schedule and the Member’s current Identification Card.

3. ALCOHOL AND/OR DRUG ABUSE – Any use of alcohol or other drugs which produces a pattern of

pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. For the purposes of this Agreement, "drugs" shall be defined as addictive drugs and drugs of abuse listed as scheduled drugs in "The Controlled Substance, Drug, Device and Cosmetic Act" (35 P.S. §780-101 et seq.).

4. ALTERNATIVE TREATMENT PLAN – A voluntary program whereby the Member is offered cost-effective

treatment alternatives in lieu of the stated benefits in this Agreement, without compromising the quality of care. First Priority Health’s Care Management Department, in cooperation with the Primary Care Physician, organizes and coordinates managed care through multi-disciplinary resources.

5. AMBULATORY SURGICAL FACILITY – A Facility Provider, with an organized staff of Physicians, which has

been approved by the Joint Commission on the Accreditation of Healthcare Organizations, by the Accreditation Association for Ambulatory Health Care, Inc., or a similar accrediting agency acceptable to the Plan, which:

a. has permanent facilities and equipment for the purpose of performing surgical procedures on an

Outpatient basis; b. provides nursing Services and treatment by or under the supervision of Physicians whenever the patient

is in the facility; c. does not provide Inpatient accommodations; and d. is not, other than incidentally, a facility used as an office or clinic for the private practice of a Physician or

Dentist.

6. ANNUAL OPEN ENROLLMENT PERIOD - the annual period during which an eligible individual may enroll for coverage under this Agreement.

7. ANCILLARY PROVIDER - a person or entity licensed where required and performing Services within the scope

of such licensure. Ancillary Providers include, but are not limited to: Ambulance Service Independent Diagnostic Testing Facility (IDTF) Clinical Laboratory Suite Infusion Therapy Provider Home Infusion Therapy Provider Diabetes Prevention Provider

Suppliers

8. APPLICANT –The Eligible Person who applies for coverage under this agreement.

9. APPLICATION – The written or electronic request for coverage on the form furnished by First Priority Health

and/or via the federally-facilitated marketplace.

SECTION DE - DEFINITIONS

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10. ARTIFICIAL INSEMINATION - a procedure, also known as intrauterine insemination (IUI) or intracervical/intravaginal insemination (ICI), by which sperm is directly deposited into the vagina, cervix or uterus to achieve fertilization and pregnancy.

11. ASSISTED REPRODUCTIVE TECHNOLOGY - includes all treatments or procedures that involve the in vitro

(i.e., outside of the living body) handling of both human oocytes (eggs) and sperm, or embryos, for the purpose of establishing a pregnancy. Treatments and procedures include, but are not limited to, in vitro fertilization (IVF) and embryo transfer, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), tubal embryo transfer (TET), peritoneal ovum sperm transfer, zona drilling, sperm microinjection, gamete and embryo cryopreservation (freezing), oocyte and embryo donation, and gestational surrogacy or carrier, but does not include artificial insemination in which sperm are placed directly into the vagina, cervix or uterus.

12. BEHAVIORAL HEALTH ACUTE CARE – Health care delivered to a Member, experiencing an acute illness or

trauma, consisting of high level skilled psychiatric or Substance Abuse Services within a free-standing psychiatric hospital, a psychiatric unit of a general hospital or a detoxification unit within a Hospital setting.

13. BENEFIT PERIOD – The calendar year beginning January 1st and ending December 31st of any given year. For

purposes of computing payment in the applicable Benefit Period, a charge shall be considered incurred on the date the service or supply was provided to the Member.

14. BILLED CHARGE - The amount(s) that a Provider bills a Member for health care Services rendered. In the

absence of Prior Authorization from First Priority Health, it is equal to the full cost of such Services without any allowances, discounts, or reductions for which the Member will be responsible.

15. BLUECARD – A program, which allows a Member to access Covered Services from Participating Providers

located outside the geographic area serviced by First Priority Health that are participating with their local Blue Cross and/or Blue Shield Licensee. The local Blue Cross and/or Blue Shield Licensee which serves the geographic area where the Covered Service is provided may also be referred to as the Host Blue or the on-site Blue Cross and/or Blue Shield Licensee.

16. BLUE CROSS BLUE SHIELD GLOBAL CORE - a program sponsored by the Blue Cross Blue Shield

Association that provides Members access to Emergency Care Services and Urgent Care Services from a network of health care Providers outside the United States.

17. BUSINESS DAY – A day that the Plan is open for business.

18. CERTIFICATE OF CREDITABLE COVERAGE – A statement prepared by First Priority Health, in accordance

with the Health Insurance Portability and Accountability Act (“HIPAA”) regulations, for Members who terminate coverage under this Agreement. The statement lists the dates of continuous coverage in this Health Maintenance Organization Agreement and can be used to establish credit toward a waiting period for pre-existing conditions in another health insurance program. A Certificate of Creditable Coverage will be provided to each member at the time the individual ceases to be covered under this Agreement. You can request an additional Certificate of Creditable Coverage by contacting the appropriate First Priority Health Member Service Representative.

19. CHEMOTHERAPY – The treatment of disease by chemical or biological therapeutic agents. 20. CHEMOTHERAPY MEDICATION – A medication prescribed to kill or slow the growth of cancerous cells. 21. CLAIM - a request made by or on behalf of a Member for Preauthorization or prior approval of a Covered

Service, as required under this Agreement, or for the payment or reimbursement of the charges or costs associated with a Covered Service that has been received by a Member. Claims for benefits provided under this Agreement include:

a. Pre-service Claim - a request for Preauthorization or prior approval of a Covered Service which, as a

condition to the payment of benefits under this Agreement, must be approved by the Plan before the Covered Service is received by the Member.

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b. Urgent Care Claim - a Pre-service Claim which, if decided within the time periods established by the Plan for

making non-urgent care Pre-service Claim decisions, could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function or, in the opinion of a Physician with knowledge of the Member’s medical condition, would subject the Member to severe pain that cannot be adequately managed without the Service requested. Whether a request involves an Urgent Care Claim will be determined by the Member’s attending Physician or Provider.

c. Post-service Claim - a request for payment or reimbursement of the charges or costs associated with a

Covered Service that has been received by a Member.

For purposes of the Claim determination and appeal procedure provisions of this Agreement, whether a Claim or an appeal of a denied Claim involves a Pre-service Claim, an Urgent Care Claim or a Post-service Claim will be determined at the time that the Claim or appeal is filed with the Plan in accordance with its procedures for filing Claims and appeals.

22. COPAYMENT – The amount a Member must pay directly to Providers in connection with Covered Services set

forth in this Agreement and/or in the Schedule of Benefits. 23. COST-SHARING REDUCTIONS - reductions as determined by the Exchange in the cost-sharing amounts for

which the Member is otherwise responsible to pay under this Agreement. 24. COSMETIC PROCEDURE – A medical or surgical procedure which is primarily performed to improve the

appearance of any portion of the body. 25. COVERED PHARMACY EXPENSE – A service or supply specified in this Agreement for which benefits for

Prescription Drugs and supplies will be provided pursuant to the terms of this Agreement. Benefits for Prescription Drugs and supplies will be provided pursuant to the terms of this Agreement.

26. COVERED SERVICE (Covered Medical Expense) – A service or supply specified in this Agreement for which

benefits will be provided pursuant to the terms of this Agreement.

27. CUSTODIAL CARE – Services to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered. Custodial Care essentially is personal care that does not require the continuing attention of skilled, trained medical or paramedical personnel. In determining whether a person is receiving Custodial Care, the factors considered are the level of care and medical supervision required and furnished. The decision is not based on diagnosis, type of condition, degree of functional limitation, rehabilitation potential, or place of service.

28. DEDUCTIBLE – A specified amount of Covered Services, as set forth in the Schedule of Benefits, expressed in

dollars that must be incurred by a Member before First Priority Health will assume any liability for all or part of the remaining Covered Medical Expenses.

29. DEPENDENT – The spouse or Domestic Partner of a Member; or the Member’s or Member’s Spouse’s or the

Member’s Domestic Partner’s child(ren) including: newborn children, step-children, children legally placed for adoption, legally adopted children, handicapped individuals and children required to be covered under a Court Order.

30. DESIGNATED AGENT - an entity that has contracted, either directly or indirectly, with the Plan to perform a

function and/or service in the administration of this Policy. Such function and/or service may include, but is not limited to, medical management.

31. DESIGNATED TELEMEDICINE PROVIDER – a Physician, licensed where required and performing within the

scope of such licensure, who has an agreement with a vendor that has contracted with the Plan to provide Telemedicine Services.

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32. DETOXIFICATION – The process whereby an alcohol intoxicated or drug-intoxicated or alcohol-dependent or drug-dependent person is assisted, in a facility licensed by the Pennsylvania Department of Health, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or other drugs, alcohol, drug or other drug dependency factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum.

33. DIABETES PREVENTION PROGRAM - a twelve (12) month program utilizing a curriculum approved by the

Centers for Disease Control to deliver a prevention lifestyle intervention for individuals at high risk of developing type 2 diabetes. The Diabetes Prevention Program includes behavioral and motivational content focusing on moderate changes in both diet and physical activity.

34. DIABETES PREVENTION PROVIDER - an entity that offers a Diabetes Prevention Program based on an in-

person/onsite or digital model and that has agreement with the Plan. 35. DIAGNOSTIC SERVICES – The following procedures ordered by a Physician because of specific symptoms and

signs to determine a definite condition or disease. Diagnostic Services are covered to the extent specified in Description of Benefits, subject to Prior Authorization requirements for certain tests/scans, and include, but are not limited to:

a. diagnostic imaging; b. diagnostic pathology, consisting of laboratory and pathology tests; c. diagnostic medical procedures, consisting of electrocardiogram (ECG), electroencephalogram (EEG),

and other diagnostic medical procedures approved by First Priority Health; and d. allergy testing consisting of percutaneous, intracutaneous and patch tests.

36. DOMESTIC PARTNER – a member of a Domestic Partnership consisting of two (2) partners, each of whom has registered with a Domestic Partner registry in effect in the municipality/governmental entity within which the Domestic Partner currently resides or who meets the definition of a Domestic Partner as defined by the state or local government where the individual currently resides or meets all of the following:

a. Is unmarried, at least eighteen (18) years of age, resides with the other partner and intends to continue to reside with the other partner for an indefinite period of time;

b. Is not related to the other partner by adoption or blood;

c. Is the sole Domestic Partner of the other partner and has been a member of this Domestic Partnership

for the last six (6) months;

d. Agrees to be jointly responsible for the basic living expenses and welfare of the other partner; and

e. Meets (or agrees to meet) the requirements of any applicable federal, state, or local laws or ordinances for Domestic Partnerships which are currently enacted or which may be enacted in the future.

37. DOMESTIC PARTNERSHIP – A voluntary relationship between two (2) Domestic Partners. 38. DRUG FORMULARY - A listing of Preferred Prescription Drugs and supplies covered by First Priority Health,

which is subject to periodic review and modification at least annually by a committee of appropriate actively practicing preferred Physicians and Pharmacists. Prescription Drug inclusions in the Drug Formulary are based on a combination of criteria including clinical quality and cost effectiveness. The Drug Formulary is available upon request from C u s t o m e r Service Representatives by calling toll-free 1-888-510-1084 or via First Priority Health’s web site, www.highmarkbcbs.com.

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39. DURABLE MEDICAL EQUIPMENT – Equipment which:

a. can withstand repeated use; and b. is primarily and customarily used to serve a medical purpose; and c. generally is not useful to a person in the absence of an illness or injury; and d. is appropriate for use in the home.

40. EFFECTIVE DATE – The date coverage begins under this Agreement as shown on the records of First Priority

Health. 41. ELIGIBLE PERSON – A person entitled to be a Member as specified in the Schedule of Eligibility. 42. EMERGENCY CARE SERVICES - the treatment:

a. of bodily injuries resulting from an accident; b. following the sudden onset of a medical condition; or c. following, in the case of a chronic condition, a sudden and unexpected medical event that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in one or more of the following:

i) placing the Member’s health or, with respect to a pregnant Member, the health of the Member or the

unborn child in serious jeopardy; ii) causing serious impairment to bodily functions; or iii) causing serious dysfunction of any bodily organ or part;

and for which care is sought as soon as possible after the medical condition becomes evident to the Member, or the Member’s parent or guardian.

Transportation and related emergency services provided by an Ambulance Service shall constitute Emergency Ambulance Services if the injury or the condition satisfies the criteria above.

Use of an ambulance as transportation to an emergency room of a Facility Provider for an injury or condition that does not satisfy the criteria above will not be covered as Emergency Ambulance Services.

Treatment for any occupational injury for which benefits are provided under any Worker’s Compensation Law or any similar Occupational Disease Law is not covered.

43. EMERGENCY MEDICAL CONDITION – means a medical condition manifesting itself by acute symptoms of

sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section 1867 (e) (1) (A) of the Social Security Act as follows:

(i) placing the health of the individual (or, with respect to pregnant woman, the health of the woman

or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.

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44. ENHANCED VALUE - the level of Network benefits providing for reduced Member cost-sharing for Covered

Services.

45. ENTERAL FOODS – a liquid source of nutrition equivalent to a prescription drug that is administered orally or enterally and which may contain some or all nutrients necessary to meet minimum daily nutritional requirements. Enteral Foods are intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements are identified through medical evaluation.

46. ESSENTIAL HEALTH BENEFITS PLAN - Per the Patient Protection and Affordable Care Act (“PPACA”),

health insurance coverage that provides for the essential health benefits defined by the Secretary of Health and Human Services under subsection (b) of Section 1302 of PPACA; limits cost-sharing for such coverage in accordance with subsection (c) of Section 1302 of PPACA; and subject to subsection (e) of Section 1302 of PPACA, provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d) of Section 1302 of PPAC.

47. EXPERIMENTAL OR INVESTIGATIVE – Any treatment, procedure, facility, equipment, drug or drug usage,

device or supply which is not accepted, Standard Value medical practice by the general medical community or First Priority Health, or does not have federal or government agency approval.

48. FACILITY OTHER PROVIDER – An institution or entity other than a Hospital which is licensed, where required,

to render Covered Services.

49. FACILITY PROVIDER – A Hospital or Facility Other Provider, licensed where required, to render Covered Services.

50. FAMILY COVERAGE – Coverage for the Member and one or more of the Member’s Dependents. 51. FIRST PRIORITY HEALTH NETWORK (“FPH Network”) – The HMO Network or any other Participating

Provider network sponsored by the Plan. Pediatric dental Services are only available through the United Concordia Advantage Plus Provider Network, and pediatric vision Services are only available through the Davis Vision network.

52. FOLLOW-UP CARE – Medical care necessary to treat an illness or injury subsequent to the initial treatment.

53. FREESTANDING DIALYSIS FACILITY – A Facility Other Provider, which is primarily engaged in providing

dialysis treatment, maintenance or training to patients on an Outpatient or home-care basis. 54. FREESTANDING OUTPATIENT FACILITY – A Facility Other Provider, which is primarily engaged in providing

Outpatient Diagnostic and/or therapeutic Services by or under the direction of Physicians.

55. GENERIC EQUIVALENT PRESCRIPTION DRUG – Any Prescription Drug that is considered to be therapeutically equivalent to other pharmaceutical equivalent products by the Food and Drug Administration, has received an “A Code” in the FDA “Approved Drug Products with Therapeutic Equivalence Evaluations,” and is in compliance with applicable state generic substitution laws and regulations.

56. HABILITATIVE AND REHABILITATIVE SERVICES - the following Services or supplies ordered by a

Professional Provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies. Habilitative and Rehabilitative Services are covered to the extent specified in SECTION SB - SCHEDULE OF BENEFITS of this Agreement.

a. Cardiac Rehabilitation - the physiological rehabilitation of patients with cardiac conditions through regulated

exercise, diet and other lifestyle modification programs.

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b. Occupational Therapy - the treatment by means of constructive activities designed and adapted to promote the ability to satisfactorily accomplish the ordinary tasks of daily living and those required by a particular occupational role.

c. Physical Medicine - the treatment by physical means or modalities such as, but not limited to, mechanical

stimulation, heat, cold, light, air, water, electricity, sound, massage, mobilization, and the use of therapeutic exercises and activities.

d. Speech Therapy - the treatment for the correction of a speech impairment.

57. HIPAA – The federal Health Insurance Portability and Accountability Act of 1996.

58. HOMEBOUND – A Member will be considered homebound, if he/she has a condition due to an illness or injury

which restricts his/her ability to leave his/her place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person, or if he/she has a condition which is such that leaving his/her home is medically contraindicated. The condition of these Members should be such that there exists a normal inability to leave home and, consequently, leaving their homes would require a considerable and taxing effort.

59. HOME HEALTH CARE AGENCY – A Facility Other Provider which has been approved by the Joint Commission

on the Accreditation of Healthcare Organizations or a similar accrediting agency acceptable by the Plan, is recognized and licensed by the appropriate regulatory agency to provide Services within the scope of its license, which:

a. provides skilled Outpatient Services on a visiting basis in the Member's home; and b. is responsible for supervising the delivery of such Services under a plan authorized by the Primary Care

Physician.

60. HOME INFUSION THERAPY – The preparation and administration of parenteral and enteral nutrition and/or intravenous drugs and solutions, which are provided in the home or infusion center setting.

61. HOME INFUSION THERAPY AGENCY – A Facility Other Provider, which has been approved by the Joint

Commission on the Accreditation of Healthcare Organizations or a similar accrediting agency acceptable by the Plan; is recognized and licensed by the appropriate regulatory agency to provide Services within the scope of its license; provides Home Infusion Therapy Services in the Member’s home or an infusion center; and is responsible for supervising the delivery of such Services under a plan authorized by the Physician.

62. HOME INFUSION THERAPY PROVIDER - an Ancillary Provider, which has been licensed by the state

accredited by The Joint Commission and Medicare, if appropriate, and is organized to provide Infusion Therapy to Members at their place of residence.

63. HOSPICE – A Facility Other Provider, which is primarily engaged in providing supportive care to terminally ill

individuals.

64. HOSPICE CARE – A health care program which provides an integrated set of Services, primarily in the patient’s home, designed to provide supportive care intended to promote comfort to and relieve suffering of terminally ill patients and their families. Services are coordinated through a Hospice interdisciplinary team and the Member’s Primary Care Physician.

65. HOSPITAL – A Provider that is a short-term, acute care or Rehabilitation Hospital, which has been approved by

the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Hospital Association, the Pennsylvania Department of Health, or a similar accrediting agency acceptable by the Plan, or a Provider that is a state-owned Psychiatric Hospital, and which:

a. is a duly licensed institution;

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b. is primarily engaged in providing Inpatient diagnostic and therapeutic Services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians;

c. has organized departments of medicine and/or major surgery; d. provides 24-hour nursing service by or under the supervision of Registered Nurses; and e. is not, other than incidentally, a:

- Skilled Nursing Facility - nursing home - Custodial Care home - health resort - spa or sanitarium - place for rest - place for the aged - place for the provision of Hospice care, or - personal care home.

66. IDENTIFICATION CARD/ – The currently effective card issued to the Member and Dependents by First Priority

Health. 67. IMMEDIATE FAMILY – The Member's spouse, Domestic Partner, child, stepchild, parent, brother, sister, mother-

in-law, father-in-law, sister-in-law, brother-in-law, daughter-in-law or son-in-law. 68. INDIAN - an individual that meets the requirements of section 4(d) of the Indian Self-Determination and

Education Assistance Act (Pub. L. 93-638). 69. INDIAN HEALTH SERVICE (IHS) PROVIDER - the Indian Health Service, an Indian Tribe, Tribal Organization,

or Urban Indian Organization as defined in 25 U.S.C. §1603. 70. INFUSION THERAPY – the treatment by the administration of medically necessary and appropriate fluid or

medication via a central or peripheral vein when performed, furnished and billed by a facility provider or Ancillary Provider in accordance with accepted medical practice. Benefits will be provided when performed by a Facility Provider, Professional Provider or Ancillary Provider or if the components are furnished and billed by a Facility Provider, Professional Provider or Ancillary Provider. However, certain Infusion Therapy Services as identified by the Plan will only be provided when performed by an Ancillary Provider.

71. INPATIENT – A Member who is treated as a registered overnight bed patient in a Hospital or Facility Other

Provider, who is expected to stay overnight and for whom a room and board charge is made.

72. INPATIENT ALCOHOL AND/OR DRUG ABUSE NON-HOSPITAL RESIDENTIAL CARE – The provision of medical, nursing, counseling, or therapeutic Services to patients suffering from Alcohol and/or Drug Abuse or dependency in a residential environment, according to individualized treatment plans.

73. INPATIENT MENTAL HEALTH HOSPITAL – A short-term acute care Hospital, which has been approved by the

Joint Commission on the Accreditation of Healthcare Organizations, or the American Osteopathic Hospital Association, or a similar accrediting agency acceptable by the Plan and which provides Services that are necessary for short-term evaluation, diagnosis, and treatment (or crisis intervention) of Serious Mental Illness.

74. INPATIENT MENTAL HEALTH NON-HOSPITAL RESIDENTIAL CARE – The provision of medical, nursing,

counseling, or therapeutic Services to patients suffering from Serious Mental Illness, or Mental and Nervous Disorders in a residential environment, according to individualized treatment plan

75. INTENSIVE OUTPATIENT PROGRAM – Medical, nursing, and therapeutic Outpatient Services delivered on a

structured and predetermined schedule to those patients determined as requiring more intensive levels of treatment than those typically available through traditional outpatient alcohol and/or drug abuse programs.

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Intensive Outpatient Programs must be licensed with the Department of Health to provide outpatient drug and alcohol addiction or mental health treatment.

76. LICENSED PRACTICAL NURSE (LPN) – A nurse who has graduated from a formal practical nursing education

program and is licensed by appropriate state authority. 77. LIMITED OPEN ENROLLMENT PERIOD - a period during which an eligible individual who experiences certain

qualifying events may enroll or change enrollment in the coverage provided under this Agreement when such coverage is not provided pursuant to enrollment through the Exchange. Limited Open Enrollment Periods are provided to individuals who experience qualifying events, which applicable federal law, regulations and guidance have determined result in limited open enrollment period rights.

78. LONG-TERM RESIDENTIAL CARE – The provision of long-term diagnostic or therapeutic Services (i.e.,

assistance or supervision in managing basic day to day activities and responsibilities) to patients suffering from Alcohol and/or Drug Abuse or dependency. This care is provided in a long-term residential environment known as a Transitional Living Facility, on an individual, group, and/or family basis, with a program duration greater than sixty (60) days. Long-Term Residential Care is not Inpatient Non-Hospital Residential Care.

79. MAINTENANCE PRESCRIPTION DRUG – Any Prescription Drug, not including Specialty Injectable Drugs,

which First Priority Health makes available through a Participating Mail Order Pharmacy, which is generally used to treat chronic medical conditions and is generally not needed urgently for an immediate acute illness and which the Member chooses to obtain, or First Priority Health requires be obtained, from a Participating Mail Order Pharmacy. First Priority Health may specify certain Prescription Drugs that are not available through a Participating Mail Order Pharmacy.

80. MASTECTOMY – Removal of all or part of the breast for Medically Necessary reasons as determined by a licensed

Physician.

81. MAXIMUM – The greatest benefit amount payable by the Plan. This could be expressed in dollars, number of days, or number of Services for a specified period of time.

a. BENEFIT MAXIMUM – The greatest benefit amount payable by the Plan for a specific Covered Service. b. LIFETIME BENEFIT MAXIMUM – The greatest benefit amount payable by the Plan in the Member's

lifetime, which is unlimited. 82. MEDICAL CARE/MEDICAL SERVICES – Services rendered by a Professional Provider to prevent illness

(preventive care) and/or restore health (treatment of an illness or injury).

83. MEDICAL NECESSITY

Medically Necessary or Medical Necessity – means health care Services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

a. In accordance with generally accepted Standard Values of medical practice;

b. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and

c. not primarily for the convenience of the patient or the provider, and not more costly than an alternative service or sequence of Services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

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For these purposes, “generally accepted Standard Values of medical practice” means Standard Values that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Specialty Society recommendations, and the views of providers practicing in relevant clinical areas and any other relevant factors.

84. MEDICARE – The programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.

85. MEMBER – An Eligible Person who has satisfied the specifications in Section ER – Eligibility Requirements of

this Agreement and is enrolled under this Agreement. 86. MENTAL OR NERVOUS DISORDER – Mental, nervous, or emotional disorder means a neurosis,

psychoneurosis, psychopathy, or psychosis.

87. MORBID OBESITY – The term refers to patients who have a body mass index (BMI) of 40 or greater.

88. NUTRITIONAL THERAPY – Nutritional diagnostic, therapy, and counseling Services for the purpose of disease management which are furnished by a licensed health care professional to help a person make and maintain healthy dietary changes.

89. ORTHOSIS – A rigid or semi-rigid appliance used for the purpose of supporting a weak or deformed body part or

for restricting or eliminating motion in a diseased or injured part of the body.

90. OUT-OF-POCKET MAXIMUM – A specified dollar amount (as dictated by the Internal Revenue Service) as indicated in the Schedule of Benefits incurred by the Member, as set forth in the Schedule of Benefits for Covered Medical Expenses, which includes Deductible, Coinsurance, and Copayment amounts. It does not include premiums, amounts in excess of the Plan Allowance, charges for non-Covered Services, and charges after Covered Services have been exhausted.

91. OUTPATIENT – A Member who receives Services or supplies while not an Inpatient. 92. PARTIAL HOSPITALIZATION AND INTENSIVE OUTPATIENT PROGRAM – The provision of medical, nursing,

counseling, or therapeutic Services on a planned and regularly scheduled basis in a Hospital or non-hospital facility licensed by the Department of Health to provide an alcohol or drug addiction treatment program designed for a patient or client who would benefit from more intensive Services than are offered in Outpatient treatment but who does not require Inpatient care.

93. PARTIAL HOSPITALIZATION PSYCHIATRIC CARE SERVICES – The provision of diagnostic and therapeutic

Services for the treatment of Mental Illness on an Outpatient basis through a state-licensed Partial Hospitalization program, which is approved by the Joint Commission on the Accreditation of Healthcare Organizations or similar accrediting agency acceptable to First Priority Health.

94. PARTICIPATING COMMUNITY PHARMACY PROVIDER - Any Participating Pharmacy Provider, which is a

public, walk-in Pharmacy. 95. PARTICIPATING FACILITY PROVIDER – An approved Facility Provider which has an agreement with First

Priority Health pertaining to payment for Covered Services rendered to a Member or a Facility Provider that has been selected to participate in the Blue Distinction Centers Program for Transplants.

96. PARTICIPATING MAIL ORDER PHARMACY PROVIDER – A Participating Pharmacy, which has entered into a

Participating Mail Order Pharmacy agreement with First Priority Health, its affiliates, agents, and assigns. 97. PARTICIPATING PHARMACY PROVIDER - Any Pharmacy, which has entered into a Participating Pharmacy

agreement with First Priority Health or other entity contracted by First Priority Health to furnish a Pharmacy Provider network. Participating Pharmacy Providers include: Participating Community Pharmacy Providers, Participating Mail Order Pharmacy Providers and Participating Pharmacy Providers for Specialty Drugs.

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98. PARTICIPATING PHAMACY PROVIDER FOR SPECIALTY DRUG - A Participating Pharmacy Provider, which

has entered into a Specialty Drug Provider Agreement with First Priority Health, its affiliates, agents, and assigns.

99. PARTICIPATING PROFESSIONAL PROVIDER – A non-Facility Provider which or who has entered into a

contractual agreement with First Priority Health for the provision of Services to Members on an agreed-upon basis.

100. PARTICIPATING PROVIDER AGREEMENT – An agreement between a Provider and First Priority Health

pursuant to which negotiated rates are established for payment of Covered Services rendered to a Member. 101. PHARMACIST – An individual who has been issued a license by the appropriate 100state licensing

agency to engage in the practice of pharmacy, including the preparation and dispensing of Prescription Drugs and the dissemination of drug information to patients and health professionals.

102. PHARMACY – An establishment which has been issued a permit by the appropriate state licensing

agency wherein the practice of pharmacy is conducted under the direct supervision and control of a licensed Pharmacist.

103. PHYSICIAN – A person, who is a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.), licensed and legally

entitled to practice medicine in all of its branches, perform Surgery and prescribe and administer drugs.

104. PLAN – refers to First Priority Health which is an independent licensee of the Blue Cross Blue Shield Association. Any reference to the Plan may also include its Designated Agent as defined herein and with whom the Plan has contracted, either directly or indirectly, to perform a function or service in the administration of this Policy.

105. PLAN ALLOWANCE - the amount used to determine payment by the Plan for Covered Services provided to a

Member as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, and to determine Member liability. Plan Allowance is based on the type of Provider who renders such Services or as required by law.

In the case of a Participating Provider who has signed a Provider Agreement with First Priority Health, the Plan

Allowance is established by a Provider Agreement and will be accepted by the Participating Provider as payment in full for Covered Services less any Member liability, as specified herein and in the Schedule of Benefits. In the case of a Participating Professional Provider, Member liability will be calculated on the Plan Allowance or on the Billed Charge, whichever is less. In the case of a Participating Facility Provider, Member liability will be calculated on the Plan Allowance.

In the case of a Participating Provider within a Host Blue’s service area who has not signed a Provider Agreement with First Priority Health, when Prior Authorization is obtained, the Plan Allowance is based on the Negotiated Price that the Host Blue passes on to First Priority Health or the billed covered charge, whichever is less.

In the case of a Participating Provider within a Host Blue’s service area, when Prior Authorization is not obtained, the Member will be responsible for the full cost of any Services rendered. In the case of a Non-Participating Provider, wherever located, when Prior Authorization is obtained, the percentage of cost-sharing will be the same as that which the Member would have been responsible for if the Member had received Services from a Participating Provider. Non-Participating Providers will accept the Plan payment as payment in full for prior authorized Covered Services less any Member cost-sharing, as specified herein and in the Schedule of Benefits.

In the case of Outpatient Emergency Services rendered by a Non-Participating Provider, the Plan Allowance is the amount First Priority Health would pay to a Participating Provider for Outpatient Emergency Services. The percentage of cost-sharing will be the same as that which the Member would have been responsible for if the

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Member had received Outpatient Emergency Services from a Participating Provider. The Member is also responsible for the difference between the amount First Priority Health reimburses the Provider and the Billed Charge. In the case of a Non-Participating Provider, wherever located, when Prior Authorization is not obtained, the Member will be responsible for the full cost of any Services rendered.

In all cases where the Plan Allowance applies, the Member will be responsible for any cost-sharing, as specified herein and in the Schedule of Benefits, plus any amounts that exceed the Plan Allowance, amounts exceeding any Benefit Maximums, amounts exceeding any Lifetime Maximums, charges after Covered Medical Expenses have been exhausted, and charges for non-Covered Services.

Members may contact Member Service Representatives toll-free at 1-800-822-8753 weekdays during normal business hours for a determination of benefits. Members may also write to:


19 North Main Street Wilkes-Barre, PA 18711

106. PREFERRED PRESCRIPTION DRUG – Any Prescription Drug, which is listed in the Drug Formulary and

preferred by First Priority Health. Preferred Prescription Drugs are those listed in Enhanced Value or Standard Value of the Drug Formulary.

107. PRESCRIBER – An individual who has been issued a license by the appropriate state licensing agency to

engage in a health care professional practice, who, acting within the scope of his/her license, is duly authorized by law to prescribe Prescription Drugs.

108. PRESCRIPTION – An order from a Prescriber for a single Prescription Drug of a particular strength and/or

dosage form. 109. PRESCRIPTION DRUG – Any medication, which by federal and/or state law may not be dispensed without a

Prescription order issued by a Prescriber. 110. PRESCRIPTION DRUG COPAYMENT – The amount a Member must pay directly to Pharmacy Providers in connection with Covered Services set forth in the Schedule of Benefits provided to the Member as an addendum to this Agreement. 111. PRESCRIPTION DRUG DEDUCTIBLE – A specified amount of Covered Pharmacy Expenses, usually

expressed in dollars that must be incurred by a Member before First Priority H e a l t h will assume any liability for all or part of the remaining Covered Pharmacy Expenses.

112. PRIMARY CARE PHYSICIAN – A Physician, who supervises, coordinates and provides initial care and basic

medical Services to Members as a general or family practitioner, an internist, or a pediatrician, and maintains continuity of patient care.

113. PRIOR AUTHORIZATION – The process whereby Participating Providers, including the Member’s Primary Care

Physician as well as participating Providers of a Host Blue located outside of the area serviced by First Priority Health’s Network, obtain approval from First Priority Health for Covered Services prior to the date of Services. Prior Authorization is usually conducted via telephone, telefax, or electronically and the process results in the issuance of a Prior Authorization number by First Priority Health, without which the claim will not be paid. It is the responsibility of a Participating Provider to obtain Prior Authorization, when required, in accordance with First Priority Health’s policies and procedures. First Priority Health may add or delete Services, which require Prior Authorization, as it deems necessary. Any notice of a change shall be considered to have been given when mailed to the Agreement Holder and to the Member at the address on the records of First Priority Health at least thirty (30) days in advance of such change.

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With regard to prescription drug benefits, Prior Authorization means the process whereby the prescriber and/or Member is given prior approval by First Priority Health for certain prescription drugs, including drug formulary exceptions, and utilization review criteria, which have been designated by First Priority Health as requiring Prior Authorization. It is the responsibility of the Member to obtain Prior Authorization for prescription drug benefits, when required, in accordance with First Priority Health’s policies and procedures. The Member’s Physician must complete the form and send it to the Plan by fax or electronically. The director of pharmacy will review the request and provide a decision based on Medical Necessity. If the Member’s prescription has been authorized, coverage for the drug will be made available and the Member will be notified of the decision in writing.

114. PRIVATE DUTY NURSING – Total patient care provided by a Registered Nurse or licensed practical nurse on an individual basis.

115. PROFESSIONAL PROVIDER – An individual or practitioner, who is licensed/certified to render Covered Services.

Professional Providers include, but are not limited to:

Certified Addiction Counselor Optometrist Chiropractor Physical Therapist Clinical Psychologist Physician Clinical Nurse Specialist Physician Assistant Dentist Podiatrist Licensed Dietitian-Nutritionist Registered Nurse Licensed Practical Nurse Social Worker Nurse Midwife Speech Therapist Nurse Practitioner Occupational Therapist

116. PROSTHESIS – An artificial body part which replaces all or part of a body organ or which replaces all or part of

the function of a permanently inoperative or malfunctioning body part.

117. PROVIDER – A Facility Provider, Professional Provider, Pharmacy Provider, or Supplier licensed, where required, and performing Services within the scope of the license.

a. PARTICIPATING PROVIDER – A Provider who signed a Participating Provider Agreement with First

Priority Health or a Participating Provider of a Host Blue located outside the geographic area serviced by First Priority Health, who signed a Provider Agreement with their on-site Blue Cross and/or Blue Shield Licensee. Members can verify whether a Provider is in the First Priority Health Network or is a Participating Provider of a Host Blue by contacting their Primary Care Physician or consulting the Provider directories located on the Plan’s web site, www.highmarkbcbs.com. Members may also contact Member Service Representatives toll-free weekdays during normal business hours.

b. NON-PARTICIPATING PROVIDER – A Provider who has not signed a Participating Provider Agreement

with First Priority Health and is not a Participating Provider of a Host Blue.

118. PROVIDER AGREEMENT – An agreement between a Provider and First Priority Health or any other Blue Plan (Host Blue) participating in BlueCard pursuant to which negotiated rates are established on a participating provider basis for payment of Covered Services rendered to a Member.

119. PSYCHIATRIC HOSPITAL – A Facility Provider, approved by the Joint Commission on the Accreditation of

Healthcare Organizations or a similar accrediting agency acceptable to First Priority Health, which is primarily engaged in providing diagnostic and therapeutic Services for the Inpatient treatment of Mental Illness. Such Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing Services are provided by or under the supervision of a Registered Nurse.

120. PSYCHOLOGIST – A licensed clinical Psychologist.

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http://www.highmarkbcbs.com/


121. QUALIFIED HEALTH PLAN - a health plan, including coverage provided under this Agreement, which has been certified by the Exchange as meeting the standards of a qualified health plan as defined under the Affordable Care Act.

122. QUALIFIED INDIVIDUAL – A Member who is eligible to participate in an approved clinical trial, as defined by the

Section 2709(d)(1)A-C of the Patient Protection and Affordable Care Act, according to the trial protocol with respect to treatment of cancer or other life-threatening disease(s) or condition(s), and meets either of the following criterion:

• The referring health care professional is a qualified participating health care provider and has

concluded that the individual’s participation in such trial would be appropriate; or • The Member provides peer reviewed medical and scientific information establishing that his or her

participation in such trial would be appropriate. 123. RECONSTRUCTIVE PROCEDURE/SURGERY – Procedures, including surgical procedures, performed on a

structure of the body to restore or establish satisfactory bodily function or correct a functionally significant deformity resulting from disease, accidental injury, or a previous therapeutic process. This includes a surgical procedure performed on one breast or both breasts following a Mastectomy, as determined by the treating Physician, to reestablish symmetry between the two breasts or alleviate functional impairment caused by the Mastectomy and it includes, but is not limited to: augmentation mammoplasty, reduction mammoplasty and mastopexy. This also includes surgical procedures performed to improve appearance, but only if necessitated by a covered sickness or injury; required for correction of a condition directly resulting from accidental injury; or for a newborn to correct a congenital birth defect; or for the treatment of complications resulting from Surgery.

124. REGISTERED NURSE (RN) – A nurse who has graduated from a formal program of nursing education (diploma

school, associate degree or baccalaureate program) and is licensed by appropriate state authority. 125. REHABILITATION HOSPITAL – A Facility Provider approved by the appropriate accrediting agency or a similar

accrediting agency acceptable to First Priority Health, which is primarily engaged in providing rehabilitation care Services on an Inpatient basis. Rehabilitation care Services consist of the combined use of medical, social, educational, and vocational Services to enable patients disabled by disease or injury to achieve the highest possible level of functional ability. Services are provided by or under the supervision of an organized staff of Physicians. Continuous nursing Services are provided by or under the supervision of a Registered Nurse.

126. RESIDENTIAL TREATMENT FACILITY - a Facility Provider which, for compensation by its patients, is primarily

engaged in providing intensive, structured psychological Services either directly by, or under the supervision of, a medical professional for the treatment of behavioral, emotional, mental, or psychological conditions. This Facility Provider must also meet the minimum standards of the Plan’s credentialing criteria for Residential Treatment Facilities as well as those standards required by the appropriate governmental agencies.

127. RESPITE CARE – Residential Medical Care given in a setting outside the patient’s home, such as in a Skilled

Nursing Facility, in order to provide a brief interval of relief for the patient’s primary caregiver, which is usually a family member.

128. RETAIL CLINIC CARE – The treatment of common minor ailments (in a health care facility located in a

convenient setting, such as a retail store, grocery store or pharmacy, which offers unscheduled, walk-in care) including, but not limited to, sore throat, coughs or pink eye.

129. ROUTINE COSTS – Routine patient costs associated with phase(s) I, II, III, or IV clinical trials designed to

prevent, detect, or treat cancer or other life-threatening diseases or conditions, including all items and Services consistent with the coverage provided in the Plan that are typically covered for a Qualified Individual who is not enrolled in a clinical trial. Per Section 2709(a)(2)B, the following are excluded from the definition of Routine Costs:

(i) The investigational item, device, or service, itself; (ii) Items and Services that are provided solely to satisfy data collection and analysis needs that are not

used in the direct clinical management of the patient; or

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(iii) A service that is clearly inconsistent with widely accepted and established Standard Values of care for a particular diagnosis.

130. SEMI-PRIVATE ROOM – The bed, board and nursing care regularly provided to patients in a room which is

designated as semi-private by the Provider of care and which contains more than one bed.

131. SERIOUS MENTAL ILLNESS – Any of the following Mental Illnesses, as defined by the American Psychiatric Association; schizophrenia, bipolar disorder, obsessive-compulsive disorder, major depressive disorder, panic disorder, anorexia nervosa, bulimia nervosa, schizo-affective disorder and delusional disorder.

132. SERVICE - Each treatment rendered by an Ancillary Provider, Facility Provider or Professional Provider to a

Member for a Covered Service. 133. SERVICE AREA – The following thirteen (13) Pennsylvania counties: Bradford, Carbon, Clinton, Lackawanna,

Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne and Wyoming. 134. SKILLED INPATIENT CARE – Covered Services that are authorized by the Physician as skilled and/or

rehabilitative Services (not maintenance or Custodial Care), performed in a Skilled Nursing Facility on a daily basis and which can only be performed by, or under the supervision of, licensed professional personnel or professional therapists, such as physical therapists, occupational therapists, and speech pathologists or audiologists. Services which are needed only occasionally, such as once or twice a week, or rehabilitation Services which are no longer improving the Member’s condition and may be carried out by someone other than the skilled therapist, are not considered Skilled Inpatient Care.

135. SKILLED NURSING FACILITY – A Facility Other Provider which is an institution or a distinct part of an

institution, other than one which is primarily for the care and treatment of mental disorders, alcoholism or drug addiction, which is certified as a Skilled Nursing Facility under the Medicare Law, or which is qualified to receive such approval, if so requested.

136. SPECIAL ENROLLMENT PERIOD - the period during which an eligible individual who experiences certain

qualifying events may enroll or change enrollment in the coverage provided under this Agreement when provided pursuant to enrollment through the Exchange. Special enrollment periods also apply to individuals eligible to enroll during a Limited Open Enrollment Period or who experience such other events in connection with which applicable federal laws, regulations and guidance have determined results in special enrollment rights.

137. SPECIALTY DRUG - Any Prescription Drug, which has been specifically designated by First Priority Health

as being available from only a Participating Pharmacy for Specialty Drugs. Such Prescription Drugs classes include, but are not limited to self-administrable injectables, such as antihemophilic agents, hematopoietic agents, anticoagulants, growth hormones, enzyme replacement agents, immunomodulators, immunosuppressives, monoclonal antibodies, and other biotech drugs. From time-to-time, such as when new biotech drugs become available, First Priority Health may specify certain Prescription Drugs that are available from only a Participating Pharmacy for Specialty Drugs.

138. SPECIALIST PHYSICIAN – a Physician, other than a Primary Care Physician, who limits his or her practice to a

particular branch of medicine or Surgery. 139. SPECIALIST VIRTUAL VISIT – a real-time office Visit with a Specialist at a remote location, conducted via

interactive audio and streaming video telecommunications. 140. SPINAL MANIPULATION – the detection and correction by manual or mechanical means of structural imbalance

or subluxation resulting from or related to distortion, misalignment, or subluxation of the vertebral column. 141. STANDARD VALUE - the level of Network benefits providing for Member cost-sharing which is higher than the

Enhanced Value level of benefits.

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142. SUBSTANCE ABUSE – Any use of drugs and/or alcohol which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal.

143. SUBSTANCE ABUSE TREATMENT FACILITY – A licensed Facility Provider, which is primarily engaged in

Detoxification and/or rehabilitation treatment for Alcohol and/or Drug Abuse. The Facility Provider must meet the minimum Standard Values for such facilities set by the Pennsylvania Department of Health.

144. SUITE INFUSION THERAPY PROVIDER - an Ancillary Provider licensed by the state, accredited by The Joint

Commission, if appropriate, and organized to provide Infusion Therapy to patients at an infusion suite. 145. SUPPLIER – An individual or entity that is in the business of leasing and selling Durable Medical Equipment and

supplies, Prostheses and Orthoses. 146. SURGERY – The performance of generally accepted operative and cutting procedures, including specialized

instrumentations, endoscopic examinations and other procedures; the correction of fractures and dislocations; and usual and related pre-operative and post-operative care.

147. TELEMEDICINE SERVICE – a real time interaction between a Member and a Designated Telemedicine Provider

conducted by means of telephonic or audio and video telecommunications, for the purpose of providing specific Outpatient medical care Services.

148. THERAPY SERVICE – Services or supplies used for the treatment of an illness or injury to promote the recovery

of a Member. Therapy Services are covered to the extent specified in this Agreement.

a. CHEMOTHERAPY - the treatment of malignant disease by chemical or biological antineoplastic agents.

b. COGNITIVE REHABILITATION THERAPY – A structured set of therapeutic activities designed to retain an individual’s ability to think, use judgment and make decisions. The focus is on improving deficits in memory, attention, perception, learning, planning, and judgment. The term, cognitive rehabilitation, is applied to a variety of intervention strategies or techniques that attempt to help patients reduce, manage, or cope with cognitive deficits caused by brain injury.

c. DIALYSIS TREATMENT – The treatment of acute renal failure or chronic irreversible renal insufficiency

or removal of waste materials from the body to include hemodialysis or peritoneal dialysis. d. OCCUPATIONAL THERAPY – The treatment of a physically disabled person by means of constructive

activities designed and adapted to promote the restoration of the person's ability to satisfactorily accomplish the ordinary tasks of daily living and those required by the person's particular occupational role.

e. PHYSICAL MEDICINE – The treatment by physical means or modalities such as, but not limited to,

mechanical stimulation, heat, cold, light, air, water, electricity, sound, massage, mobilization, and the use of therapeutic exercises and activities.

f. PULMONARY REHABILITATION THERAPY – A program of exercise training, psychological support

and pulmonary physiotherapy education which is intended to improve the patient’s functioning and quality of life by controlling and alleviating symptoms, including complications of pulmonary disorders.

g. RADIATION THERAPY – The treatment of disease by x-ray, gamma ray, accelerated particles, mesons,

neutrons, radium or radioactive isotopes. h. RESPIRATORY THERAPY – The introduction of dry or moist gases into the lungs for treatment

purposes.

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i. SPEECH THERAPY – The treatment for the correction of a speech impairment resulting from disease, surgery, injury, anomalies or previous therapeutic processes.

j. INFUSION THERAPY – the treatment by the administration of medically necessary and appropriate fluid

or medication via a central or peripheral vein when performed, furnished and billed by a facility provider or Ancillary Provider in accordance with accepted medical practice. Benefits will be provided when performed by a Facility Provider, Professional Provider or Ancillary Provider or if the components are furnished and billed by a Facility Provider, Professional Provider or Ancillary Provider. However, certain Infusion Therapy Services as identified by the Plan will only be provided when performed by an Ancillary Provider.

149. TRANSITIONAL LIVING FACILITY – A facility that renders Long-Term Residential Care. This type of facility can

be licensed, when appropriate, by the Pennsylvania Department of Health. However, a facility providing Long-Term Residential Care is not to be considered an Inpatient Non-Hospital Residential Facility rendering inpatient Non-Hospital Residential Care. Specific Transitional Living Facilities include half-way houses, group homes or supervised apartment settings.

150. TRANSPLANT PROCEDURES – The pre-testing and/or initial evaluation and/or consultation processes occurring

before as well as leading up to and including Surgery for the transplant of human tissue and/or organs. 151. UNATTENDED SERVICES – Services that are not accompanied by a Provider or monitored by a Provider. 152. UPMC - the non-profit, tax-exempt corporation organized under the laws of the Commonwealth of Pennsylvania

having its principal address at: 200 Lothrop Street, Pittsburgh, PA 15213. Unless otherwise specified, all references to UPMC include all of its controlled non-profit and for-profit subsidiaries, partnerships, trusts, foundations, associations or other entities however styled.

153. UPMC HOSPITALS - the Hospitals operated by the following UPMC subsidiaries: UPMC Presbyterian-

Shadyside, Children’s Hospital of Pittsburgh of UPMC, Magee Women’s Hospital of UPMC, UPMC McKeesport, UPMC Passavant, UPMC St. Margaret, UPMC Bedford Memorial, UPMC Horizon, UPMC Northwest, UPMC Mercy, UPMC East, UPMC Hamot, UPMC Hamot affiliate - Kane Community Hospital, UPMC Altoona, Western Psychiatric Institute and Clinic of UPMC and any other Hospital acquired by UPMC in the future.

154. UPMC PHYSICIANS - all Physicians which were previously defined in provider agreements between Highmark Inc. and UPMC including those:

a. employed by UPMC Hospitals; b. employed by the University of Pittsburgh Physicians (“UPP”) and any successors of UPP that are under the

direction and control of the UPMC Hospitals or UPMC; c. employed by Children’s Community Pediatrics (“CCP”) and any successors of CCP that are under the

direction and control of UPMC Hospitals or UPMC; d. employed by UPMC Community Medicine, Inc. (“CMI”) and any successors of CMI that are under the

direction and control of UPMC Hospitals or UPMC; e. that are hospital-based Physicians and who provide Services under an arrangement (written or otherwise)

with the UPMC Hospitals including, but not limited to, all hospital-based Physicians practicing in the specialties of anesthesiology, pathology, radiology and emergency medicine; or

f. controlled or otherwise affiliated, either directly or indirectly, with UPMC.

155. UPMC PROVIDERS - collectively, UPMC, all UPMC Hospitals, UPMC Physicians and any other Providers

contemplated under the Consent Decree entered into by Highmark Inc. on June 27, 2014.

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156. URGENT CARE CENTER - a formally structured hospital-based or freestanding full-service, walk-in health care clinic, outside of a hospital-based emergency room, that is open twelve (12) hours a day, Monday through Friday and eight (8) hours a day on Saturdays and Sundays, that primarily treats patients who have an injury or illness that requires immediate care, but is not serious enough to warrant a visit to an emergency room. An Urgent Care Center can also provide the same Services as a family Physician or Primary Care Provider, such as treatment of minor illnesses and injuries, physicals, x-rays and immunizations.

157. URGENT CARE SERVICES - treatment for an unexpected illness or injury, which is not life threatening but which

the Member must receive and cannot be reasonably postponed until the Member returns to the Network Service Area.

158. VISION PROVIDER - a Physician or Professional Provider licensed, where required, and performing Services

related to the examination, diagnosis and treatment of conditions of the eye and associated structures. 159. VISIT –

a. the physical presence of a Member at a location designated by the Provider for the purpose of providing Covered Services;

b. an interaction between a Member and a PCP, Specialist or Retail Clinic for the purpose of providing

Outpatient Covered Services for treatment of a condition not related to Surgery or pregnancy conducted by means of audio and video telecommunications system established by the Provider and approved by the Plan; or

c. an interaction between a Member and a Provider for the purpose of providing Outpatient Covered Services

for the treatment of a condition not related to Surgery or pregnancy conducted by means of a secure store-and-forward electronic communications system established by the Provider and approved by the Plan.

A. ELIGIBILITY

1. Eligible Subscriber To be eligible to enroll as a Subscriber for coverage under this Agreement, an individual must: a. be a U.S. citizen, national or other individual lawfully present in the United States; b. not entitled for benefits under Medicare Part A or be enrolled in Medicare Part B, Medicaid or CHIP; c. not be incarcerated (other than incarceration pending the disposition of charges); and d. reside in the geographic area in which the product represented by this Agreement is available from the

Plan; and 2. Eligible Dependent

An eligible Dependent is a U.S. citizen, national or other individual lawfully present in the United States: a. not entitled for benefits under Medicare Part A or enrolled in Medicare Part B, Medicaid or CHIP; b. not incarcerated (other than incarceration pending the disposition of charges); and

SECTION ER - ELIGIBILITY REQUIREMENTS

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c. who has been identified by the Subscriber through the appropriate enrollment process or on an application form accepted by the Plan as:

i) The Subscriber’s spouse under a legally valid existing marriage. ii) The Subscriber’s Domestic Partner for the duration of the Domestic Partnership. In addition, the

child(ren) of the Domestic Partner shall be considered, for eligibility purposes, as if they were the child(ren) of the Subscriber as long as the Domestic Partnership exists.

iii) The Subscriber’s child, including a newborn child, step-child, child legally placed for adoption,

child awarded coverage pursuant to an order of court, and legally adopted child of the Subscriber or Subscriber’s spouse. The limiting age for a covered child is twenty-six (26), unless the period of eligibility for such Dependent is otherwise extended pursuant to applicable state or federal law.

Eligibility will be continued past the date that a Dependent child turns age twenty-six (26) for the Subscriber’s unmarried child who, as medically certified by a Physician, is incapable of self-support due to mental retardation or physical disability, Mental Illness or developmental disability that started before age twenty-six (26). The Plan may require proof of such Dependent’s disability from time to time.

NOTE: To the extent mandated by the requirements of Pennsylvania Act 83 of 2005, eligibility will be

continued past the date that a Dependent child turns age twenty-six (26) for unmarried children who are enrolled as Dependents under their parent’s coverage at the time they are called or ordered into active military duty. The Dependent must be a member of the Pennsylvania National Guard or any reserve component of the armed forces of the United States, who is called or ordered to active duty, other than active duty for training, for a period of thirty (30) or more consecutive days, or be a member of the Pennsylvania National Guard ordered to active state duty for a period of thirty (30) or more consecutive days. If the Dependent becomes a full-time student for the first term or semester starting sixty (60) or more days after his or her release from active duty, the Dependent shall be eligible for coverage as a Dependent past the date that the Dependent child turns age twenty-six (26) for a period equal to the duration of the Dependent’s service on active duty or active state duty.

For the purposes of this Note, full-time student shall mean a Dependent who is enrolled in, and

regularly attending, an accredited school, college or university, or a licensed technical or specialized school for fifteen (15) or more credit hours per semester, or, if less than fifteen (15) credit hours per semester, the number of credit hours deemed by the school to constitute full-time student status.

A Dependent child who takes a medically necessary leave of absence from school, or who changes his or her enrollment status (such as changing from full-time to part-time) due to a serious illness or injury may continue coverage for one (1) year from the first day of the medically necessary leave of absence or other change in enrollment or, if earlier, until the date coverage would otherwise terminate under the terms of the Agreement. The Plan may require a certification from the Dependent child’s treating Physician in order to continue such coverage.

3. Newborn Children

A newborn child, whether natural born, adopted, or placed for adoption, of the Subscriber or eligible Dependent is covered under this Agreement from the moment of birth to a maximum of thirty-one (31) days from the date of birth. To be covered as a Dependent beyond the thirty-one (31) day period, the newborn child must be enrolled as a Dependent under this Agreement and appropriate premium payment must be received within such period. In the event that a newborn child is not eligible for continuing coverage as a Dependent under this Agreement, the eligible Dependent may enroll or apply for a separate Agreement to be issued by the Plan.

4. Unmarried children under the age specified in the Schedule of Benefits who are Full-Time Students

dependent solely upon the Member or Member's spouse for support.

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Except as set forth below, coverage will continue until the end of the period specified in the Schedule of Benefits or until the end of the premium payment period following the date in which such child ceases to be a Full-Time Student, marries or becomes employed full-time, whichever occurs first. (If First Priority Health accepts a premium amount to continue coverage beyond this schedule time period, the coverage will continue to the end of the period for which premium was accepted.)

Except, however, eligibility shall be extended to Full-Time Students who remain eligible for coverage as dependent children under this Policy and shall not terminate when a Full-Time Student is required to take a medically necessary leave of absence before the date that is the earlier of:

- the date that is one year after the first day of the medically necessary leave of absence; or

- the date on which such coverage would otherwise terminate under the terms of the plan or health insurance coverage.

House Bill 2851 (“Michelle’s Law”) defines a Medically Necessary leave of absence as being a leave from school or any other change in enrollment that commences while the child is suffering from a serious illness or injury, is medically necessary, and causes such child to lose student status for purposes of coverage under the terms of their health plans/coverage.

5. The determination of eligibility will be made by First Priority Health. However, the Member will have the right to appeal such determinations as set forth in Section GP – General Provisions, Subsection J.

B. ENROLLMENT

Subject to the terms and conditions of this Agreement, the Plan must receive, within the applicable enrollment period, a completed application or other appropriate request for enrollment, documentation of eligibility, if required, and the applicable premium payment by the Member before coverage will be provided under this Agreement. Eligible individuals may enroll in coverage under this Agreement during the Annual Open Enrollment Period. When applicable, enrollment is also permitted during a Limited Open Enrollment Period or Special Enrollment Period. Coverage under this Agreement shall become effective on the date established by the ACA or, when appropriate, as determined by the Plan. The Effective Date of coverage under this Agreement shall appear on the Member’s enrollment confirmation letter and Identification Card. A Member may also obtain confirmation of the Effective Date of his or her coverage by contacting the Member Service Department of the Plan at the toll-free telephone number listed on the Member’s Identification Card.

C. NOTICE OF INELIGIBILITY

It shall be the responsibility of the Member to immediately notify the Plan or the Exchange, if applicable, of any changes that will affect his or her eligibility for coverage under this Agreement.

D. RULES OF ELIGIBILITY No person will be refused enrollment or re-enrollment by the Plan because of health status, age, requirements for

health Services, or the existence, on the Effective Date of coverage under this Agreement, of a pre-existing physical or mental condition, including pregnancy. In addition, no Member’s coverage shall be terminated by the Plan due to health status or health care needs.

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Subject to the exclusions, conditions, and limitations of this A g r e e m e n t , a Member is entitled to benefits for Covered Services under this Agreement, provided that components of the care coordination plan are followed. Benefit and payment allowances are described in the Schedule of Benefits.

A. EFFECTIVE DATE

Subject to First Priority H e a l t h ’s receipt of the applicable premium payment, the completed Application, and the acceptance of both the premium and Application by First Priority Health, First Priority Health will issue an Agreement, Enrollment Confirmation Letter, Highmark Preventive Schedule, and Identification Card. The Effective Date of the coverage is the date inserted on the label on the face page of this Agreement. It is the date on which benefits become available under this Agreement. A member may obtain confirmation of the Effective Date of his or her coverage by contacting a Member Service Representative at the toll-free telephone number listed on the Member’s Identification Card. Coverage of a newborn child of the Mem ber is effective at the time of birth and shall automatically extend for a period of thirty-one (31) days following birth. Coverage shall include sickness or injury, including medically diagnosed congenital defects, birth abnormalities, pre-maturity, and routine nursery care.

B. MEDICAL NECESSITY

Members will receive benefits under this Agreement only when Medically Necessary. Medical Necessity for Covered Services will be determined prior to the service being rendered when Prior Authorization is required.

First Priority Health may determine whether any benefit provided under this Agreement was Medically Necessary, and the Member along with his/her Primary Care Physician has the option to select the appropriate Participating Hospital to render Services if hospitalization is necessary. Decisions as to Medical Necessity are subject to review by a Medical Director of First Priority Health or his/her Physician designee. First Priority Health will not, however, seek reimbursement from a Member for the cost of any benefit provided under this Agreement that is later determined not to have been Medically Necessary, provided that the Member was not notified prior to the provision of such benefit that such benefit would not be Medically Necessary. If a Member has a concern about a service being covered, he/she should contact the Plan by calling a Member Service Representative prior to the service being rendered. The Member shall have the right to appeal such determinations as set forth in Section GP – General Provisions, Subsection J.

C. PRIOR AUTHORIZATION If a Member has a concern regarding whether Prior Authorization is required, he/she should contact the Plan by

calling a Member Service Representative prior to the service being rendered. Additionally, the Member is responsible to confirm with a Member Service Representative that their Provider obtained Prior Authorization prior to the service being rendered.

Maternity admissions to participating Hospitals do not require Prior Authorization. However, Prior

Authorization is required for maternity admissions to Hospitals which do not participate in the FPH Network of Providers.

With the exception of maternity admissions to Hospitals participating in the First Priority Health

Network and Outpatient Emergency Services, Prior Authorization is required before all other Inpatient admissions in a Hospital, Skilled Nursing Facility, Rehabilitation Hospital or Psychiatric Hospital, regardless of Provider.

SECTION CC – CARE COORDINATION

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For Inpatient emergency admission to a Participating Provider, the Provider is responsible for notifying the Plan within forty-eight (48) hours of the emergency admission or as soon as reasonably possible. For all other Inpatient emergency admissions, the Member is responsible for notifying the Plan within forty-eight (48) hours of the emergency admission or as soon as reasonably possible.

Services of certain Participating Providers and all other Providers, related to observation status

require Prior Authorization. Certain procedures/surgeries performed in an acute-care Hospital’s short procedure unit or a free-

standing surgical facility, certain diagnostic tests/scans, and home health care Services require Prior Authorization, regardless of the Provider.

Prior Authorization is required for a member to receive Covered Services from all Providers who are not part of

the First Priority Health Network of Providers or BlueCard providers, except in the case of Outpatient Emergency Services. Prior Authorization for Covered Services from Providers outside of the FPH Network or BlueCard providers will only be granted when:

First Priority Health determines prior to the service being rendered that the service is Medically

Necessary; and First Priority Health does not have in its network a Participating Provider who can provide the

needed service.

Non-Participating Providers are not obligated to accept the Plan's determination, and therefore, may bill the Member for Services. The Member can avoid this responsibility by choosing a Participating Provider. If a Member circumvents the Primary Care Physician or participating Specialist Physician and obtains Services from a Provider outside of the First Priority Health Network of Providers without the required Prior Authorizations, the Member will be responsible for the full cost of any Services rendered.

Participating Providers should obtain the authorizations on behalf of Members prior to Services being rendered. First Priority Health may add or delete Services and procedures, which require Prior Authorization, as it deems necessary. Any notice of a change shall be considered to have been given when mailed to the Agreement Holder and the Member at the address on the records of First Priority Health at least thirty (30) days in advance of such change.

Payment for prior authorized non-participating Services will be subject to the applicable limitations, exclusions, and conditions of this Agreement. If the Member’s Primary Care Physician or participating Specialist Physician believes that the Member needs to see a Physician or other Provider who does not participate with First Priority Health, then the Member’s Primary Care Physician or participating Specialist Physician must submit medical information telephonically or in writing to First Priority Health. First Priority Health’s medical staff will review the information and will notify the Member’s Primary Care Physician or participating Specialist Physician of the decision. Authorizations for visits to Providers who are not part of the First Priority Health Network of Providers are approved only when Medically Necessary and when First Priority Health does not have in its network a Participating Provider who can provide the needed service. When a Participating Provider in the First Priority Health Network cannot render the service, the Member along with his/her Primary Care Physician and First Priority Health will determine where the service can be performed in order for coverage to be provided. Only those visits made after approval is given are covered. If the Member’s Primary Care Physician or participating Specialist Physician is not available, another member of his or her group can assist the Member in obtaining an authorization from First Priority Health. The following guidelines must be followed:

1. Before seeing any Provider who is not in the FPH Network, even if the Member is under the Physician’s care

prior to enrolling in First Priority Health, it will be necessary to obtain First Priority Health’s approval prior to Services being received. The Member’s Primary Care Physician or participating Specialist Physician must submit in writing, medical information to First Priority Health to request the authorization on behalf of the Member.

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2. Authorization for visits to Providers who are not in the FPH Network will be granted for a specified condition

and are assigned a specific number of visits. If the Services rendered are different from the Services authorized, those Services will not be covered by First Priority Health.

3. All authorizations to receive Services from Providers not in the FPH Network will be assigned an expiration

date that is one hundred and eighty (180) calendar days from the date the authorization is given. If the Member is unable to schedule an appointment with the Provider within this one hundred and eighty (180)-day period, or if additional visits are necessary following the expiration of this one hundred and eighty (180)-day period, the Member must contact the Primary Care Physician or participating Specialist Physician who initiated the authorization to request that he/she contact First Priority Health to obtain approval to have the number of visits increased or extended.

4. If the Member is unsure whether or not the Primary Care Physician or participating Specialist Physician’s

office has obtained an authorization or if it is necessary to verify the number of unused visits or the expiration date, the Member may call First Priority Health to speak with a Member Service Representative for assistance at the number located on the Member’s identification card. If a Member circumvents the Primary Care Physician or participating Specialist Physician and obtains Services from a Provider outside of the FPH Network of Providers without the required Prior Authorizations, the Member will be liable for the full cost of any Services rendered.

Failure to obtain Prior Authorization before Services are rendered will result in a denial of benefits.

When a Member circumvents the Primary Care Physician or the participating Specialist

Physician and obtains Services from a Provider outside of the FPH Network of Providers without the required Prior Authorizations, the Member will be responsible for the full cost of the Services, even if it is determined that the Services were Medically Necessary.

Participating Providers are responsible for obtaining the Prior Authorization on behalf of a

Member. If the Participating Provider fails to obtain the necessary Prior Authorization before the service is provided, the Participating Provider will be responsible for the full cost of the Services and First Priority Health will hold the Member harmless from any financial obligation other than the applicable Deductible, Coinsurance, Copayment amounts, or amounts in excess of any Benefit Maximum.

D. TO REQUEST PRIOR AUTHORIZATION

For other than mental health care, Prior Authorization can be obtained by contacting the Prior Authorization Department of First Priority Health at 1-800-452-8507.

The telephone number for Prior Authorization for mental health care benefits is 1-800 258-9808

E. CONCURRENT REVIEW A review by a utilization review entity of all reasonably necessary supporting information, which occurs during a

Member’s Hospital stay or course of treatment and results in a decision to approve or deny payments for health care Services. This involves a review of all clinical information and current treatment plans. This ensures that treatment is Medically Necessary and/or being provided in the most appropriate setting. Concurrent review is performed on select Inpatient and ancillary Services.

F. ALTERNATIVE TREATMENT PLAN SERVICES

Notwithstanding anything in this Agreement to the contrary, First Priority Health through case Management may elect to provide benefits pursuant to an approved Alternative Treatment Plan for Services that would otherwise not be covered. All decisions regarding the implementation of alternative care or alternative treatment to be provided to a Member shall remain the responsibility of the Primary Care Physician and/or the attending Physician and the Member. The Member has the right, at any time, to have the Alternative Treatment Plan discontinued.

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First Priority Health shall provide such alternative benefits only when and for so long as it determines that the Services are Medically Necessary, cost effective relative to benefits that would otherwise be covered, and subject to a documented Alternative Treatment Plan specifying the alternative benefits and their cost efficacy. The total benefits paid for such Services will not exceed the total benefits to which the Member would otherwise be entitled under this Agreement in the absence of alternative benefits.

When Member and/or the Member’s Physician are requesting consideration for Alternative Treatment Plan Services, a Blue Health Solutions case manager will be involved in an effort to support the Member in navigating the request. Also, the First Priority Health Medical Director will review the Alternative Treatment Plan Services recommended by the Member’s Physician to determine if they are Medically Necessary, and if approved, facilitate the implementation of that plan. If First Priority Health elects to provide alternative benefits for a Member in one instance, it shall not obligate First Priority Health to provide the same or similar benefits for any Member in any other instance, nor shall it be construed as a waiver of First Priority Health’s right to administer this Agreement thereafter in strict accordance with its express terms.

G. PROVIDER REIMBURSEMENT

In-Area Claims – Participating Providers

For claims incurred from Providers contracting with First Priority Health, the calculation of Member liability will be based on the lower of the Provider’s billed charges or the interim negotiated rate First Priority Health pays the Provider. Interim payments may be subject to final settlements and/or adjustments between First Priority Health and the Provider. Any such settlements or adjustments will not be considered in calculating the Member’s liability.

In-Area Claims – Non-Participating Providers In the event that Covered Services are rendered by a Non-Participating Provider, First Priority Health shall bill the amount it pays the Non-Participating Provider to the Member. Inter-Plan Arrangements

The Plan covers only limited health care services received outside of the geographic area the Plan serves. As used in this Subsection, “Out-of-Area Covered Services” includes Emergency Care Services, Urgent Care Services and follow-up Services obtained outside of the geographic area the Plan serves. Any other services will not be covered when processed through any Inter-Plan Arrangements, unless authorized by the Plan.

1. Out-of-Area Services

The Plan has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Arrangements”. These Inter-Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever Members access health care services outside of the geographic area the Plan serves, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below. Typically, when accessing care outside of the geographic area the Plan serves, Members obtain care from health care providers that have a contractual agreement (“participating providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, Members may obtain care from providers in the Host Blue geographic area that do not have a contractual agreement (“non-participating providers”) with the Host Blue. The Plan remains responsible for fulfilling its contractual obligations to the Member. The Plan payment practices in both instances are described below.

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2. BlueCard® Program

The BlueCard® Program is an Inter-Plan Arrangement. Under this Arrangement, when Members access Out-of-Area Covered Services within the geographic area served by a Host Blue, the Host Blue will be responsible for contracting and handling all interactions with its participating health care providers.

The financial terms of the BlueCard Program are described generally below.

Liability Calculation Method Per Claim

Unless subject to a fixed dollar copayment, the calculation of the Member liability on claims for Out-of-Area Covered Services processed through the BlueCard Program will be based on the lower of the provider’s billed charges for Out-of-Area Covered Services or the negotiated price made available to the Plan by the Host Blue. Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s health care provider contracts. The negotiated price made available to the Plan by the Host Blue may be represented by one of the following:

i) an actual price. An actual price is a negotiated rate of payment in effect at the time a claim is

processed without any other increases or decreases; or

ii) an estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance-related bonuses or incentives; or

iii) an average price. An average price is a percentage of billed charges for Out-of-Area Covered Services in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price.

The Host Blue determines whether or not they will use an actual price, estimated price or average price. The use of estimated or average pricing may result in a difference (positive or negative) between the price the Member pays on a specific claim and the actual amount the Host Blue pays to the provider. However, the BlueCard Program requires that the amount paid by the Member is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims.

In some instances federal or state laws or regulations impose a surcharge, tax or other fee that applies to insured accounts. If applicable, the Plan will include such surcharge, tax or other fee in your premium.

3. Return of Overpayments

Recoveries of overpayments/from a Host Blue or its participating and non-participating providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, provider/hospital bill audits, credit balance audits, utilization review refunds and unsolicited refunds. Recoveries will be applied so that corrections will be made, in general, on a claim-by-claim or prospective basis. If recovery amounts are passed on a claim-by-claim basis from a Host Blue to the Plan, they will be credited to your account. In some cases, the Host Blue will engage a third party to assist in identification or collection of overpayments. The fees of such a third party may be charged to you as a percentage of the recovery.

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4. Non-Participating Health Care Providers Outside the Network Service Area

a. Member Liability Calculation

When Out-of-Area Covered Services are provided outside of the Network Service Area by non-participating providers, the amounts a Member pays for such services will generally be based on either the Host Blue’s non-participating provider local payment or the pricing arrangements required by applicable law. In these situations, the Member may be responsible for the difference between the amount that the non-participating provider bills and the payment the Plan will make for the Out-of-Area Covered Services as set forth in this Subsection. Payments for out-of-network emergency services will be governed by applicable federal and state law.

b. Exceptions

In some exception cases, the Plan may pay claims from non-participating providers for Out-of-Area Covered Services based on the provider’s billed charge. This may occur in situations where a Member did not have reasonable access to a participating provider, as determined by the Plan in the Plan’s sole and absolute discretion or by applicable law. In other exception cases, the Plan may pay such a claim based on the payment the Plan would make if the Plan were paying a non-participating provider for the same Covered Service inside of the Network Service Area, as described elsewhere in this Agreement. This may occur where the Host Blue’s corresponding payment would be more than the Plan in-service area non-participating provider payment. The Plan may choose to negotiate a payment with such a provider on an exception basis. Unless otherwise stated, in any of these exception situations, the Member may be responsible for the difference between the amount that the non-participating provider bills and payment the Plan will make for the Out-of-Area Covered Services as set forth in this Subsection.

5. Blue Cross Blue Shield Global Core Program

a. General Information If Members are outside the United States (hereinafter “BlueCard service area”), they may be able to take advantage of the Blue Cross Blue Shield Global Core Program when accessing Out-of-Area Covered Services. The Blue Cross Blue Shield Global Core Program is unlike the BlueCard Program available in the United States in certain ways. For instance, although the Blue Cross Blue Shield Global Core Program assists Members with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when Members receive care from providers outside the United States, the Member will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services.

b. Inpatient Out-of-Area Covered Services

In most cases, if Members contact the service center for assistance, hospitals will not require Members to pay for covered inpatient Out-of-Area Covered Services, except for their cost-sharing amounts. In such cases, the Blue Cross Blue Shield Global Core contracting hospital will submit Member claims to the service center to initiate claims processing. However, if the Member paid in full at the time of service, the Member must submit a claim to obtain reimbursement for Out-of-Area Covered Services.

c. Outpatient Out-of-Area Covered Services

Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require Members to pay in full at the time of service. Members must submit a claim to obtain reimbursement for Out-of-Area Covered Services.

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d. Submitting a Blue Cross Blue Shield Global Core Claim

When Members pay for Out-of-Area Covered Services outside the BlueCard service area, they must submit a claim to obtain reimbursement. For institutional and professional claims, Members should complete a Blue Cross Blue Shield Global Core International claim form and send the claim form with the provider’s itemized bill(s) to the service center (the address is on the form) to initiate claims processing. The claim form is available from the Plan, the service center or online at www.bcbsglobalcore.com. If Members need assistance with their claim submissions, they should call the service center at 1-(800)-810-BLUE (2583) or call collect at 1-(804)-673-1177, 24 hours a day, seven days a week.

H. SELECTION OF PROVIDERS

A Member covered under this Agreement must receive Covered Services from Participating Providers, except in the following circumstances: 1. for Emergency Care Services and Urgent Care Services; 2. when a Member receives Preauthorization to receive Services from a Non-Participating Provider; 3. as set forth in the TRANSITION/CONTINUITY OF CARE Subsection of this Section; 4. as required by law; or 5. as otherwise provided herein. In addition, covered Dental Services must be rendered by Dentist who is a Participating Provider, covered vision care Services must be rendered by a Vision Provider who is a Participating Provider and covered Telemedicine Services must be rendered by a Telemedicine Provider that is a Participating Provider. The Provider Directory, which lists health care Providers who participate in the Network, includes their addresses and telephone numbers and indicates whether a PCP is accepting new patients. However, Members should always contact a Provider to verify whether that Provider is still participating in the Network and accepting new patients. 1. Selection of a Primary Care Provider

Upon initial enrollment, the Subscriber and each covered Dependent must select a PCP. For children, the Member may designate a pediatrician as the child’s PCP. However, if no PCP is selected, the Member may be responsible for payment for certain Covered Services. If a Member fails to select a valid PCP within thirty (30) days of membership in this program, the Plan reserves the right to select a PCP for the Member. Members should always contact the PCP to verify whether that Provider is accepting new patients.

2. Changing a Primary Care Provider

a. If a Member wishes to transfer from one (1) PCP to another PCP, the Member may contact the Plan at the toll-free telephone number or through the website listed on his/her Identification Card. Upon receiving the appropriate information, the Plan will process the change of the PCP. A Member may also initiate a change of PCP in writing by requesting a “PCP Change Form” which may be completed and mailed to the Plan. In all cases:

i) if the change is received between the first and fifteenth day of the month, the PCP change will

become effective the first day of the following month; or ii) if the change is received between the sixteenth and the last day of the month, the change will

become effective the first day of the second month after it is received.

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http://www.bcbsglobalcore.com/


b. Transfer of a Member to another PCP may be required if the Plan determines the Member-PCP relationship is unsatisfactory.

c. If the PCP terminates his/her relationship with the Plan, the Member must select another PCP within

thirty (30) days of notification of such termination. The Plan will assist the Member in the selection of another PCP. Upon transfer to a new PCP, the Member will receive a new Identification Card with the new PCP's name and telephone number.

I. TRANSITION/CONTINUITY OF CARE

Benefits are also provided for Services and supplies received by a Member for the following:

1. Transition of Care

If a Member is receiving medical care from an Non-Participating Provider at the time of his/her Effective Date of coverage, which is not otherwise covered by his/her prior coverage, the Member may, at his/her option, continue an ongoing course of treatment with that Provider for a period of up to sixty (60) days from the Member’s Effective Date of coverage. The Plan must be notified by the Member of his/her request to continue an ongoing course of treatment for the transition of care period.

2. Continuity of Care

If, at the time a Member is receiving medical care from a Participating Provider, notice is received from the Plan that it intends to terminate or has terminated the contract of that Participating Provider for reasons other than cause, the Member may, at his/her option, continue an active course of treatment with that Provider for a period of up to ninety (90) days from the date the notification of the termination or pending termination is received. For purposes of this Subsection, active course of treatment means: 1. an ongoing course of treatment for a life-threatening condition, defined as a disease or condition for

which likelihood of death is probable unless the course of the disease or condition is interrupted;

2. an ongoing course of treatment for a serious acute condition, defined as a disease or condition requiring complex ongoing care which the Member is currently receiving, such as chemotherapy, radiation therapy or post-operative visits;

3. the second or third trimester of pregnancy, through the postpartum period; or

4. an ongoing course of treatment for a health condition for which a treating Physician or health care

provider attests that discontinuing care by that Physician or health care provider would worsen the condition or interfere with anticipated outcomes.

If, however, the Participating Provider is terminated for cause and a Member continues to seek treatment from that Provider, the Plan will not be liable for payment for health care Services provided to the Member following the date of termination.

This transition/continuity of care period may be extended if determined to be Medically Necessary and Appropriate by the Plan following consultation with the Member and the Provider. Any Services authorized under this Subsection will be covered in accordance with the same terms and conditions as applicable to Participating Providers. Nothing in this Subsection shall require the Plan to pay benefits for health care Services that are not otherwise provided under the terms and conditions of this Agreement.

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J. SPECIAL CIRCUMSTANCES RELATED TO OUT-OF-NETWORK SERVICES

1. Continued Care

Where a Member is in a continuing course of treatment, as described in this Paragraph, from a UPMC Provider that is an Out-of-Network Provider under this Contract, the Member may opt to continue treatment with that UPMC Provider. Covered Services shall be available at the Standard Value level of benefits. The need for a continuing course of treatment with a UPMC Provider shall be determined, in the first instance, by the Member’s treating Physician acting in consultation and in accordance with the wishes of the Member or the Member’s authorized representative. A Member with a pregnancy that has been confirmed before December 31, 2015 or who has started a continuing course of treatment for a chronic or persistent medical condition with a UPMC Provider in calendar years 2013, 2014 or 2015 (or on or before June 30, 2016 for UPMC Mercy) may continue treatment with that UPMC Provider through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Notwithstanding the above, a Member who was treated at UPMC Mercy and by a UPMC Mercy Physician for a confirmed pregnancy on or before June 30, 2016, may continue to receive treatment at UPMC Mercy through the period of delivery and post-partum care for that pregnancy or completed treatment of the chronic or persistent medical condition. Services such as routine wellness care and routine preventive care are not considered to be continued care under this Paragraph. Furthermore, benefits will not be provided under this Paragraph when the course of treatment for a chronic or persistent medical condition started before January 1, 2013 but for which no treatment was subsequently received from a UPMC Provider, unless the UPMC Provider can demonstrate that the Member was receiving ongoing care in accordance with recognized medical protocols and/or standards. While undergoing a continuing course of treatment with such UPMC Provider, benefits will include all Covered Services reasonably related to the treatment including, but not limited to, testing and follow-up care. In the event that the Plan disputes the opinion of the treating Physician that a continuation of care is Medically Necessary and Appropriate, or disputes the scope of that care, the Pennsylvania Department of Health or its designated representative will review that matter and make a final non-appealable determination.

2. Oncology Services

Where a Member’s treating Physician determines that a Member, who has been diagnosed with cancer, should be treated by a UPMC Provider who renders oncology Services and who is an Out-of-Network Provider under this Agreement, the Member may, at his/her option, request treatment from such UPMC Provider. In such cases, Member liability will be no greater than if such Covered Services had been rendered by a Network Provider. Treatment includes care for illnesses resulting from such cancer treatment such as, but not limited to, mental health, endocrinology, orthopedics and cardiology. The need for a treatment of a resulting illness shall be determined, in the first instance by the Member’s treating Physician acting in consultation with and in accordance with the wishes of the Member or the Member’s authorized representative.

3. Local Community Needs

Where a Member’s treating Physician believes that a Member requires certain medical Services and the Department of Health has determined that such Services are not available from another source locally other than from a UPMC Provider that is an Out-of-Network Provider under this Agreement, the Member may receive Covered Services from such UPMC Provider. In such cases, the Member will not be responsible for any greater out-of-pocket amount than if Services had been rendered by a Network Provider.

4. Emergency Care Services

When Emergency Care Services are received from a UPMC Provider that is an Out-of-Network Provider under this Agreement, benefits are provided as set forth in the Schedule of Benefits of this Agreement, and

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also includes such other Services and supplies necessary to continue to treat the Member, including any resulting Inpatient admission, through the period of discharge. In such cases, the Member will not be responsible for any greater out-of-pocket amount than if Services had been rendered by a Network Provider.

5. Other Out-of-Network Services

In cases where the other Paragraphs of this Subsection are not applicable, Members who receive Covered Services from a UPMC Provider that is an Out-of-Network Provider under this Agreement are subject to Member liability as set forth in Schedule of Benefits.

K. MEMBER LIABILITY

The Plan uses the Plan Allowance to calculate the benefit payable and the financial liability of the Member for Medically Necessary and Appropriate Services covered under this Agreement. See SECTION DE - DEFINITIONS of this Agreement for the definition of “Plan Allowance”. The Plan’s payment is determined by first subtracting any Deductible and Copayment liability from the Plan Allowance. The Coinsurance percentage set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement is then applied to that amount. This amount represents the Plan’s payment. Any remaining Coinsurance amount is the Member’s responsibility. The Member’s total cost-sharing liability is the sum of the Deductible plus any Coinsurance and/or Copayment obligations. The Member will not be liable for any charges for Covered Services, except applicable Deductible, Copayment or Coinsurance obligations, when such Covered Services are received from a Network Provider or, when appropriate, are Preauthorized by the Plan. However, in the event a Member receives Emergency Care Services or Urgent Care Services from an Out-of-Network Provider and subsequently receives a bill from the Out-of-Network Provider which represents the difference between the Plan payment and that Provider’s billed charge for such Services, the Member should notify the Plan. The Plan will then resolve the bill so that the Member will not be liable for any amounts in excess of the Plan payment, except for applicable Deductible, Coinsurance and/or Copayment obligations. Except Emergency Care Services or as otherwise set forth herein, in the event a Member receives Covered Services from an Out-of-Network Provider without the required Preauthorization, the Member will be responsible for all charges associated with those Services regardless of whether the services received were Medically Necessary and Appropriate.

If the Plan terminates the contract of a Network Provider for cause, the Plan will not be responsible for health care services or supplies provided to the Member by that terminated Provider following the date of termination.

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Subject to the exclusions, conditions, and limitations of this Agreement, and subject to SECTION DB – DESCRIPTION OF BENEFITS of this Agreement, a Member is entitled to benefits for Covered Services as set forth in this SECTION SB - SCHEDULE OF BENEFITS of this Agreement during a Benefit Period. Benefits are subject to the Deductible and Coinsurance, if any, and in the amounts as specified in this Section. Except for Emergency Care Services and Urgent Care Services Out of Area, Out-of-Network Services are Not Covered. A charge for a Covered Service shall be considered incurred on the date the service or supply was provided to a Member. COPAYMENT – The amount, if any, a Member must pay directly to Providers in connection with Covered Services.

ENHANCED VALUE DEDUCTIBLE – Unless otherwise noted, the Enhanced Value Deductible applies to all Covered Services received during a Benefit Period from a Participating Provider participating at the Enhanced Value level of benefits, except where exempted by law. Additionally, the Enhanced Value Deductible also applies to the dollar amounts incurred by a Member for Covered Services which are always paid at the Enhanced Value level of benefits, including Mental Health Care Services Inpatient and/or Outpatient, Substance Abuse Services, Inpatient and/or Outpatient, when received from a Network Provider and to Emergency Services regardless of where received. Amounts incurred and paid by the Member under the Enhanced Value Deductible also accrue towards satisfaction of the Standard Value Deductible. STANDARD VALUE DEDUCTIBLE - The Standard Value Deductible applies to all Covered Services received during a Benefit Period from a Participating Provider participating at the Standard Value level of benefits, except those Covered Services to which the Enhanced Value Deductible applies when received from a Participating Provider, or where exempted by law. Amounts Incurred and paid by the Member under the Standard Value Deductible also accrue towards satisfaction of the Enhanced Value Deductible. FAMILY DEDUCTIBLE (Enhanced Value or Standard Value) – The eligible Deductible amounts, which are incurred by any combination of family members covered under this Policy, contribute to the Family Deductible, which is two (2) times the amount for an individual in a Benefit Period. No single family member’s Deductible expense may exceed the individual Deductible. OUT-OF-POCKET MAXIMUM (Enhanced Value or Standard Value) – When a Member incurs the amount of out-of-pocket expense specified in the Schedule of Benefits in a Benefit Period for Covered Medical Expenses/Covered Pharmacy Expenses, the Coinsurance percentage will be reduced to 0% and the Prescription Drug Copayments will be reduced to $0 for the balance of that Benefit Period. The Out-of-Pocket Maximum does not include, amounts in excess of Plan Allowance, charges for non-Covered Services, and charges after Covered Medical Expenses have been exhausted. Amounts applied toward the Out-of-Pocket Maximum include Deductible, Coinsurance, and Copayment amounts, if any, payable by the Member for Covered Medical Expenses under this Agreement. Also, Copayments and Deductible amounts payable by the Mem ber for Covered Pharmacy Expenses under this Policy will be applied toward the Out-of-Pocket Maximum. Amounts incurred toward the Enhanced Value Out-of-Pocket Maximum will be applied to the Standard Value Out-of-Pocket Maximum. Amounts incurred toward the Standard Value Out-of-Pocket Maximum will be applied to the Enhanced Value Out-of-Pocket.

SECTION SB – SCHEDULE OF BENEFITS FOR COVERED MEDICAL EXPENSES

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FAMILY OUT-OF-POCKET MAXIMUM (Enhanced Value or Standard Value) – When Members covered under the same Family Coverage have incurred the Out-of-Pocket Maximum for a family for a Benefit Period, which is two (2) times the amount for an individual, the eligible Coinsurance percentage will be reduced to 0% and the Prescription Drug Copayments will be reduced to $0 for the balance of the Benefit Period. The Plan will begin to pay benefits for each Member who satisfies his or her own individual Deductible whether or not the entire family Deductible has been satisfied. The entire Family Deductible must be satisfied in one (1) Benefit Period by two (2) or more family members in order for the family to satisfy the Family Deductible. No individual Member may satisfy the entire family Deductible. Once the entire family Deductible amount has been satisfied, the Plan will pay benefits for all remaining family members. The Out-of-Pocket Maximum does not include, amounts in excess of Plan Allowance, charges for non-Covered Services, and charges after Covered Medical Expenses have been exhausted. Amounts applied toward the Out-of-Pocket Maximum include Deductible, Coinsurance, and Copayment amounts, if any, payable by the Member for Covered Medical Expenses under this Agreement. Also, Copayments and Deductible amounts payable by the Mem ber for Covered Pharmacy Expenses under this Ag reem en t will be applied toward the Out-of-Pocket Maximum. I. BENEFIT PERIOD

Calendar year. II. COINSURANCE

Enhanced Value Standard Value

A. PLAN PAYMENT 60% Plan Allowance 50% Plan Allowance B. MEMBER LIABILITY 40% Plan Allowance 50% Plan Allowance

III. DEDUCTIBLE

Except where exempted by law or indicated in Subsection V. COVERED SERVICES of this Section, Deductible amounts are applied to all Covered Services provided to a Member during a Benefit Period.

NETWORK SERVICES Enhanced Value Standard Value

INDIVIDUAL $6,900 $7,150

FAMILY $13,800 $14,300

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A. The Enhanced Value Deductible applies to all Covered Services received during a Benefit Period from a Network Provider participating at the Enhanced Value level of benefits. Additionally, the Enhanced Value Deductible also applies to the dollar amounts Incurred by a Member for Covered Services which are always paid at the Enhanced Value level of benefits, including Mental Health Care Services Inpatient and/or Outpatient, and Substance Abuse Services Inpatient and/or Outpatient when received from a Network Provider and to Emergency Services, regardless of where received. Amounts Incurred and paid by the Member under the Enhanced Value Deductible also accrue towards satisfaction of the Standard Value Deductible.

B. The Standard Value Deductible applies to all Covered Services received during a Benefit Period from a

Network Provider participating at the Standard Value level of benefits, except those Covered Services to which the Enhanced Value Deductible applies when received from a Network Provider as indicated in Paragraph A. of this Subsection. Amounts Incurred and paid by the Member under the Standard Value Deductible also accrue towards satisfaction of the Enhanced Value Deductible

C. The Plan will begin to pay benefits for each Member who satisfies his or her own individual Deductible

whether or not the entire Family Deductible has been satisfied. The entire Family Deductible must be satisfied in one (1) Benefit Period by two (2) or more family members in order for the family to satisfy the Family Deductible. No individual Member may satisfy the entire Family Deductible. Once the entire Family Deductible amount has been satisfied, the Plan will pay benefits for all family members.

IV. OUT-OF-POCKET MAXIMUM

NETWORK SERVICES INDIVIDUAL $7,350 FAMILY $14,700

All amounts are based on the Plan Allowance.

A. INDIVIDUAL OUT-OF-POCKET MAXIMUM

1. Network Covered Services

When a Member incurs $7,350 in Deductible, Copayment and Coinsurance expenses for Network Covered Services furnished to the Member in one (1) Benefit Period, the benefits payable for claims received by the Plan for that Member during the remainder of the Benefit Period will increase to one hundred percent (100%) of the Plan Allowance.

The dollar amount specified shall not include amounts in excess of the Plan Allowance.

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B. FAMILY OUT-OF-POCKET MAXIMUM

1. Network Covered Services

When Members under the same Family Coverage have Incurred $14,700 in Deductible, Copayment and Coinsurance expenses for Network Covered Services furnished to the Members in one (1) Benefit Period, the benefits payable for claims received by the Plan thereafter for all Members under that same Family Coverage during the remainder of the Benefit Period will increase to one hundred percent (100%) of the Plan Allowance.

In the case of Family Coverage, no individual Member may contribute cost-sharing expense greater than their Individual Out-of-Pocket Maximum. However, as each Member reaches their Individual Out-of-Pocket Maximum, the benefits payable for that Member will increase to one hundred percent (100%) of the Plan Allowance for the remainder of the Benefit Period, whether or not the Family Out-of-Pocket Maximum has been met.

The dollar amount specified shall not include amounts in excess of the Plan Allowance.

V. PLAN PAYMENT AND MEMBER LIABILITY

The Plan uses the Plan Allowance to calculate the benefit payable and the financial liability of the Member for Medically Necessary and Appropriate Services covered under this Agreement. In the case of Outpatient Prescription Drug benefits, the Plan uses the Provider’s Allowable Price for this calculation. See SECTION DE - DEFINITIONS of this Agreement for the definitions of “Plan Allowance” and “Provider’s Allowable Price”.

A. PLAN PAYMENT

The Plan’s payment is determined by first subtracting any Deductible and/or Copayment liability from the Plan Allowance. The Coinsurance percentage of the Plan Allowance set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement is then applied to that amount. This amount represents the Plan’s payment. Any remaining Coinsurance amount is the Member’s responsibility.

B. MEMBER LIABILITY

The Member’s total liability is the sum of any applicable Deductible, Copayment and/or Member Coinsurance obligations. Network Providers will accept the Plan's payment plus the Member's total liability as payment in full for the Covered Services provided to the Member. Out-of-Network Providers are not required to accept the Plan’s payment as payment in full. When a Member receives Covered Services from an Out-of-Network Provider, the Out-of-Network Provider may bill the Member for the difference between the Out-of-Network Provider’s billed amount and the Plan’s payment. This is in addition to any Member Coinsurance, Deductible and/or Copayment obligations. If a Member receives Services which are not covered under this Agreement, the Member is responsible for all charges associated with those Services.

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C. PLAN PAYMENT AND MEMBER LIABILITY FOR COVERED MEDICATIONS

The Plan’s payment for Covered Medications purchased from a Participating Pharmacy Provider is the Coinsurance percentage as set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Any remaining Coinsurance amount is the Member’s responsibility, subject to the minimum and maximum Coinsurance amounts set forth in SECTION SB - SCHEDULE OF BENEFITS. The Member’s total liability for Covered Medications is the sum of any Deductible and Coinsurance obligations, if any. Preventive Medications are exempt from any Deductible, Copayment and/or Coinsurance obligation. No benefits are payable for Covered Medications purchased from a Pharmacy Provider that is not a Network Provider.

D. PLAN PAYMENT FOR VISION CARE SERVICES

The Plan Allowance for Vision Providers who are Network Providers within or outside of Pennsylvania is the amount agreed to by such Vision Provider as payment in full, as set forth in the agreement between such Vision Provider and the Plan.

E. PLAN PAYMENT FOR PEDIATRIC DENTAL SERVICES

The Plan Allowance for Dentists who are Network Providers within or outside of Pennsylvania is the amount agreed to by such Dentist as payment in full, as set forth in the agreement between the Participating Dentist and the Plan.

VI. COVERED SERVICES

Benefits for Covered Services are based upon the Plan Allowance and include, but are not limited to, those Covered Services listed in this schedule. See SECTION DB - DESCRIPTION OF BENEFITS of this Agreement for further explanation and additional limitations.

The Deductible applies to all Covered Services, except where exempted by law or as otherwise indicated in this Section. Subject to the provisions of this Agreement, a Member is responsible for payment of any cost-sharing amounts due to the Provider after the amounts paid by the Plan hereunder. The payment amount is based on the Plan Allowance at the time Services are rendered. The payments to a Hospital or Facility Provider may be adjusted from time to time based on settlements with the Providers. Such adjustments will not affect the Member’s Deductible, Copayment and/or Coinsurance obligation.

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COVERED SERVICES ENHANCED VALUE STANDARD VALUE AMBULANCE SERVICE

Emergency Ambulance Service

60%, Plan Allowance

Subject to the Enhanced Value Network Deductible

Non-Emergency Ambulance Service

60% Plan Allowance

Subject to the Enhanced Value Network Deductible

ANESTHESIA 60% Plan Allowance 50%, Plan Allowance

ARTIFICIAL INSEMINATION

60% Plan Allowance 50%, Plan Allowance

BLOOD 60% Plan Allowance 50%, Plan Allowance

DENTAL SERVICES

Services for Accidental Injury and Covered and Non-Covered Dental Procedures


Pediatric Dental Services

Pediatric Oral Examinations, Prophylaxis (Cleanings), Radiographs (x-rays), Fluoride Treatments, Palliative Treatment (Emergency), Sealants and Space Maintainers

100% Plan Allowance

Not Subject to Deductible

Other Pediatric Dental Services

50% Plan Allowance


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COVERED SERVICES ENHANCED VALUE STANDARD VALUE Important: See Pediatric Dental Services of SECTION DB - DESCRIPTION OF BENEFITS of this Agreement for conditions and limitations which affect a Member’s pediatric dental coverage.

DIABETES TREATMENT

Equipment and Supplies


Diabetes Education Program


Outpatient Prescription Drugs required for the treatment of Diabetes

Prescription Drugs are covered in accordance with OUTPATIENT PRESCRIPTION DRUGS in this Subsection.

DIAGNOSTIC SERVICES

Advanced Imaging Services


Diagnostic Services - Basic Imaging/ Diagnostic Medical

100% Plan Allowance after $90 Copayment



Not Subject to Deductible Diagnostic Services - Basic Lab /Pathology/ Allergy Testing





The Deductible, Copayment and/or Coinsurance amount, if any, does not apply to Basic Diagnostic Services provided for preventive purposes in accordance with a predefined schedule based on age and sex described in PREVENTIVE SERVICES of SECTION DB - DESCRIPTION OF BENEFITS of this Agreement

DURABLE MEDICAL EQUIPMENT


EMERGENCY CARE SERVICES

60% Plan Allowance after deductible

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COVERED SERVICES ENHANCED VALUE STANDARD VALUE ENTERAL FOODS 60% Plan Allowance Not Subject to Deductible HABILITATIVE AND REHABILITATIVE SERVICES

Cardiac Rehabilitation 60% Plan Allowance 50%, Plan Allowance

Cardiac Rehabilitation does not include Services provided for habilitative purposes.

Occupational Therapy and Speech Therapy

60% Plan Allowance 50% Plan Allowance

Limited to a combined total of thirty (30) Outpatient Visits for rehabilitative

purposes per Benefit Period and a combined total of thirty (30) Outpatient Visits for Habilitative purposes per Benefit Period. This limit does not apply when Services for habilitative purposes are prescribed for the treatment of Mental Illness or Substance Abuse.

Physical Medicine 60% Plan Allowance 50% Plan Allowance

Limited to thirty (30) Outpatient Visits for rehabilitative purposes per

Benefit Period and thirty (30) Outpatient Visits for Habilitative purpose per Benefit Period. This limit does not apply when Services for habilitative purposes are prescribed for the treatment of Mental Illness or Substance Abuse.

HOME HEALTH CARE SERVICES


Limited to sixty (60) Visits per Benefit Period HOSPICE CARE SERVICES


Respite Care is limited to seven (7) days every six (6) consecutive months HOSPITAL SERVICES

Inpatient Services 60% Plan Allowance 50%, Plan Allowance

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COVERED SERVICES ENHANCED VALUE STANDARD VALUE

Private Room Allowance


For the most common semiprivate room charge. Private Room covered

when Medically Necessary and Appropriate.

Surgery 60% Plan Allowance 50%, Plan Allowance

Outpatient Services 60% Plan Allowance 50%, Plan Allowance

Pre-Admission Testing

Tests and studies other than Basic Diagnostic Services


Diagnostic Services - Basic Imaging/ Diagnostic Medical





Diagnostic Services - Basic Lab /Pathology/Allergy Testi





Surgery 60% Plan Allowance 50%, Plan Allowance MATERNITY SERVICES 60% Plan Allowance 50%, Plan Allowance

Maternity Home Health Care Visit

One (1) maternity home health care visit within forty-eight (48) hours of discharge when discharge occurs prior to (a) forty-eight (48) hours of Inpatient care following a normal vaginal delivery; or (b) ninety-six (96) hours of Inpatient care following a Caesarean delivery. Such visit is exempt from any Deductible, Copayment and/or Coinsurance. See MATERNITY SERVICES in SECTION DB - DESCRIPTION OF BENEFITS of this Agreement.

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COVERED SERVICES ENHANCED VALUE STANDARD VALUE MEDICAL SERVICES

Inpatient Medical Care Services

Inpatient Medical Care Visits and Intensive Medical Care


Concurrent Care 60% Plan Allowance 50%, Plan Allowance

Consultation 60% Plan Allowance 50%, Plan Allowance Routine Newborn Care


Outpatient Medical Care Services

Members may be responsible for a facility or clinic based Coinsurance and/or Copayment amount in addition to the Professional Provider charge if an office Visit or Service is provided at a Hospital, Facility Provider, Ancillary Provider, Retail Clinic or Urgent Care Center.

Allergy Extracts 60% Plan Allowance 50%, Plan Allowance

Allergy Injections 60% Plan Allowance 50%, Plan Allowance

Medical Care Visits

Primary Care Provider



Not Subject to Deductible Not Subject to Deductible

Retail Clinic 100% Plan Allowance after $50 Copayment



Specialist Visit 100% Plan Allowance after $80 Copayment



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Specialist Virtual Visit





Specialist Virtual Visit Originating Site Fee


Urgent Care Center Visit




Telemedicine Services



Therapeutic Injections


Surgical Services

Anesthesia 60% Plan Allowance 50%, Plan Allowance

Assistant at Surgery 60% Plan Allowance 50%, Plan Allowance

Second Surgical Opinion Services


Special Surgery 60% Plan Allowance 50%, Plan Allowance

Surgery 60% Plan Allowance 50%, Plan Allowance

MEDICAL SUPPLIES 60% Plan Allowance 50%, Plan Allowance MENTAL HEALTH CARE SERVICES

Inpatient Care 60%, Plan Allowance

Outpatient Services

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100% Plan Allowance after $80 Copayment Not Subject to Deductible

NEWBORN CARE 60% Plan Allowance 50%, Plan Allowance ORTHOTIC DEVICES 60% Plan Allowance 50%, Plan Allowance OUTPATIENT PRESCRIPTION DRUGS

NOTE: In the case of a Maintenance Prescription Drug, the Member must designate whether the

Maintenance Prescription Drug should be filled on a retail or mail order basis. Members may change their retail or mail order designation for a specific Maintenance Prescription Drug at any time. The cost-sharing amounts set forth below are applicable to all fills obtained after the Member has designated a preferred method of delivery. Please note that if after the initial fill and one (1) refill of a Maintenance Prescription Drug the Member still has not designated a preferred delivery method, the Member will be responsible for the full amount of the Provider’s Allowable Price for subsequent refills for any Maintenance Prescription Drug.

NOTE: Certain retail Participating Pharmacy Providers may have agreed to make Maintenance

Prescription Drugs available pursuant to the same terms and conditions, including cost-sharing and quantity limits, as the mail service coverage set forth in this Agreement. Members may contact the Plan at the toll-free number or the website appearing on the back of the Member’s Identification Card for a listing of those retail Participating Pharmacy Providers who have agreed to do so.

NOTE: No Member cost-sharing will apply to self-administered Chemotherapy Medications, including

Oral Chemotherapy Medications.

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Retail Covered Medications

Tier 1 85% of the Provider’s Allowable Price Not Subject to Deductible

However, the Member’s minimum and maximum Coinsurance obligation

for up to a 90 day supply at retail shall be indexed as follows: For each separate prescription order or refill for up to a 31 day supply, the

Member’s minimum Coinsurance obligation is $3 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $10 .

For each separate prescription order or refill for between 32 days and 60-

days supply, the Member’s minimum Coinsurance obligation is $6 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $20.

For each separate prescription order or refill for between 61 days and 90


Tier 2

75% Provider’s Allowable Price Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation

for up to a 90 day supply at retail shall be indexed as follows:

For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $20 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $75.





Tier 3

65% Provider’s Allowable Price

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However, the Member’s minimum and maximum Coinsurance obligation for up to a 90 day supply at retail shall be indexed as follows:

For each separate prescription order or refill for up to a 31 day supply, the

Member’s minimum Coinsurance obligation is $70 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $250.





Tier 4

50% Provider’s Allowable Price

Not Subject to Deductible However, the Member’s minimum and maximum Coinsurance obligation

for up to a 90 day supply at retail shall be indexed as follows:

For each separate prescription order or refill for up to a 31 day supply, the Member’s minimum Coinsurance obligation is $150 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $1000.





*Certain Specialty Prescription Drugs, including those which must be

obtained through an Exclusive Pharmacy Provider, are limited to a day supply up to 31 days.

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Mail Order Maintenance Covered Medications

Tier 1

85% Provider’s Allowable Price Not Subject to Deductible

For each separate prescription order or refill for up to 90 days supply, the Member’s minimum Coinsurance obligation is $6 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $20.

Tier 2

75% Provider’s Allowable Price Not Subject to Deductible For each separate prescription order or refill for up to 90 days supply, the


Tier 3 65% Provider’s Allowable Price

Not Subject to Deductible For each separate prescription order or refill for up to 90 days supply, the


Tier 4

50% Provider’s Allowable Price Not Subject to Deductible

For each separate prescription order or refill for up to 90 days supply, the Member’s minimum Coinsurance obligation is $300 or the cost of the Covered Medication, whichever is lower, and the Member’s maximum Coinsurance obligation is $2000.

Certain Specialty Prescription Drugs, including those which must be

obtained through an Exclusive Pharmacy Provider, are limited to a day supply up to 31 days.

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PREVENTIVE SERVICES NOTE: Visits for preventive health Services are exempt from all Deductibles, Copayments and dollar limits

when provided in accordance with a predefined schedule. This schedule is reviewed and updated periodically by the Plan based on the requirements of the Affordable Care Act and the advice of the American Academy of Pediatrics, U.S. Preventive Services Task Force, the Blue Cross Blue Shield Association, and medical consultants. Accordingly, the frequency and eligibility of Services is subject to change.

Adult Care 100% Plan Allowance Adult Immunizations 100% Plan Allowance

(Adult immunizations required by an employer are subject to the Deductible.)

Diabetes Prevention Program Mammographic Screening

100% Plan Allowance

100% Plan Allowance

Pediatric Care 100% Plan Allowance

Pediatric Immunizations 100% Plan Allowance

Preventive Covered Medications

100% Provider's Allowable Price

NOTE: For the purposes of this Preventive Covered Medication Benefit Schedule, Network Services are those Services received from a Participating Pharmacy Provider.

Routine Gynecological Examination and Papanicolaou Smear

100% Plan Allowance

Tobacco Use Counseling and Interventions

100% Plan Allowance

Well-Woman Care 100% Plan Allowance

PROSTHETIC APPLIANCES


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SKILLED NURSING FACILITY SERVICES


Limited to (120) days per Benefit Period SPINAL MANIPULATIONS



Not Subject to Deductible Not Subject to Deductible Limited to 20 visits per benefit period SUBSTANCE ABUSE SERVICES

Inpatient Care 60% Plan Allowance

Outpatient Care 100% Plan Allowance after $80 Copayment

Not Subject to Deductible THERAPY SERVICES

Chemotherapy 60% Plan Allowance 50%, Plan Allowance

Dialysis Treatment 60% Plan Allowance 50%, Plan Allowance

Infusion Therapy 60% Plan Allowance 50%, Plan Allowance Pulmonary Therapy 60% Plan Allowance 50%, Plan Allowance

Radiation Therapy 60% Plan Allowance 50%, Plan Allowance

Respiratory Therapy 60% Plan Allowance 50%, Plan Allowance

TRANSPLANT SERVICES


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VISION CARE SERVICES

Pediatric Services 100% Plan Allowance Not Covered

Comprehensive routine eye examination

One (1) every twelve (12) consecutive months

Not Covered

Eyeglass Frames One (1) every twelve (12)

consecutive months Not Covered

Eyeglass Lenses One (1) every twelve (12)

consecutive months Not Covered

Covered Vision Care Services are exempt from all Deductibles, Coinsurance and Copayments.

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SECTION PE – SCHEDULE OF BENEFITS FOR COVERED PHARMACY EXPENSES

PRESCRIPTION DRUG COPAYMENT- The amount a Member must pay directly to Pharmacy Providers in connection with Covered Pharmacy Expenses as set forth in the Schedule of Benefits. Except for special circumstances described in the following Section MM, Prescription Drugs with Mail Order, Prescription Drugs dispensed by a Non-Participating Pharmacy are not covered. Benefits will be provided for covered Prescription

Drugs dispensed by a Participating Pharmacy in the amounts specified in the Schedule of Benefits. Reimbursement will not exceed that set for the Generic Equivalent Drug. The difference in cost between the brand-name drug and the Generic Equivalent Drug will be payable by the Member in addition to their Prescription Drug Copayment.

There is a Deductible, Coinsurance and/or Copayment specific to Prescription Drugs. The Prescription Drug Deductible, Coinsurance and/or Copayment, payable directly to the Participating Pharmacy or to a Participating Mail Order Pharmacy for Maintenance Prescription Drugs, is outlined in the Schedule of Benefits.

No Member cost-sharing will apply to self-administered Chemotherapy Medications, including oral Chemotherapy Medications.

No coverage is provided for any refill of a Covered Medication that is dispensed before the date of the Member’s predicted use of at least ninety percent (90%) of the days’ supply of the previously dispensed Covered Medication, unless the Member’s Physician obtains Preauthorization from the Plan for an earlier refill.

Subject to the conditions, exclusions and limitations of this Agreement, Members are entitled to benefits for Covered Services described in this Agreement, in accordance with Copayment, Deductible and Coinsurance, if any, and in the amounts as specified herein and in the Schedule of Benefits. Copayments, Deductibles and Coinsurance, if applicable, are described for the Members in the Schedule of Benefits attached to this Agreement, as referenced herein. Covered Services will be provided to Members when Medically Necessary and at or through the Member’s Primary Care Physician’s office of record, or at other participating specialists. Payment will be made for Covered Services provided by Providers who are not in the First Priority Health Network, if Medically Necessary and upon Prior Authorization by the Member’s Primary Care Physician or participating Specialist Physician and First Priority Health and for Outpatient Emergency Services. Coverage for the removal of bony impacted wisdom teeth, however, is limited to Services of Participating Providers within the First Priority Health Network as discussed in this Section. In accordance with First Priority Health’s policies and procedures, certain procedures/surgeries performed in an acute-care Hospital’s short procedure unit or a free-standing surgical facility and certain diagnostic tests/scans require Prior Authorization, regardless of Provider. The Member is always responsible for Copayments, Deductibles and Coinsurance in the amounts shown for Covered Services as included herein, in the Schedule of Benefits that accompanies this Agreement. A. PRIMARY CARE PHYSICIANS AND PARTICIPATING SPECIALIST PHYSICIANS

Benefits are provided for Medical Care, visits, Telemedicine Services and consultations when Medically Necessary and at or through the Member’s Primary Care Physician’s office of record, or by a participating Specialist Physician. Members may utilize their Primary Care Physician for obstetrical Services. When

SECTION DB – DESCRIPTION OF BENEFITS

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Copayments apply to obstetrical Services provided by a Primary Care Physician or a participating Specialist Physician, Copayments only apply to the first visit. For such obstetrical Services, there is no charge after the first visit. Subsection M. Maternity and Gynecological Services of this Description of Benefits Section describes obstetrical Services. Services by a Primary Care Physician include the examination, diagnosis, and treatment of an illness or injury and preventive office visits. Adult care includes physical examinations, once per Benefit Period, and additional examinations when Medically Necessary, including a complete medical history plus necessary Diagnostic Services. Benefits are also provided for a Specialist Virtual Visit which is subsequent to the Member’s initial Visit with his or her treating Specialist Physician for the same condition. The Provider based location from which the Member communicates with the Specialist Physician is referred to as the “original site”. Benefits will not be provided for a Specialist Virtual Visit if such Visit is related to the treatment of Mental Illness or Substance Abuse. Covered Services by participating Specialist Physicians, if Medically Necessary, include the examination, diagnosis, and treatment of an illness or injury, as well as coverage for vision care to diagnose and treat a disease process involving the anatomy of the eye and for annual eye examinations for Members diagnosed with diabetes. Coverage will be provided for the initial prescription of cataract glasses or contact lenses, with or without an implant, after cataract Surgery Payment will be made for Covered Services provided by Providers who are not in the FPH Network, if Medically Necessary, and upon Prior Authorization by the Member’s Primary Care Physician or participating Specialist Physician and First Priority Health. See SECTION SB – MEDICAL BENEFITS.

B. HOSPITAL SERVICES

Prior Authorization requirements must be followed as discussed in Section CC – Care Coordination. Inpatient emergency admissions must be reviewed within forty-eight (48) hours of the admission, or as soon as reasonably possible. A concurrent review is required for any continued length of stay beyond what First Priority Health has authorized. Inpatient Copayments, Deductibles and/or Coinsurance included in the Schedule of Benefits apply per admission.

1. Room and Board

Benefits are payable for general nursing care and such other Services as are covered by the Hospital's regular charges for accommodations in the following:

a. a Semi-Private Room, as designated by the Hospital; or a private room, when designated by First Priority

Health as semi-private for the purposes of this Agreement, in Hospitals having primarily private rooms; b. a private room, when Medically Necessary and upon Prior Authorization by the Member’s Primary Care

Physician and a Medical Director of First Priority Health; (A Member who occupies a private room without such authorization shall be directly liable to the participating Hospital or participating Skilled Nursing Facility for the difference between payment by First Priority Health to the participating Hospital or participating Skilled Nursing Facility of the per-diem or other agreed-upon rate established between First Priority Health and the participating Hospital or the participating Skilled Nursing Facility and the private room rate. The private room allowance is the Semi-Private Room charge. A private room. The private room allowance is the Semi-Private Room charge;

c. a special care unit, such as intensive or coronary care, when such a designated unit with concentrated

facilities, equipment and supportive Services is required to provide an intensive level of care for a critically ill patient;

d. a bed in a general ward; and

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e. nursery facilities. Benefits are payable for a length of stay following a Mastectomy that a treating Physician determines is necessary to meet generally accepted criteria for safe discharge. Benefits are payable for hospital Services for an Inpatient admission resulting from an accident or Emergency Medical Condition that a treating Physician determines is medically necessary. Benefits are provided for an unlimited number of days per Benefit Period. In computing the number of days of benefits, the day of admission, but not the date of discharge, shall be counted. If the Member is admitted and discharged on the same day, it shall be counted as one day.

Days available under this Agreement shall be allowed only during uninterrupted stays in a Hospital. Benefits shall not be provided: (1) for any day during which a Member interrupts his/her stay; or (2) after the discharge hour that the Member's attending Physician has recommended that further Inpatient care is not required.

2. Ancillary Services

Benefits are payable for all ancillary Services usually provided and billed for by Hospitals (except for personal convenience items), including, but not limited to the following:

a. meals, including special meals or dietary Services as required by the patient's condition; b. use of operating, delivery, recovery, or other specialty service rooms and any equipment or supplies

therein; c. casts, surgical dressings, and supplies, devices or appliances surgically inserted within the body, except

when considered Experimental or Investigative by First Priority Health; d. oxygen and oxygen therapy; e. administration of blood and blood plasma, including the processing of blood from donors, but excluding

the blood or blood plasma, except as provided under Subsection BB – Blood and Blood Plasma of this Section;

f. anesthesia and the supplies and use of anesthetic equipment; g. Diagnostic Services; h. Therapy Services; i. Inpatient rehabilitation therapy limited to forty-five (45) days per Benefit Period and requires Prior

Authorization; j. all FDA-approved drugs (including intravenous solutions), cancer Chemotherapy and cancer hormone

treatment for use while in the Hospital; k. use of special care units, including, but not limited to, intensive or coronary care; and l. pre-admission testing and studies required in connection with the Member's admission rendered or

accepted by a Provider on an Outpatient basis prior to a scheduled admission to a Hospital or Facility Provider. Pre-admission testing does not include tests or studies performed to establish a diagnosis. Benefits for pre-admission testing will not be provided if the Member cancels or postpones the admission. If the Provider or Physician cancels or postpones the admission, benefits will be provided.

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Benefits are payable for ancillary Services provided for and billed for by the Hospital for an Inpatient admission resulting from an accident or Emergency Medical Condition.

3. Outpatient Ancillary Services

Hospital Services and supplies including, but not restricted to:

a) Drugs and medicines provided to a Member who is an Outpatient in a Facility Provider. However,

benefits for certain therapeutic injectables as identified by First Priority Health and which are appropriate for self-administration will be provided only when received from a Participating Pharmacy Provider as set forth in the Schedule of Benefits.

b) Therapy Services. However, benefits for certain Infusion Therapy Services as identified by First Priority

Health will only be provided when performed by an Ancillary Provider.

C. OBSERVATION STATUS In accordance with First Priority Health’s policies and procedures, Services of certain Participating Providers and

all other Providers require Prior Authorization. Coverage will be provided for Services related to observation status. Services furnished on a Hospital’s premises include use of a bed and periodic monitoring by Hospital’s nursing or other staff, which are reasonable and necessary to evaluate an Outpatient’s condition or determine the need for a possible admission to the Hospital as an Inpatient.

D. EMERGENCY CARE BENEFITS WITHIN AND OUTSIDE THE FIRST PRIORITY HEALTH NETWORK

Emergency Care Services are available seven (7) days a week, twenty-four (24) hours a day. In the event that the Member requires Emergency Care Services, the Member should immediately proceed to the nearest emergency services Provider. All reasonably necessary costs for Emergency Care Services will be paid whether provided within or outside the Network Service Area. No prior authorization is required for Emergency Care. The Member should notify the PCP or Network Specialist of the receipt of Emergency Care Services to coordinate any follow-up care. In the event a Member receives Emergency Care Services from an Out-of-Network Provider and subsequently receives a bill from the Out-of-Network Provider which represents the difference between the Plan payment and that Provider’s billed charge for such Services, the Member should notify the Plan. The Plan will then resolve the bill so that the Member will not be liable for any amounts in excess of the Plan payment, except for applicable Deductible, Coinsurance and/or Copayment obligations. Treatment for an occupational injury for which benefits are provided under any Workers’ Compensation Law or any similar Occupational Disease Law is not covered. Emergency care benefits include treatment and Services in the Outpatient department of a Hospital for an Emergency Medical Condition.

Outpatient Services and supplies provided by a Hospital or Facility Provider and/or Professional

Provider for emergency treatment of bodily injury resulting from an accident shall be covered. Outpatient Services and supplies provided by a Hospital or Facility Provider and/or Professional

Provider for emergency treatment of a medical condition with acute symptoms, which would result in requiring immediate Medical Care, shall be covered.

If accident Services are classified as Surgery (e.g., suturing, fracture care, etc.), payment to a Professional Provider will be made as a surgical benefit. Visits performed in the Outpatient department of a Hospital that are follow-up to emergency accident care and medical Emergency Services are classified and payable as Outpatient benefits.

First Priority Health will reimburse the Provider or Member for the reasonable cost of emergency accident Services or a medical Emergency Service (less appropriate Copayments) performed within or outside the First Priority Health Network (including out of the country), regardless of Provider.

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Emergency Care Services (Within or Outside the Network Service Area) - In the event that the Member requires Emergency Care Services, the Member should immediately proceed to the nearest emergency services Provider. No prior authorization is required for Emergency Care Services, whether received within or outside of the Network Service Area. Once a Member is stabilized, the Plan reserves the right to transfer the Member’s care from an Out-of-Network Provider to a Network Provider. In the event a Member receives Emergency Care Services from an Out-of-Network Provider and subsequently receives a bill from the Out-of-Network Provider which represents the difference between the Plan payment and that Provider’s billed charge for such Services, the Member should notify the Plan. The Plan will then resolve the bill so that the Member will not be liable for any amounts in excess of the Plan payment, except for applicable Deductible, Coinsurance and/or Copayment obligations. The Member is responsible for a Copayment for each emergency visit to a Physician's office and a Copayment for each emergency visit to a Hospital Outpatient department or emergency room in the amount shown in the Schedule of Benefits. If the Member is admitted to the Hospital from the emergency room, the emergency room Copayment is waived. See SECTION SB – EMERGENCY CARE SERVICES.

E. OUT-OF-AREA BENEFITS

Urgent Care – Care for an unexpected illness or injury that is not life-threatening, but which cannot be reasonably postponed until the Member returns home. Examples of urgent care include, but are not limited to, a fever, cold or the flu. For urgent care outside of the area serviced by First Priority Health’s Network of Providers, Members can receive coverage through BlueCard. Prior to receiving urgent care, the Member must call the toll-free number listed on the Identification Card for instruction on availing themselves of this coverage. Appropriate Copayments will apply.

F. COVERAGE FOR NON-EMERGENCY SERVICES WHILE TRAVELING OUTSIDE THE NETWORK SERVICE AREA

1. INTER-PLAN ARRANGEMENTS In the event that a Member is traveling outside the Network Service Area, coverage is provided for the

following: a) medical care for an unexpected illness or injury that is not life threatening, but which cannot reasonably be postponed until the Member returns home (“Urgent Care”); or b) medical care necessary to treat an illness or injury that originated in the Network Service Area (“Follow-up Care”). Members should call the toll-free telephone number listed on their Member Identification Card or refer to the Member Handbook for details. In an emergency, the Member should go directly to the nearest Provider.

2. BLUE CROSS BLUE SHIELD GLOBAL CORE

Coverage is provided through the Blue Cross Blue Shield Global Core Program when a Member requires Emergency Care Services or Urgent Care Services while traveling or living outside the United States. Members may call the service center toll-free telephone number appearing in the Member Handbook or on their Member Identification Card for assistance. In an emergency, the Member should go directly to the nearest Provider. All Emergency Care Services and Urgent Care Services are covered in accordance with this Agreement. When Covered Emergency Care Services or Urgent Care Services are rendered in a Hospital that participates in Blue Cross Blue Shield Global Core Program, Members are responsible for any Deductible or Copayment amount appearing in this Agreement. However, for Outpatient Hospital care or Physician services, or if Covered Emergency Care Services or Urgent Care Services are rendered in a Hospital that does not participate in Blue Cross Blue Shield Global Core Program, Members may be responsible for full payment at the time Covered Emergency Care Services or Urgent Care Services are received. In the event that full payment for Covered Emergency Care Services or Urgent Care Services is made by the Member, reimbursement may be obtained upon submission of the appropriate claim form(s). Information regarding Blue Cross Blue Shield Global Core Program may be obtained by calling the Member Service telephone number listed on the Member Identification Card.

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G. SURGERY

1. Surgical Benefits

Surgery benefits will be provided for Services rendered by a Professional Provider and/or Facility Provider in a Physician’s office or in a short procedure unit, Hospital, Outpatient department, or Freestanding Outpatient Facility for the treatment of disease or injury. Separate payment will not be made for Inpatient pre-operative care or all post-operative care normally provided by the surgeon as part of the surgical procedure.

For questions concerning Prior Authorization, a Member should contact the Plan by calling a Member Service Representative prior to the service being rendered. Ambulatory Surgery (i.e., Surgery performed in an acute-care Hospital’s short procedure unit or a free-standing surgical facility) and Outpatient Surgery (i.e., Surgery performed in a Physician’s office or in an acute-care Hospital’s Outpatient department) require Prior Authorization by First Priority Health for certain procedures performed in Participating Provider facilities. Prior Authorization is required for all ambulatory Surgery and Outpatient Surgery performed in Provider facilities that are not part of the FPH Network.

• Reconstructive Surgery will only be covered when required to restore function following accidental injury, infection, or disease in order to achieve reasonable physical or bodily function; in connection with congenital disease or anomaly through the age of eighteen (18) unless specifically stated as not covered in Section EX – Exclusions, Paragraph 16; or in connection with the treatment of malignant tumors or other destructive pathology which causes functional impairment; or breast reconstruction following a Mastectomy.

• Covered surgical procedures shall also include routine neonatal circumcision and any voluntary

surgical procedure for sterilization regardless of Medical Necessity. Surgery performed for the reversal of sterilization is not covered.

• Benefits are provided for a Mastectomy performed on an Inpatient or Outpatient basis, and for the

following:

a. Surgery to reestablish symmetry or alleviate functional impairment, including, but not limited to augmentation, mammoplasty, reduction mammoplasty and mastopexy;

b. Coverage for initial and subsequent prosthetic devices to replace the removed breast or

portions thereof, due to a Mastectomy; and

c. Physical complications of all stages of Mastectomy, including lymphedemas.

Coverage is also provided for one (1) home health care visit, as determined by the Member’s Physician, received within forty-eight (48) hours after discharge.

• The orthodontic treatment of congenital cleft palates involving the maxillary arch, performed in conjunction with bone graft Surgery to correct the bony deficits associated with extremely wide clefts affecting the alveolus is covered.

2. Assistant Surgeon

Benefits will be payable for Services by an assistant surgeon who actively assists the operating surgeon in the performance of covered Surgery for a Member. The condition of the Member or the type of Surgery must require the active assistance of an assistant surgeon as determined by First Priority Health. Surgical assistance is not covered when performed by a Professional Provider who himself performs and bills for another surgical procedure during the same operative session.

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3. Removal of Bony Impacted Wisdom Teeth

The removal of partially or bony impacted wisdom teeth, when performed by a Participating Provider within the First Priority Health Network (a Participating Provider Enhanced Value or Standard Value) in other than a Hospital or Ambulatory Surgical Facility, will be covered.

The Surgery may occur in a First Priority Health Network Hospital or Ambulatory Surgical Facility only under the following circumstances:

• Children under the age of eighteen (18), or • Adults who are developmentally disabled or • Members with complex medical conditions when performing the surgery/procedure in any setting

other than a Hospital or Ambulatory Surgical Facility would present an unacceptable risk to the Member’s health.

General anesthesia charges will be covered for removal of bony impacted wisdom teeth in a Hospital or Ambulatory Surgical Facility only under the following circumstances:

• Children under the age of eighteen (18), or • Adults who are developmentally disabled or • Members with complex medical conditions when performing the surgery/procedure in any setting

other than a Hospital or Ambulatory Surgical Facility would present an unacceptable risk to the Member’s health.

Local anesthesia and conscious sedation are covered regardless of setting. Covered Services are subject to Deductible and Coinsurance as specified in the Schedule of Benefits.

4. Physician, Hospital or Ambulatory Surgical Facility Charges for Dental Procedures or Dental Surgery

Dental Procedures are not covered (as set forth in Section EX – Exclusions, #18). Benefits will be payable for Physician, Hospital or Ambulatory Surgical Facility charges in connection with dental procedures for dental Surgery performed in a Hospital or Ambulatory Surgical Facility only under the following circumstances:

• Children under the age of eighteen (18), or • Adults with significant cognitive impairment, or • Members with complex medical conditions, when performing the surgery/procedure in any setting

other than a Hospital or Ambulatory Surgical Facility would present an unacceptable risk to the Member’s health, or

• When one of the following is present:

a. It is a required part of a broader treatment plan requiring radiation of the head and/or neck. b. There is non-dental disease eroding or invading the maxilla and/or mandible, the treatment of

which necessitates removal of the Member’s teeth. c. There is infection of the teeth and gums that places the Member’s health at risk if uncorrected prior

to other Medically Necessary treatment such as but not limited to chemotherapy or transplant.

5. Oral Surgery

Oral Surgery rendered by a Professional Provider and/or Facility Provider will be a Covered Service only for treatment of diseases and injuries of the jaw, head and neck. Surgery for the treatment of diseases of the teeth or gums are not covered as set forth in Section EX – Exclusions, Paragraph 18. Coverage is limited to Services performed by a Professional Provider within the First Priority Health Network (a Participating Provider Enhanced Value or Standard Value). Services performed by a Professional Provider outside of the First Priority H e a l t h Network (Non-Participating Provider) are not covered.

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Surgical removal of teeth and procedures performed for the preparation of the mouth for dentures are excluded from benefits for oral Surgery unless such procedures were for the treatment of accidental bodily injury or as described in Subsection G, Paragraph 4 above.

Covered Services are subject to Deductible and Coinsurance as specified in the Schedule of

Benefits.

6. Dental Services related to Accidental Injury

Dental Services rendered by a Professional Provider and/or a Facility Provider, as a result of accidental injury to the jaws, natural teeth, mouth or face, are covered when performed for immediate post injury stabilization. Injury as a result of chewing or biting shall not be considered an accidental injury.

Dental implants are excluded from benefits as set forth in Section EX – Exclusions, Paragraph 18.

7. Eyeglasses or Contact Lenses following Surgery

Coverage will be provided for eyeglasses or contact lenses which perform the function of a human lens lost as a result of ocular Surgery (i.e., cataract Surgery) or injury; pinhole glasses prescribed for use after Surgery for detached retina; lenses prescribed in lieu of Surgery for the following:

1) contact lenses used for treatment of infantile glaucoma; 2) corneal or scleral lenses prescribed in connection with the treatment of keratoconus; 3) scleral lenses prescribed to retain moisture in cases where normal tearing is not present or

adequate; and 4) corneal or scleral lenses to reduce a corneal irregularity other than astigmatism (for example, B & L

Griffon Softcon Bandage Type Lenses). Coverage will be provided for the initial prescription of cataract glasses or contact lenses, with or without

an implant, after cataract Surgery. See SECTION SB – HOSPITAL SERVICES. H. ANESTHESIA

Administration of general anesthesia in a Hospital or Ambulatory Surgical Facility when in connection with the performance of Covered Services and when rendered by or under the direct supervision of a Professional Provider other than the surgeon, assistant surgeon, or attending Professional Provider is covered.

Coverage for general anesthesia in connection with the extraction of partially or totally bony impacted wisdom teeth is described in Section DB – Description of Benefits, Subsection G, Paragraph 3 above.

Hospitalization and all related medical expenses normally incurred as a result of the administration of general anesthesia in a Hospital or Ambulatory Surgical Facility in connection with the performance of non-covered dental procedures or non-covered oral Surgery is covered only under the following circumstances:

• Children under the age of eighteen (18), or • Adults who are developmentally disabled or • Members with complex medical conditions, when performing the surgery/procedure in any setting

other than a Hospital or Ambulatory Surgical Facility would present an unacceptable risk to the Member’s health, or

• When one of the following is present:

a. It is a required part of a broader treatment plan requiring radiation of the head and/or neck. b. There is non-dental disease eroding or invading the maxilla and/or mandible, the treatment of

which necessitates removal of the Member’s teeth.

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c. There is infection of the teeth and gums that places the Member’s health at risk if uncorrected prior to other medically necessary treatment such as but not limited to chemotherapy or transplant.

Local anesthesia and conscious sedation are covered regardless of setting.

I. SECOND SURGICAL OPINION

Second opinion consultations for Surgery to determine the Medical Necessity of an elective surgical procedure are covered. Elective Surgery is Surgery that is not for an emergency or life-threatening condition.

Such Covered Services must be performed and billed by a Professional Provider other than the one who initially recommended performing the Surgery. See SECTION SB – MEDICAL SERVICES.

J. TRANSPLANT PROCEDURES

If a human organ or tissue transplant is provided from a human donor to a human transplant recipient:

1. When both the recipient and the donor are Members, each is entitled to the benefits of this Agreement. 2. When only the recipient is a Member, both the donor and the recipient are entitled to the benefits of this

Agreement. The donor benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to: other insurance coverage, or coverage by First Priority Health or any government program. Benefits provided to the donor will be charged against the recipient's coverage under this Agreement to the extent benefits remain and are available under the Agreement after the benefits of the recipient have been paid.

3. When only the donor is a Member, the donor is entitled to the benefits of this Agreement. The benefits are

limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage or coverage by First Priority Health or any government program available to the recipient. No benefits will be provided to the non-Member transplant recipient.

4. If any organ or tissue is sold rather than donated to the Member recipient, no benefits will be payable for the

purchase price of such organ or tissue; however, other costs related to evaluation and procurement are covered up to the Member recipient's Agreement limit.

5. Benefits for immunosuppressant drugs used in connection with covered transplants will be covered under the

Prescription Drug with Mail Order Section of the Agreement and the cost of these drugs is detailed in the Schedule of Benefits.

Prior Authorization for Transplant Procedures is required as set forth in Section CC – Care Coordination. Providers within the First Priority Health Network are responsible for obtaining the Prior Authorization on behalf of a Member. The Member is responsible to confirm with a Member Service Representative that their Provider obtained Prior Authorization prior to the service(s) being rendered. M e m b e r s should contact a Member Service Representative during the early stages of the transplant evaluation process to discuss Prior Authorization.

Facilities nationwide have been selected to participate in the Blue Cross Blue Shield Association Blue Distinctionsm Program for Transplants. Blue Distinction Centers for Transplants provide a range of Services for transplants, including but not limited to:

- Heart - Lung (deceased and living donor) - Combination heart bilateral lung - Liver (deceased and living donor) - Simultaneous pancreas kidney (SPK) - Pancreas (PAK/PTA) - Kidney-only in conjunction with SPK/PAK

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- Bone marrow/stem cell (autologous and allogeneic)

Blue Distinction Centers for Transplants have been contracted on a transplant specific basis. In order for benefits to be provided at the level of coverage as if the Member had been able to obtain Services from a Provider within the First Priority Health Network of Providers, a Member must utilize a Blue Distinction Transplant facility that has been specifically designated by Blue Cross and Blue Shield companies for the specific transplant type. When Covered Services are provided by Providers within the First Priority Health Network or by a Blue Distinction Transplant facility that has been specifically designated by Blue Cross and Blue Shield companies for the specific transplant type, the Member will be responsible for the application of a lower Coinsurance level.

With regard to Services provided by Blue Distinction Centers for Transplants, Providers within the First Priority Health Network and participating Providers of a Host Blue HMO Network are responsible for obtaining Prior Authorization on behalf of a Member. The Member is ultimately responsible to confirm with a Member Service Representative that his or her Provider obtained Prior Authorization prior to the service being rendered.

If Covered Services are provided at a Blue Distinction Transplant facility that has not been specifically designated by Blue Cross and Blue Shield companies for the specific transplant type and/or a Host Blue facility that does not participate in the Blue Distinction Transplant Program the Member will be responsible for the application of a higher Coinsurance level.

There is no coverage for Services provided by a Non-Participating Provider or at a Blue Distinction Transplant facility that has not been specifically designated by Blue Cross and Blue Shield companies for the specific transplant type unless approved by a Medical Director of First Priority Health. In the case of a transplant as a result of an Emergency Medical Condition, approval by a Medical Director of First Priority Health is required within forty-eight hours of the emergency admission or as soon as reasonably possible. Prior Authorization for Transplant Procedures is required as set forth in Section CC – Care Coordination. Providers must contact First Priority Health Utilization Management at the time the Member is referred for a transplant consultation/evaluation. Providers within the FPH Network and Participating Providers of a Host Blue HMO Network are responsible for obtaining the Prior Authorization on behalf of a Member. The Member is responsible to confirm with a Member Service Representative that their Provider obtained Prior Authorization prior to the service(s) rendered. See SECTION SB - TRANSPLANT SERVICES.

K. CONCURRENT CARE

Services rendered to an Inpatient in a Hospital, Rehabilitation Hospital or Skilled Nursing Facility by a Professional Provider who is not in charge of the case but whose particular skills are required for the treatment of complicated conditions. This does not include observation or reassurance of the Member, standby Services, routine pre-operative physical examinations or Medical Care routinely performed in the pre- or post-operative or pre- or post-natal periods or Medical Care required by a Facility Provider's rules and regulations. See SECTION SB – MEDICAL SERVICES.

L. CONSULTATIONS

Consultation Services when rendered to an Inpatient in a Hospital, Rehabilitation Hospital or Skilled Nursing

Facility by a Professional Provider at the request of the Primary Care Physician’s office of record. Consultations do not include staff consultations, which are required by Facility Provider's rules and regulations. See SECTION SB – MEDICAL SERVICES.

M. MATERNITY AND GYNECOLOGICAL SERVICES

Services rendered in the care and management of a pregnancy for a Member are Covered Services under this Agreement. A female Member may select their Primary Care Physician or a participating Specialist Physician for maternity and gynecological Services, including Medically Necessary follow-up care and diagnostic testing relating to maternity and gynecological care. Such health care Services shall be within the scope of practice of the selected participating Specialist Physician, who is responsible for keeping the Member’s Primary Care

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Physician informed of all health care Services provided.

Benefits are payable for:

1. Gynecological Services Annual gynecological examinations including a pelvic examination, clinical breast examination and one

routine Papanicolaou smear for female Members per Benefit Period. Members can utilize their Primary Care Physician for this service or they can choose any participating Specialist Physician.

2. Normal Pregnancy Normal pregnancy includes any condition usually associated with the management of a difficult pregnancy,

but not considered a complication of pregnancy. 3. Complications of Pregnancy Physical effects directly caused by pregnancy, but which were not considered from a medical viewpoint to be

the effect of normal pregnancy, including conditions related to ectopic pregnancy or those that require cesarean section.

4. Minimum Length of Stay Coverage will be provided for a minimum of forty-eight (48) hours of Inpatient care following normal vaginal

delivery and ninety-six (96) hours of care following cesarean delivery. A shorter length of stay may be justified when the treating or attending Physician determines in consultation with the mother that she and the newborn meet medical criteria for safe discharge in accordance with guidelines of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Those guidelines determine appropriate length of stay based upon, but not limited to, the following: the evaluation of the antepartum, intrapartum and postpartum course of the mother and infant; the gestational stage, birth weight and clinical condition of the infant; the demonstrated ability of the mother to care for the infant post-discharge; and the availability of the post-discharge follow-up care to verify the condition of the infant and mother within forty-eight (48) hours after discharge.

When a discharge occurs within forty-eight (48) hours following a Hospital admission for a normal vaginal delivery or within ninety-six (96) hours following a Hospital admission for cesarean delivery, benefits will be available for one (1) home health care visit within forty-eight (48) hours of the Hospital discharge. At the discretion of the mother, a visit may occur at home or at the facility of the Provider. Home health care visits shall include parent education, assistance and training in breast and bottle feeding, infant screening and clinical tests and the performance of any necessary maternal and neonatal physical assessments.

5. Interruptions of Pregnancy

a. Miscarriage. b. Services, which are necessary to avert the death of the woman and Services to terminate pregnancies caused by rape or incest.

6. Nursery Care

Ordinary nursery care of the newborn infant is covered.

7. Routine Newborn Care

The newborn child of any covered Member, spouse, or Dependent shall be entitled to benefits provided by this Agreement from the date of birth up to a Maximum of thirty-one (31) days. Such coverage within the thirty-one (31) days shall include care, which is necessary for the treatment of medically diagnosed

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congenital defects, birth abnormalities, pre-maturity and routine nursery care. Coverage for a newborn may be continued beyond thirty-one (31) days by enrolling the newborn child as a Dependent under this Agreement, provided that all premium payments required are paid for such child. In order to continue coverage for the newborn beyond this time, Application must be made within thirty-one (31) days of the date of birth. Evidence of insurability will not be required for such newborn children during that period. If the newborn does not otherwise qualify for coverage as a Dependent, the child will be entitled to Hospital service during the thirty-one (31) days after birth, in accordance with Act 81, Statute of the Commonwealth of Pennsylvania, adopted August 1, 1975. In order to continue coverage for the newborn beyond this time, Application for membership must be made within thirty-one (31) days of the date of birth.

Prenatal care and routine neonatal circumcision are covered.

N. ARTIFICIAL INSEMINATION

Benefits will be provided for Artificial Insemination and associated diagnostic, medical and surgical Services and pharmacological or hormonal treatments used in conjunction with Artificial Insemination when ordered by a Physician and determined to be Medically Necessary.

O. THERAPEUTIC DRUGS THAT ARE NOT SELF-ADMINISTRABLE

Benefits are provided for FDA-approved therapeutic drugs, including cancer Chemotherapy and cancer hormone treatment that are not self-administrable and required in the treatment of an illness or injury in all medically appropriate treatment settings covered by this Agreement. See SECTION SB – MEDICAL SERVICES.

P. DIAGNOSTIC SERVICES-OUTPATIENT

Benefits are provided for the following Diagnostic Services when ordered by a Professional Provider and billed by a Professional Provider, independent clinical laboratory, and/or a Facility Provider:

1. Diagnostic radiology, consisting of x-ray, ultrasound and nuclear medicine.

2. Diagnostic laboratory and pathology tests.

3. Diagnostic medical procedures consisting of electrocardiogram (ECG), electroencephalogram (EEG), and

other diagnostic medical procedures approved by First Priority Health.

4. Diagnostic imaging procedures consisting of Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography (CT) scan, Positron Emission Tomography (PET) scan, and nuclear cardiology studies approved by First Priority Health.

5. Allergy testing consisting of percutaneous, intracutaneous and patch tests.

Certain diagnostic tests/scans require Pre-Certification, regardless of Provider. Refer to the Schedule of Benefits for Deductible, Coinsurance, and/or Copayment information.

Q. REHABILITATIVE/HABILITATIVE OUTPATIENT SERVICES Benefits shall be provided, subject to the Maximums specified below, for the following Services prescribed

by a Physician and performed by a Professional Provider and/or Facility Provider, which are used in treatment of an illness or injury to acquire or reacquire a functional skill:

1. Cardiac Rehabilitation (does not include Services provided for habilitative purposes).

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2. Occupational and Speech Therapy are limited to a combined Maximum of thirty (30) visits per Benefit Period for rehabilitative Services and thirty (30) visits per Benefit Period for habilitative Services.

3. Physical Medicine is limited to a Maximum of thirty (30) visits per Benefit Period for rehabilitative Services and thirty (30) visits per Benefit Period for habilitative Services.

See SECTION SB – HABILITATIVE/REHABILITATIVE SERVICES.

R. THERAPY SERVICES

Benefits will be provided for the following Covered Services only when such Services are ordered by a Physician:

1. Chemotherapy 2. Dialysis Treatment 3. Infusion Therapy 4. Pulmonary Therapy 5. Radiation Therapy 6. Respiratory Therapy

Benefits will be provided when Covered Services are performed by a Provider on an Outpatient basis or if the components are furnished and billed by a Provider. Covered Services include pharmaceuticals, pharmacy Services, intravenous solutions, medical/surgical supplies and nursing Services associated with Infusion Therapy. Specific adjunct non-intravenous therapies are included when administered only in conjunction with Infusion Therapy.

S. MENTAL HEALTH CARE SERVICES

Benefits for the treatment of Mental or Nervous Disorders and for the treatment of Serious Mental Illness are based on the Services provided and reported by the Provider. Those Services provided by and reported by the Provider as mental health care are subject to the mental health care limitation in this Agreement. When a Provider renders Medical Care, other than mental health care, for a Member with Serious Mental Illness or with a Mental or Nervous Disorder, payment for such Medical Care will be based on the medical benefits available and will not be subject to the mental health care limitations in this Agreement.

1. Inpatient Services

Inpatient Services will be provided for admissions for Serious Mental Illness and Mental or Nervous Disorders in an Inpatient Mental Health Hospital and Inpatient Non-Hospital Residential Facility. Prior Authorization requirements must be followed as discussed in Section CC – Care Coordination. A concurrent review is required for any continued length of stay beyond what has been pre-certified by First Priority Health.

2. Outpatient and Intensive Outpatient Services

Outpatient Services and Intensive Outpatient Services will be provided during a Benefit Period for Mental or Nervous Disorders and for Serious Mental Illness. Outpatient mental health care Services include Outpatient professional visits and Outpatient Partial Hospitalization days. Inpatient Mental Health Hospital and Partial Hospitalization Psychiatric Care Covered Services are provided when Medically Necessary and when First Priority Health is notified by the Participating Provider or the Member before the Covered Services are rendered, and coordinates the Member’s care. Covered Services must be Prior Authorized by the Plan. Refer to the Schedule of Benefits for Deductible, Coinsurance, and/or Copayment information.

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T. TREATMENT FOR ALCOHOL AND/OR DRUG ABUSE AND DEPENDENCY

Except in an emergency, Inpatient Detoxification, Inpatient Drug and/or Alcohol Abuse Non-Hospital Residential Care, Partial Hospitalization Substance Abuse Services and Intensive Outpatient Program requests for Drug and Alcohol treatment by non-Physicians/Psychologists must have Prior Authorization from First Priority Health before Services are rendered and must meet Medically Necessary criteria. Benefits are available to a Member who is certified by a licensed Physician or licensed Psychologist as a person who requires Substance Abuse treatment. Certification and referral by a licensed Physician or licensed Psychologist control the nature and duration of treatment for Inpatient and Outpatient Substance Abuse treatment. The certification must be provided to First Priority Health before claims for the treatment rendered will be processed for payment. The certification by a licensed Physician or licensed Psychologist is valid for forty-five (45) days per calendar year. Any treatment beyond forty-five (45) days or any subsequent treatment must meet Medical Necessity requirements and will require Prior Authorization as described in Section CC – Care Coordination. Inpatient Detoxification, Inpatient Drug and/or Alcohol Abuse Non-Hospital Residential Care, Partial Hospitalization Substance Abuse Services, and Intensive Outpatient Program requests for Drug and Alcohol treatment by non-Physicians/Psychologists must be pre-certified with First Priority Health before Services are rendered and must meet Medically Necessary criteria. In all instances, Services must be performed by a Provider within the FPH Network. 1. Inpatient Detoxification

Benefits are provided for Inpatient Detoxification when provided in either a Hospital or in an Inpatient Non-

Hospital Residential Facility. The following Services will be covered when administered by an employee of the facility:

a. lodging and dietary Services; b. rehabilitation therapy and counseling; c. diagnostic x-ray; d. psychiatric, psychological and medical laboratory testing; and e. drugs, medicines, equipment use and supplies.

2. Inpatient Alcohol and/or Drug Abuse Non-Hospital Residential Care

Benefits are provided for Inpatient Non-Hospital Residential Care in an Inpatient Non-Hospital Residential Facility. The following Services will be covered when administered by an employee of the facility:

a. lodging and dietary Services; b. Physician, Psychologist, nurse, certified addiction counselors and trained staff Services; c. rehabilitation therapy and counseling; d. family counseling and intervention; e. psychiatric, psychological and medical laboratory testing; and f. drugs, medicines, equipment use and supplies.

3. Outpatient Facility Services inclusive of Partial Hospitalization Substance Abuse Services and

Intensive Outpatient Programs for Treatment of Alcohol or Drug Abuse

Benefits are provided for Outpatient Alcohol and/or Drug Abuse Services when provided in a Substance Abuse Treatment Facility. The following Services will be covered when administered by an employee of the facility:

a. Physician, Psychologist, nurse, certified addiction counselors and trained staff Services; b. rehabilitation therapy and counseling;

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c. family counseling and intervention; d. psychiatric, psychological and medical laboratory testing; and e. drugs, medicine, equipment use and supplies.

Refer to the Schedule of Benefits for Deductible, Coinsurance, and/or Copayment information.

See SECTION SB – SUBSTANCE ABUSE SERVICES. U. OXYGEN AND RELATED EQUIPMENT/SUPPLIES

Oxygen and related equipment and supplies for use in the patient's home are covered. Oxygen and related equipment/supplies are not subject to any Maximum. Refer to the Schedule of Benefits for Deductible, Coinsurance and/or Copayment information. Covered Services are subject to Deductible and Coinsurance. See SECTION SB _ DURABLE MEDICAL EQUIPMENT.

V. SKILLED NURSING FACILITY SERVICES

Benefits are provided for care in a Participating Skilled Nursing Facility, when determined to be Medically Necessary and upon Prior Authorization by First Priority Health. Covered Services in Participating Skilled Nursing Facilities are limited to one hundred twenty (120) days per Benefit Period. The Member must require treatment by skilled nursing personnel, which can be provided only on an Inpatient basis in a Skilled Nursing Facility.

Prior Authorization procedures apply as set forth in Section CC – Care Coordination. The Member's Primary Care Physician must provide First Priority Health with clinical information that skilled nursing care in a Skilled Nursing Facility is Medically Necessary pursuant to Section CC – Care Coordination. No benefits are payable:

1. after the Member has reached the Maximum level of recovery possible for his or her particular condition and

no longer requires definitive treatment other than routine Custodial Care; 2. when confinement in a Skilled Nursing Facility is intended solely to assist the Member with the activities of

daily living or to provide an institutional environment for the convenience of a Member; or 3. for the treatment of alcoholism, drug addiction, or Mental Illness.

W. HOME HEALTH CARE

Subject to the following provision, benefits will be provided for up to sixty (60) home health care visits per Benefit Period. The Member must be Homebound in order to receive home health care benefits, except when Services are provided in conjunction with:

Home Infusion Therapy, including the care of venous lines; The post Mastectomy visit; and The post-partum visit; or When Services are not routinely provided in a Physician’s office or the Outpatient setting and are

Medically Necessary and have approval of a Medical Director of First Priority Health.

Benefits will be provided for the following Covered Services when performed by a licensed Home Health Care Agency:

1. Professional Services of a Registered Nurse or Licensed Practical Nurse, but not including private duty

nurses; 2. Home health aide Services as assigned and supervised by a Registered Nurse or Licensed Practical Nurse;

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3. Physical Medicine treatments performed by a licensed Physical Therapist; 4. Speech Therapy Services when provided by a licensed Speech Therapist holding a Certificate of Clinical

Competency; 5. Occupational Therapy treatments when provided by or supervised by a licensed Occupational Therapist; 6. medical social service consultations when provided by a qualified medical social service worker holding a

masters degree in social work; 7. Nutritional Therapy provided by a Licensed Dietitian;1 8. diagnostic and therapeutic radiology Services; 9. laboratory Services; 10. medical diagnostic tests and studies; 11. oxygen and Respiratory Therapy; 12. medical and surgical supplies, including bandages, ostomy supplies, dressings and casts and 13. the rental of Durable Medical Equipment but only on a short term basis and if not owned by the Home Health

Care Agency.

The Member must be Homebound in order to receive home health care benefits, except when Services are provided in conjunction with:

Home Infusion Therapy, including the care of venous lines; The post Mastectomy visit; and The post-partum visit; or When Services are not routinely provided in a Physician’s office or the Outpatient setting

and are Medically Necessary and have approval of a Medical Director of First Priority Health.

Benefits will be provided only for Covered Services if (a) the Services are prescribed by the Member's attending Physician, (b) the Member received Prior Authorization from First Priority Health as set forth in Section CC – Care Coordination, and (c) the Member's Physician has furnished, in consultation with the Home Health Care Agency's professional personnel prior to the first visit, a plan of treatment stating that the Services are Medically Necessary. Continuing eligibility requires that the attending Physician provide such a plan of treatment at intervals of no less than every thirty (30) days.

When a discharge occurs within forty-eight (48) hours following a Hospital admission for a Mastectomy, benefits will be provided for one (1) home health care visit within forty-eight (48) hours of the Hospital discharge. Prior Authorization will not be required for this visit. When a discharge occurs within forty-eight (48) hours following a Hospital admission for a normal vaginal delivery or within ninety-six (96) hours following a Hospital admission for cesarean delivery, benefits will be available for one (1) home health care visit within forty-eight (48) hours of the Hospital discharge. Prior Authorization will not be required for this visit.

1 Nutritional Therapy provided to a Homebound Member will not reduce the benefit provided under Subsection DD of the Description of Benefits Section of this Agreement.

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At the discretion of the mother, a visit may occur at home or at the facility of the Provider. A visit occurs when the Member receives such treatment from one of the qualified professionals as listed above under the Covered Services of this benefit section. Postpartum home health care visits are exempt from any Coinsurance or Deductible amounts. No home health care benefits will be provided for:

1. food or home delivered meals; 2. professional Medical Services billed by a Physician; 3. Custodial Care; 4. Services of a housekeeper; 5. Private Duty Nursing; 6. ambulance service; 7. drugs; including Prescription Drugs, and; 8. Services provided by Immediate Family or persons of the Member's household.

X. HOME INFUSION THERAPY

Benefits will be provided for the following Services provided to a Member by a Home Infusion Therapy Agency:

1. total parenteral nutrition *; 2. enteral nutrition *; 3. intravenous therapy; 4. cancer Chemotherapy and cancer hormone treatment; 5. anti-infective therapy (* Lyme Disease); 6. pain management (continuous and epidural analgesics); and 7. immune globulin therapy *.

The Home Infusion Therapy Agency shall supply all items used directly with Home Infusion Therapy to achieve therapeutic benefits and to assure proper functioning of the system, including, but not limited to: catheters, concentrated nutrients, dressings, enteral nutrition preparation, extension tubing, filters, heparin sodium (parenteral only), infusion bottles, IV pole, liquid diet (for catheter administration), needles, pumps, tape and volumetric monitors. All therapies are subject to prospective, concurrent and/or retrospective utilization review by health care professionals, and further may require Prior Authorization to determine if a therapy is Medically Necessary and appropriate. Before delivering the therapy, a participating Home Infusion Therapy Agency will advise the Member if Prior Authorization is required. Prior Authorization is required for all therapies when provided by Providers who are not in the FPH Network. *Therapies that generally require Prior Authorization are noted with an asterisk above. Any therapy or drug, the use of which is not FDA approved may be considered Experimental/Investigative and, therefore, must be pre-approved. Prior Authorization procedures apply as set forth in Section CC – Care Coordination. Failure to obtain Prior Authorization for any Services which require it shall result in a denial of benefits. Home Infusion Therapy benefits will not be provided for:

a. Members who are receiving benefits under the Hospice Care program; b. blood and blood products therapy; and

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c. any injectable drugs covered under any other benefit section of this Agreement. See SECTION SB – THERAPY SERVICES.

Y. ENTERAL FOODS

Enteral foods only for the therapeutic treatment of phenylketonuria (PKU), branched-chain ketonuria, galactosemia and homocystinuria. This benefit does not include coverage for normal food products used in the dietary management of rare genetic metabolic disorders. Benefits for Enteral foods are exempt from any Deductible requirements.

Amino acid-based elemental enteral foods are covered only for infants and children for the usual and customary cost of amino acid-based elemental enteral food ordered by a physician as medically necessary and administered orally or enterally for food protein allergies, food protein-induced enterocolitis syndrome, eosinophilic disorders and short-bowel syndrome. An amino acid-based elemental formula covered under this section is a formula made of 100% free amino acids as the protein source. Benefits for Amino acid-based elemental formulas are not subject to Deductible requirements. See SECTION SB – ENTERAL FOODS.

Z. HOSPICE CARE

When the Member's attending Physician certifies to First Priority Health that the Member has a terminal illness with a life expectancy of six (6) months or less and when the Member elects to receive care primarily in the home to relieve pain and to enable the Member to remain at home rather than to receive other types of care, the Member shall be eligible for Hospice Care benefits. These benefits are in addition to, and not in lieu of, any other benefits in this Agreement. If the Member or the Member's responsible party elects to institute curative treatment to sustain life, the Member will not be eligible to receive further Hospice Care benefits until the cessation of such curative treatment. The Hospice Care benefit will include, coverage for continuous care consisting of nursing care for up to twenty-four (24) hours per day necessary to maintain the patient at home or acute Inpatient care for a period of crisis when Medically Necessary and not solely for comfort measures. Respite Care on a short-term Inpatient basis in a Hospital or Skilled Nursing Facility will also be covered when the Hospice considers such care necessary to relieve primary caregivers in the patient’s home. Respite Care is available 7 days per 6 months. Benefits are payable according to the Maximums set forth in herein.

Benefits will be provided for supportive Services at each level of care to a terminally-ill Member by a Hospice Care program in accordance with a treatment plan approved by and periodically reviewed by First Priority Health. The following Services provided to a Member by an approved Hospice responsible for the patient's overall care will be eligible for coverage:

1. professional Services of a Registered Nurse or Licensed Practical Nurse; 2. pain management; 3. Chemotherapy and/or Radiation Therapy; 4. parenteral or enteral nutrition therapy; 5. prescription drugs; 6. laboratory Services; 7. dietitian Services; 8. medical and surgical supplies, ostomy supplies, and Durable Medical Equipment; 9. oxygen and its administration;

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10. medical social service consultation provided by a social worker; 11. counseling Services provided to the Member and/or family members related to the patient’s terminal

condition, including bereavement counseling; 12. home health aide and homemaker Services; and; 13. any needed therapies.

AA. DIABETES EDUCATION/EQUIPMENT/SUPPLIES

Diabetes Education

Benefits are provided for diabetes education Services as described herein. Diabetes Outpatient self-management training and education shall be provided under the supervision of a licensed health care professional with expertise in diabetes to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets. Coverage for self-management education and education relating to diet and prescribed by a licensed Physician shall include: (1) visits Medically Necessary upon the diagnosis of diabetes; (2) visits under circumstances whereby a Physician identifies or diagnoses a significant change in the patient's symptoms or conditions that necessitates changes in a patient's self-management; and (3) where a new medication or therapeutic process relating to the person's treatment and/or management of diabetes has been identified as Medically Necessary by a licensed Physician. Diabetic Equipment and Supplies Equipment and supplies for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-using diabetes when prescribed by a health care professional legally authorized to prescribe such items. Equipment and supplies shall include the following: blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar and Orthoses. See SECTION SB – DIABETES TREATMENT.

BB. BLOOD AND BLOOD PLASMA

Benefits will be provided for whole blood, blood plasma, the administration of blood and blood processing, and blood derivatives, which are not classified as drugs by the U.S. Food and Drug Administration (“FDA”).

CC. AMBULANCE SERVICES

Benefits are payable for Medically Necessary ambulance Services by land, air or water, Advanced Life Support (ALS) or Basic Life Support (BLS) for local transportation. The ambulance must be transporting the Member:

1. from home or from the scene of an accident or Medical Emergency, to the nearest Hospital; 2. between Hospitals; 3. between a Hospital and Skilled Nursing Facility; 4. from a Hospital or Skilled Nursing Facility to the Member's home; 5. from the Member’s home or from a Facility Provider to an Outpatient treatment site; or 6. from an Outpatient treatment site to the nearest Hospital.

Emergency ambulance Services are covered at the Plan Allowance.

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If there is no facility in the local area that can provide Covered Services for the Member's condition, then ambulance service means transportation to the closest facility outside the local area that can provide the necessary service. If the Member chooses to go to another facility that is farther away, payment will be based on the Plan Allowance for transportation to the closest facility that can provide the necessary Services. Medically Necessary non-emergency benefits are covered for ground transportation only. Air and water transportation Services are not covered in non-emergency situations. Emergency transportation provided by a licensed ambulance service shall constitute an emergency ambulance transport. All non-emergency transport by Providers who are not part of the FPH Network will require Prior Authorization.

DD. PREVENTIVE CARE

Coverage will be provided for the preventive care Services provided for in the Patient Protection and Affordable Care Act (PPACA) and Health Resources and Services Administration’s (HRSA) Women’s Preventive Services: Required Health Plan Coverage Guidelines. The frequency and eligibility of Services are subject to change to conform to the guidelines and recommendations of the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the Center for Disease Control, and the Health Resources and Services Administration. Preventive care Services include, but are not limited to the following:

1. Immunizations

Coverage will be provided for those pediatric and adult immunizations, including immunizing agents, which, as determined by the Department of Health, conform to the Standard Values of the Advisory Committee on Immunization Practices of the Center for Disease Control, U.S. Department of Health and Human Services. Pediatric immunizations are available until the Member attains age twenty-one (21). Pediatric and adult immunizations which are provided by Participating Providers are exempt from deductibles, Copayments, and coinsurance.

2. Gynecological Examinations and Pap Smears

Female Members are covered for gynecological examinations, including pelvic examinations, clinical breast examinations, and Pap smears. Benefits are exempt from deductibles, Copayments, and coinsurance, when provided by a Participating Provider.

3. Mammographic Screenings

Benefits are provided for the following Covered Services in amounts specified in SECTION SB - SCHEDULE OF BENEFITS of this Agreement:

a. One (1) annual routine mammographic screening starting at forty (40) years of age or older pursuant to the 2002 recommendations by the United States Preventive Services Task Force; and

b. Mammographic screenings for all Members, regardless of age, when such Services are prescribed by

a Physician. Benefits for mammographic screenings are payable only if performed by a mammography service provider who is properly certified by the Pennsylvania Department of Health in accordance with the Mammography Quality Assurance Act of 1992.

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4. Preventive Drugs

Benefits are provided for those generic preventive drugs with a prescription, which as determined by the U.S. Preventive Services Task Force have a rating of A or B, in accordance with the Affordable Care Act of 2010. Benefits are also provided for certain generic FDA-approved prescription contraceptives for female Members with a prescription, in accordance with the Health Resources and Services Administration’s (HRSA) Women’s preventive Services: Required Health Plan Coverage Guidelines. If contraceptives are not covered, coverage will not be provided for any prescription drug, supply or device including all dosage forms of contraceptives. These generic preventive drugs are exempt from deductibles, Copayments and coinsurance, when dispensed by a participating pharmacy. In order to receive benefits, the Member must present the prescription and First Priority Health Identification Card to a participating pharmacy and the claim must be filed by a participating pharmacy.

5. Nutritional Therapy

Nutritional therapy to promote a healthy diet is available to Member Persons, when provided by a licensed health care professional. Benefits are exempt from all Deductibles, Coinsurance and Copayments when provided by Participating Providers within the First Priority Health Network (designated as Enhanced Value or Standard Value). Coverage for dependent children, who are covered under this Agreement, will be provided as follows:

Dependent children, ages two (2) through twelve (12), when accompanied by a parent. Dependent children, ages thirteen (13) through seventeen (17), with parental consent.

No coverage is provided for dependent children under the age of two (2).

6. Smoking Cessation

Certain smoking-cessation aids, including Prescription Drugs and nicotine patches associated with smoking-cessation, as determined by First Priority Health and included in the Drug Formulary or the Preventive Schedule provided with this Agreement shall be covered with a prescription and if dispensed by a participating pharmacy. These smoking-cessation aids are exempt from Deductibles, Copayments, and Coinsurance.

7. Diabetes Prevention Program

Benefits are provided for those Members meeting certain medical criteria of having a high risk of developing type 2 diabetes when enrolled in a Diabetes Prevention Program that is delivered by a Diabetes Prevention Provider. Coverage is limited to one (1) enrollment in a Diabetes Prevention Program per year, regardless of whether the Member completes the Diabetes Prevention Program.

See SECTION SB – PREVENTIVE SERVICES. EE. ALLERGY EXTRACTS/INJECTIONS

Benefits are provided for allergy extracts and antigen injections.

FF. DURABLE MEDICAL EQUIPMENT/PROSTHESES/ORTHOSES

Benefits are provided for durable medical equipment, prostheses, and orthoses when prescribed by a licensed health care professional. Except for initial and subsequent prosthetic devices to replace the removed breast or

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portions thereof, replacements of Durable Medical Equipment, Prostheses and Orthoses are not included, other than as certified as Medically Necessary for children due to normal growth process. Payment will be made for Covered Services provided by Providers who are not part of the FPH Network, if Medically Necessary and upon Prior Authorization by the Member's Primary Care Physician or participating Specialist Physician and First Priority Health. Instructions regarding appropriate use of the item are covered. Covered Durable Medical Equipment includes, but is not limited to, the following:

a. hospital beds and related equipment (bed rails, mattresses); b. equipment to increase mobility (walkers, wheelchairs); c. commodes (elevated seats, portable bedside commodes); d. breathing apparatus (positive and intermittent positive pressure breathing machines, suction machines); e. therapeutic equipment; f. apnea monitors; g. Jobst pressure garments used in burn treatment; and h. Unna boots and air casts.

Covered Prostheses and Orthoses include, but are not limited to, the following:

a. artificial limbs; b. knee braces, not made of elastic or fabric support; c. splints (acrimo-clavicular or zimmer, carpal tunnel, clavicle or “figure-8", finger, Pavlik harness and wrist); d. immobilizers; e. corrective shoes, shoe inserts and supports, and/or other foot Orthoses; f. supportive back braces with metal stays; g. dynasplints; and h. cryocuffs. i. prosthetic socks; j. eye prosthetics.

Benefits are not payable for dental appliances, wigs, or eyeglasses, except as specified in Section DB – Description of Benefits, Paragraph F. Surgery. Covered Services are subject to Deductible and Coinsurance. See SECTION SB – DURABLE MEDICAL TREATMENT; PROSTHETIC APPLIANCES; ORTHOTIC DEVICES.

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GG. SPINAL MANIPULATION BENEFITS Spinal Manipulative Treatment, consultations, and Adjunctive Procedures are limited to a combined Maximum of Twenty (20) visits per Benefit Period, if Medically Necessary. Prior Authorization is required to obtain benefits from Providers who are not in the FPH Network.

HH. RETAIL CLINIC CARE

Benefits are provided for Retail Clinic Care visits and consultations rendered and billed by a Professional Provider to a Member who is an Outpatient. Benefits are provided for the examination, diagnosis, and treatment of common minor ailments. A primary care office visit copayment applies per visit. See SECTION SB – MEDICAL SERVICES.

II. URGENT CARE CENTER BENEFIT

Benefits are provided for visits rendered and billed by a Participating Provider in an Urgent Care Center to a Member who is an Outpatient. Benefits are provided for treatment of illness or injury. Outpatient covered Services rendered by a provider not in an Urgent Care Center will be processed in accordance with the terms and conditions of the respective Outpatient Hospital and/or Professional Provider benefits. See SECTION SB – MEDICAL SERVICES.

JJ. CLINICAL TRIALS

Routine Costs for items and Services furnished in connection with a Qualified Individual’s participation in a phase I, II, III, or IV clinical trial designed to prevent, detect, or treat cancer or other life-threatening diseases or conditions are covered. Routine costs associated with clinical trials are subject to Deductibles, Copayments, Coinsurance, and amounts in excess of any Benefit Maximums.

KK. PEDIATRIC VISION CARE

Benefits are provided for visits rendered and billed by a Professional Provider for routine eye examinations once per Benefit Period.

Coverage will be provided for one pair of eyeglasses or contact lenses per Member in a twelve (12) month period. Coverage for Pediatric Vision Care Services terminates at the end of the month in which the Member reaches age nineteen (19).

Pediatric vision Services are only available through the Davis Vision network. See SECTION SB – VISION CARE SERVICES.

LL. PEDIATRIC DENTAL CARE

Benefits are provided for Members for the following when rendered by a Dentist who is a Network Provider:

a. Oral Evaluations:

i) Comprehensive, periodic and limited problem focused

ii) Consultations

iii) Detailed problem focused

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b. Radiographs - Full mouth x-rays - one (1) every three (3) years. Bitewing x-rays - one (1) set per six (6) months.

c. Prophylaxis - one (1) per six (6) months. One (1) additional for Members under the care of a medical

professional during pregnancy.

d. Fluoride treatments:

i) Topical fluoride treatment - two (2) per twelve (12) months through age eighteen (18).

ii) Fluoride varnish - two (2) per twelve (12) months through age eighteen (18). e. Palliative treatment (emergency)

f. Sealants - one (1) per tooth per three (3) years on permanent first and second molars.

g. Space maintainers - through age eighteen (18) when used to maintain space as a result of prematurely

lost deciduous first and second molars, or permanent first molars that have not, or will never, develop. h. Preventive resin restorations

i. Periodontal Services:

i) Full mouth debridement ii) Periodontal maintenance following active periodontal therapy - four (4) per twelve (12) months in

addition to routine prophylaxis. iii) Periodontal scaling and root planing - one (1) per twenty-four (24) months per area of the mouth. iv) Surgical periodontal procedures - one (1) per twenty-four (24) months per area of the mouth. v) Guided tissue regeneration

j. Basic Restorations - amalgam or composite k. Crowns - ceramic, porcelain-fused to metal and metal alloy - one (1) every five (5) years. l. Inlays and onlays - one (1) every five (5) years. m. Prefabricated stainless steel crowns - one (1) per tooth within a five (5) year period. n. Replacement of restorative services only when they are not, and cannot be made, serviceable:

i) Basic restorations (including but not limited to, stainless steel crowns)

ii) Single crowns, inlays, onlays - one per tooth within a five (5) year period.

iii) Buildups and post and cores - one per tooth within a five (5) year period.

iv) Full and partial dentures - one (1) per arch within a five (5) year period.

o. Oral and maxillofacial surgical services:

i) Simple extractions.

ii) Surgical extractions.

iii) Oral surgery.

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iv) Apicoectomy/Periradicular surgery.

p. Denture relining, rebasing or adjustments are considered part of the denture charges if provided within

six (6) months of insertion by the same Dentist. Subsequent denture relining or rebasing limited to one (1) every three (3) years thereafter.

q. Pulpal therapy - through age five (5) on primary anterior teeth and through age

eleven (11) on primary posterior teeth.

r. Root canal retreatment - one (1) per tooth per lifetime.

s. Recementation - one (1) per five (5) years. Recementation during the first twelve (12) months following insertion by the same Dentist is included in the prosthetic service benefit.

t. Administration of IV sedation, nitrous oxide or general anesthesia is limited to covered oral surgical

procedures involving one or more impacted teeth (soft tissue, partial bony or complete bony impactions).

u. Therapeutic drug injections - only covered in unusual circumstances, by report.

v. Orthodontics

Covered Services which are intended to treat a severe dentofacial abnormality and are the only method capable of preventing irreversible damage to the Member’s teeth or their supporting structures, and restoring the Member’s oral structure to health and function.

Limitations

a. Orthodontic treatment limitations:

i) All pediatric orthodontic treatment is subject to Precertification by the Plan, and must be part of an

approved written plan of care. ii) To be eligible for pediatric orthodontic treatment, a Member must

(a) continue to be enrolled during the duration of treatment; and (b) have a fully erupted set of permanent teeth.

b. An alternate benefit provision (ABP) will be applied if a covered dental condition can be treated by means

of a professionally acceptable procedure which is less costly than the treatment recommended by the Dentist. The ABP does not commit the Member to the less costly treatment. However, if the Member and the Provider choose the more expensive treatment, the Member is responsible for the additional charges beyond those allowed under this ABP.

c. Coverage terminates for Pediatric Dental Services at the end of the Benefit Period in which the Member

reaches age nineteen (19). MM. PRESCRIPTION DRUGS WITH MAIL ORDER

Benefits will be provided for covered Prescription Drugs dispensed by a Participating Pharmacy in the

amounts specified in the Schedule of Benefits, as follows:

1. Covered drugs/supplies include: (a) Prescription Drugs which can be self-administered, including contraceptives for the use of birth control, if so specified in the S c h e d u l e o f B e n e f i t s , (b) insulin, (c) disposable syringes/needles for the administration of covered Prescription Drugs and insulin, (d) lancets, (e) glucose test strips, sensors, (f) spacer devices for use with metered-dose inhalers, (g) peak flow meters, (h) other drugs/supplies which may be specifically designated by First Priority Health, and (i) the

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covered pharmaceutical Services necessary to make such drugs available, not including, however, any drug or group of drugs specifically excluded by the terms of this Policy.

2. Reimbursement will not exceed that set for the Generic Equivalent Drug. The difference in cost between

the brand-name drug and the Generic Equivalent Drug will be payable by the Member in addition to their Prescription Drug Copayment. (Please see Paragraph 10, below, for the special exception process to this rule as it relates to Women’s Preventive Services.)

3.

(a.) Each Prescription Drug is limited to a thirty (30) day supply based on the Prescriber’s directions for use and further subject to the quantity limits authorized by the Prescriber on the Prescription order, maximum daily dosages as indicated in the drug information literature, and/or quantity limits allowed by First Priority Health.

(b.) Each Maintenance Prescription Drug is limited to a ninety (90) day supply based on the

Prescriber’s directions for use and further subject to the quantity limits authorized by the Prescriber on the Prescription order, maximum daily dosages as indicated in the drug information literature, and/or quantity limits allowed by First Priority Health.

4. Prescriptions are refillable for a period not in excess of one (1) year from the date written and further

subject to refill limitations as set forth in federal and/or state law or by the Prescriber. 5. Unless the Prescriber or Pharmacist has requested and received Prior Authorization for an early refill,

the claim will be denied if a refill is requested before the time ninety (90) percent of the days’ supply of medication has passed. An early refill Prior Authorization can be granted for an additional supply for reasons such as vacation or business travel. A Participating Pharmacy may receive authorization by telephone to fill the prescription early on a one-time-only basis any time before the next regular refill due-date.

6. In order to receive benefits, the Member must present the First Priority Health Identification Card to a

Participating Pharmacy and the claim must be filed by a Participating Pharmacy, except in special circumstances and such other situations as deemed appropriate by First Priority Health.

7. Special Circumstances - In special circumstances, such as when a Member needs an unexpected

Prescription when beyond a reasonable distance from a Participating Pharmacy, while vacationing or traveling out-of-area, inaccessibility to a Participating Pharmacy, inaccessibility of the First Priority H e a l t h electronic claims/eligibility systems, or for urgent or emergency needs, the Member may request reimbursement for purchased Prescriptions from First Priority Health. Reimbursement will not be in excess of the amount which would otherwise have been payable to a Participating Pharmacy for the Generic Equivalent Drug, less the Copayment. If there is no Generic Equivalent Drug, reimbursement will not be in excess of the amount which would otherwise have been payable to a Participating Pharmacy for a Preferred Prescription Drug, less the Copayment. Such requests are subject to a filing limit of one (1) year from the date of purchase.

8. All Prescription Drug claims are subject to prospective, concurrent and/or retrospective drug utilization

review by health care professionals, and further may require Prior Authorization to determine if a Prescription Drug is Medically Necessary. Before prescribing the Prescription Drug, a Participating Prescriber will advise the Member if Prior Authorization is required and request the Prior Authorization on behalf of the Member. Participating Prescribers must accept First Priority Health’s determination of Medical Necessity. In the event the Prior Authorization is denied for lack of Medical Necessity, no benefits will be provided by First Priority Health when the M e m b e r disregards the Prior Authorization denial and elects to purchase the Prescription Drug. Should a Prescription Drug, which requires Prior Authorization be presented to a Participating Pharmacy without Prior Authorization, the Participating Pharmacy will advise the Member prospectively that the claim was denied by First Priority Health because Prior Authorization is required for coverage of the Prescription Drug.

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9. In the case of a Maintenance Prescription Drug, the Member must designate whether the Maintenance Prescription Drug should be filled on a retail or mail order basis. Members may change their retail or mail order designation for a specific Maintenance Prescription Drug at any time. The cost-sharing amounts set forth below are applicable to all fills obtained after the Member has designated the preferred method of delivery, as well as to the initial fill and one (1) refill of a Maintenance Prescription Drug. If the Member does not designate the preferred delivery method, the Member will be responsible for the full amount of Plan Allowance for subsequent refills for any Maintenance Prescription Drug.

10. Women’s Preventive Services - Certain generic FDA-approved prescription contraceptives are covered

for female Members with a prescription, in accordance with the Health Resources and Services Administration’s (HRSA) Women’s Preventive Services: Required Health Plan Coverage Guidelines. Coverage is for a defined, finite list of generic hormonal and emergency contraceptives, Mirena (intra-uterine device), and diaphragms.

If the Member is unable to use the covered products that are available at no cost share, the Member’s

provider must submit a prior authorization addressing items such as why the covered products are insufficient as well as the covered products that were tried by the Member. A coverage determination will be made after receipt and review of this information. If the outcome results in an approval, the prior authorization will allow for the requested product to process at no cost share to the Member.

If the outcome results in a denial of “no cost share” coverage, or if a prior authorization is not

requested:

a.) the difference in cost between the brand-name drug and the Generic Equivalent Prescription Drug will be payable by the Member in addition to their Prescription Drug Copayment for those requests for brand versions of a Generic Equivalent Prescription Drug;

OR

b.) the tier 3 copayment will be assessed for coverage of a Non-Preferred Prescription Drug for requests

for such branded products that do not have generic equivalents.

No benefits will be provided by First Priority H e a l t h when the M e m b e r elects not to have the Participating Prescriber obtain Prior Authorization, disregards the Participating Pharmacy’s notification of the claim denial and elects to purchase the Prescription Drug. See SECTION SB – OUTPATIENT PRESCRIPTION DRUGS.

NN. OUTPATIENT PRESCRIPTION DRUGS

NOTE: Use of a Formulary, such as referenced in this Paragraph, may result in restriction of drug availability.

1. Benefits will be provided for Covered Medications appearing on the Formulary as specified in

SECTION SB - SCHEDULE OF BENEFITS of this Agreement, when prescribed by a Professional Provider in connection with a Covered Service, when purchased at a Participating Pharmacy Provider upon presentation of a valid Identification Card and when dispensed on or after the Member’s Effective Date for Outpatient use. Except for Preventive Covered Medications that are set forth within a predefined schedule* and prescribed for preventive purposes, benefits for Covered Medications are subject to a Copayment for each Prescription Order or refill as specified in SECTION SB - SCHEDULE OF BENEFITS of this Agreement. Covered Medications include:

a. Prescription Drugs appearing on the Formulary, including Specialty Prescription Drugs; b. Maintenance Prescription Drugs obtained from a Designated Mail-Order Pharmacy Provider or

from a retail Participating Pharmacy Provider for up to a 90-day supply;

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c. Selected Prescription Drugs within, but not limited to, the following drug classifications only when such drugs are Covered Medications and when dispensed through an Exclusive Pharmacy Provider:

i) Oncology related therapies; ii) Interferons; iii) Agents for multiple sclerosis and neurological related therapies; iv) Antiarthritic therapies; v) Anticoagulants; vi) Hematinic agents; vii) Immunomodulators; and viii) Growth hormones. These selected Prescription Drugs may be ordered by a Physician or other healthcare Provider on behalf of the Member or the Member may submit the Prescription Order directly to the Exclusive Pharmacy Provider. In either situation, the Exclusive Pharmacy Provider will deliver the Prescription Drug to the Member.

Members may contact the Plan at the toll-free telephone number or the website appearing on the back of the Member’s Identification Card to verify whether a particular Prescription Drug: a) appears on the Formulary; or b) is a Specialty Prescription Drug and whether it may be purchased from a Participating Pharmacy Provider or must be obtained through an Exclusive Pharmacy Provider.

2. Limitations:

a. No coverage is provided for Covered Medications purchased at a Pharmacy Provider that is not a Network Provider.

b. Each Covered Medication from a retail Participating Pharmacy Provider is limited to a 31, 60 or 90-day supply. Maintenance Prescription Drugs are available from a retail Participating Pharmacy Provider or Designated Mail-Order Participating Provider, and are limited to a ninety (90) -day supply. Certain Specialty Prescription Drugs, including those which must be obtained from an Exclusive Pharmacy Provider, are limited to a day supply up to 31 days.

NOTE: Certain retail Participating Pharmacy Providers may have agreed to make Maintenance

Prescription Drugs available pursuant to the same terms and conditions, including cost-sharing and quantity limits, as the mail service coverage set forth in this Agreement. Members may contact the Plan at the toll-free number or the website appearing on the back of the Member’s Identification Card for a listing of those retail Participating Pharmacy Providers who have agreed to do so.

c. No coverage is provided for any refill of a Covered Medication that is dispensed before the

date of the Member’s predicted use of at least ninety percent (90%) of the days’ supply of the previously dispensed Covered Medication, unless the Member’s Physician obtains Preauthorization from the Plan for an earlier refill.

d. Insulin syringes, needles, and/or disposable diabetic testing materials will be covered by the same

Copayment as the insulin, if dispensed in days supply corresponding to the amount of insulin

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dispensed. Insulin syringes, needles, and/or disposable diabetic testing material dispensed without insulin will require a Copayment when dispensed.

e. The quantity level limit of Covered Medications for which benefits are payable hereunder for each

initial Prescription Order may be reduced, dependent upon the particular medication, to a quantity level necessary to establish that the Member can tolerate the Covered Medication. Consequently, the amounts set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement will be prorated based upon the initial quantity dispensed. If the Member is able to tolerate the Covered Medication, the remainder of the available days supply for the initial Prescription Order will be filled and the Member will be charged the balance of the amount applicable to the initial Prescription Order.

f. The selected Prescription Drugs dispensed through an Exclusive Pharmacy Provider are subject to

the cost-sharing provisions for Retail Covered Medications set forth in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, and to the day supply quantity limitations for non-Maintenance Prescription Drugs as set forth in this Subparagraph 2. Limitations, item b.

g. Benefits are provided for certain specified drugs when dispensed to Members on a “stepped

basis,” referred to as the “Step Therapy” Program. Within selected drug categories, benefits are only provided for specified Prescription Drugs when one (1) or more alternative drugs prove ineffective or intolerable and the following criteria are met: (1) the Member has used alternative drug(s) within the same therapeutic class/category as the specified Prescription Drug; (2) the Member has used the alternative drugs for a length of time necessary to constitute an adequate trial; and (3) the specified Prescription Drug is being used for an FDA approved indication. If these criteria are met, the Participating Pharmacy Provider will dispense the specified Prescription Drug to the Member. The Member shall be responsible for any cost-sharing amounts and will be subject to any quantity limit requirements or other limitations set forth in this Agreement. When these criteria are not met, the treating Physician may submit a request for authorization to dispense a specified Prescription Drug to the Member for the Plan’s consideration.

Important: See SECTION EX - EXCLUSIONS of this Agreement for additional conditions and limitations which affect a Member’s Prescription Drug coverage.

OO. OUTPATIENT MEDICAL SERVICES

Medical care rendered by a Professional Provider to a Member who is an Outpatient for a condition not related to Surgery, pregnancy or Mental Illness, except as specifically provided, including allergy extracts, allergy injections, medical care visits, Telemedicine Services, therapeutic injections and consultations for the examination, diagnosis and treatment of an injury or illness, and Covered Services provided by Professional Providers at a Retail Clinic or Urgent Care Center. However, benefits for certain therapeutic injectables as identified by First Priority Health and which are appropriate for self-administration will be provided only when received from a Participating Pharmacy Provider as set forth in the Schedule of Benefits. Benefits for Outpatient Medical Care Services will be provided in the amounts specified in SECTION SB - SCHEDULE OF BENEFITS of this Agreement and are subject to additional limitations outlined in that Section. Note that when benefits are provided for Urgent Care Services, the applicable Network cost-sharing will apply and the Member may be responsible for any difference between the Plan payment and the Provider’s charge. See SECTION SB – HOSPITAL SERVICES.

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Except as may be specifically provided in Section DB – Description of Benefits, the following are not covered under this Agreement.

1. Services which are not Medically Necessary, except those that are provided within the Agreement for

preventive Services or those mandated by law. 2. Any service in connection with or required by a procedure not set forth in the foregoing Description of

Benefits Section, except as necessitated by subsequent complications. 3. Services in excess of any Benefit Maximum as stated in this Agreement and/or in the Schedule of Benefits. 4. Charges for Services or supplies incurred prior to the Member’s Effective Date. 5. Except as provided in Section GP – General Provisions, Subsection D, Benefits After Termination of

Coverage, charges for Services or supplies incurred after the date of termination of the Member’s coverage, except as provided in this Agreement.

6. With the exception charges for Emergency Services, charges which exceed the Plan Allowance. 7. Services or supplies, obtained by or on behalf of a Member without required Prior Authorization, except as

described in Section CC – Care Coordination. Services or supplies, which are not prescribed or performed by or under the direction of a Physician or Professional Provider when pre-approval is required.

8. All non-Emergency Services rendered in or performed by a Non-Participating Provider without Prior

Authorization from First Priority Health prior to Services being rendered. 9. Services which are not prescribed, performed or directed by a Provider licensed to do so. 10. Services which First Priority Health determines, in its sole discretion, are Experimental or Investigative and

the Covered Services related to them; the fact that a treatment, procedure, equipment, drug, device or supply is the only available treatment for a particular condition will not result in coverage if the service is considered to be Experimental or Investigative.

11. Payment for any Covered Services as secondary carrier, unless the required Prior Authorizations are

obtained. 12. Coverage for a Member who is on active military duty or for Services received as a result of war or any act

of war, whether declared or undeclared, or caused during service in the armed forces of any country, when the Member is legally entitled to other coverage and facilities are reasonable available to the Member.

13. Treatment or Services received as a result of a Member’s participation in a riot or insurrection. 14. Services as a result of injuries sustained during a Member’s commission of or attempt to commit a felony. 15. Cosmetic or Reconstructive Procedure/Surgery to improve the appearance or performed for psychological

or psychosocial reasons, unless required for correction of a condition directly resulting from accidental injury; for a newborn to correct a congenital birth defect; when reconstruction is pursuant to breast reconstruction following Mastectomy; or for the treatment of complications resulting from Surgery.

16. The following procedures are not covered: removal of skintags; treatment of alopecia; dermabrasion;

diastasis recti repair; ear or body piercing; electrolysis for hirsutism; excision or treatment of decorative or self-induced tattoos; salabrasion; chemosurgery and other such skin abrasion procedures associated with

SECTION EX - EXCLUSIONS

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the removal of scars; hairplasty; lipectomy; otoplasty; rhytidectomy; blepharoplasty; chemical peels; surgical treatment of acne; removal of port wine lesions, except when involving the face; augmentation mammoplasty, except to establish symmetry following a Mastectomy; removal, repair or replacement for an implant, except when reconstruction and implant are pursuant to breast reconstruction following Mastectomy; reduction mammoplasty, except to establish symmetry following Mastectomy; treatment of gynecomastia, except when mandated for breast disease; echosclerotherapy for treatment of varicose veins; non-invasive laser treatment of superficial small veins, and treatment of spider veins, or superficial telangiectasias.

17. For treatment of temporomandibular joint (jaw hinge) syndrome with intra-oral prosthetic devices, or any

other method to alter vertical dimensions and/or restore or maintain the occlusion and treatment of temporomandibular joint dysfunction not caused by documented organic joint disease or physical trauma.

18. With respect to the extraction of partially or totally bony impacted wisdom teeth:

Hospital or Ambulatory Surgical Facility Services are not covered, except as set forth in Section DB –

Description of Benefits, Subsection G, Surgery, Paragraph 3. General anesthesia charges are not covered, except as set forth in Section DB – Description of

Benefits, Subsection G, Surgery, Paragraph 3.

With respect to all other dental procedures and oral Surgery, the following are excluded:

Removal of natural teeth, except when it is a part of a broader treatment plan related to diseases and injuries of the jaw, head and neck, fractures and dislocations.

All dental Services including diagnostic, preventive and primary dental care related to the care or filling of natural teeth, regardless where or by whom performed, except if required as a result of accidental injuries to the jaws, sound natural teeth, mouth or face. Chewing or biting shall not be considered an accidental injury.

Dental appliances including, but not limited to dentures or bridges, except for the primary restoration following facial/dental trauma or when an integral part of a cleft palate repair.

Dental implants. Treatment of diseases of the teeth or gums, including, but not limited to treatment of dental cavities. Periodontics, endodontics. Orthognathic Surgery is excluded except for the treatment of obstructive

sleep apnea. Orthodontics, except orthodontic treatment related to cleft palate repair as described in Section DB –

Description of Benefits, Subsection G, Surgery, Paragraph 1. Dental care including repair, restoration or extraction of erupted teeth or teeth impacted under soft

tissue only. Surgical removal of teeth and procedures performed for the preparation of the mouth for dentures

unless such procedures were for the treatment of accidental bodily injury.

19. Routine and cosmetic foot care, except for care provided as a result of diabetes.

20. The repair and replacement of Orthoses, except if the Orthosis was provided as a result of diabetes or as certified Medically Necessary for children due to the growth process.

21. Services and associated expenses related to the non-surgical, medical treatment of obesity, including but

not limited to, dietary supplements or programs for weight reduction. 22. Assisted Reproductive Technology techniques such as, but not limited to, In Vitro Fertilization (IVF) of any

kind, including the office visits, drugs, diagnostic monitoring (ultrasound) and other Services and supplies related to these procedures, including, but not limited to: oral or injectable prescription medication treatment; embryo acquisition, storage and transport; human chorionotropin; urofollitropin; menatropins or derivatives; donor ovum and semen and related costs, including collection, preparation, preservation or storage.

23. Adult circumcision in the absence of disease.

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24. Reversal of voluntary sterilization. 25. Charges in connection with penile implants. 26. Abortions, except however, Services which are necessary to avert the death of the woman and Services to

terminate pregnancies caused by rape or incest. 27. The purchase of organs which are sold rather than donated to transplant recipients, transplants involving

mechanical organs or non-human organs and charges for organ donor searches are also excluded from coverage.

28. Charges for the procurement of blood or for blood storage or the cost of securing the Services of

professional blood donors; cord blood collection, preparation or storage. 29. Corneal surgery to change the shape of the cornea to correct vision problems, except for accidental injury

or medically necessary conditions resulting from corneal surgery. 30. Except as provided in Section DB – Description of Benefits, Subsection A, Primary Care Physicians and

Participating Specialist Physicians: routine eye examinations, refractions for eyeglasses or contact lenses; all Services associated with eyeglasses or contact lenses, including related diagnostic tests such as, but not limited to: visual fields testing, orthoptics, syntonics, optometric therapy, vision augmentation devices and vision enhancement systems. Routine eye examinations, with the exception of pediatric routine eye exams once per benefit period as set forth in Section DB – Description of Benefits, Subsection KK. Pediatric Vision Care; refractions for eyeglasses or contact lenses with the exception of pediatric refractions for eyeglasses or contact lenses as set forth in Section DB – Description of Benefits, Subsection KK. Pediatric Vision Care; all Services associated with eyeglasses or contact lenses, including related diagnostic tests such as, but not limited to: visual fields testing, orthoptics, syntonics, optometric therapy, vision augmentation devices and vision enhancement systems except as set forth in Section DB – Description of Benefits, Subsection G, Surgery, Paragraph 8.

31. Sports medicine treatment plans, corrective appliances, or artificial aids primarily intended to enhance

athletic functions, or work hardening programs. 32. Physical, psychiatric or psychological examinations, testing, reports, or treatments, when such Services

are: (a.) for purposes of obtaining, maintaining or otherwise relating to career, education, sports or camp, travel, employment, insurance, marriage or adoption; (b.) relating to judicial or administrative proceedings or orders; (c.) conducted for purposes of medical research; or (d.) to obtain or maintain a license of any type.

33. Services or supplies for personal hygiene, physical fitness or convenience items, whether or not prescribed

by a Physician, such as but not limited to, allergen filtration systems including allergy products. 34. Provision or replacement of the following items, including, but not limited to: (a) deluxe equipment of any sort or equipment which has been otherwise determined by the Plan to be

non-Standard Value; (b) items, which are primarily for personal comfort or convenience, including, but not limited to: bedboards, air conditioners, and over-bed tables; (c) disposable supplies, such as elastic bandages, support stockings, or prosthetic socks, except when administered by a home health agency as part of the home health benefit or as provided in Section DB – Description of Benefits, Subsection AA, Diabetes Education/Equipment/Supplies; (d) exercise equipment; (e) self-help devices including, but not limited to: elevators, lift-chairs, saunas, humidifiers, and air purifiers; (f) repair or replacement of Durable Medical Equipment, Prostheses and Orthoses;(g) any device or piece of equipment which is no longer Medically Necessary; (h) motor vehicles, or any modification to any vehicle for use of a disabled person; (i) intra-oral Prostheses; (j) hearing aids, eyeglasses or contact lenses, unless as specifically provided in Section DB – Description of Benefits, Subsection A, Primary Care Physicians and Participating Specialist Physicians; (k) corsets; (l) supportive back brace without metal stays; (m) knee brace made of elastic fabric support or sports braces; (n) comfort, non-therapeutic cast-brace; (o) pro-glide Orthosis; (p) garter belts, rib belts, or pressure leotards; (q) spinal pelvic stabilizers; (r) nose braces; (s) tongue retainers (equalizer,

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positioner); (t) slings and other non-sterile or over-the-counter supplies; (u) other special appliances, supplies, or equipment, including bio-mechanical devices; (v) modification or customization of any Durable Medical Equipment.

35. Examinations for the prescription, fitting or adjustment of hearing aids. 36. Charges for telephone calls or consultations which do not involve Telemedicine Services; failure to keep a

scheduled visit; completion of forms, transfer or copying of records or generation of correspondence. 37. Travel or transportation expenses, even though prescribed by a Physician, except ambulance service as

outlined in Section DB – Description of Benefits, Subsection CC., Ambulance Services or immunizations for the purpose of travel.

38. Charges for a private room when a Semi-Private Room is available. 39. Inpatient Services that could safely and adequately be performed in a home, Provider’s office or at any

other level of institutional care. 40. Long-Term Residential Care. 41. Custodial care, domiciliary care, convalescent care, or rest cures, Private Duty Nursing or specialized

nursing care. 42. Outpatient cognitive rehabilitation Services which have been determined by the Plan not to be Medically

Necessary and appropriate for the treatment of brain injury. 43. Pulmonary rehabilitative therapy on an Inpatient basis. 44. Therapy and devices to correct stuttering or pre-speech deficiencies or to improve speech skills that are

not fully developed. 45. Take-home drugs, both prescription and non-prescription, dispensed by a Facility Provider or Professional

Provider; injectable or implantable contraceptive drugs and devices that are not self-administered (except when used for an approved medical condition) and are not covered as part of the HRSA Women’s Preventive Services Guidelines under Section DB – Description of Benefits. Paragraph DD. Preventive Care; fertility drugs regardless of use; drugs in certain drug classes specifically designated by the Plan as Specialty Drugs including, but not limited to self-administered injectables, such as antihemophilic agents, hematopoietic agents, anticoagulants, growth hormones, enzyme replacement agents, immunomodulators, immunosuppressives, monoclonal antibodies, and other biotech drugs; except those drugs administered by a Participating Professional Provider that are not self-administered and/or that are provided incident to a Covered Service; those drugs and devices that are mandated to be covered by law.

46. Vitamin, mineral and electrolyte supplements, food, special diets, and feedings for adults, children and

infants except those drugs that are mandated to be covered by law and/or that provide at least thirty-five (35) percent of daily caloric requirements given enterally through an in-dwelling gastrointestinal tract tube necessitated by the inability to take nutrition by mouth, or in conditions of gastrointestinal tract impairment, parenterally through an intravenous catheter. Infant and children formulas including those prescribed for reasons of fat malabsorption, lactose intolerance, milk protein intolerance and/or milk allergies, except those that are mandated to be covered by law for the treatment of food protein allergies, food protein-induced enterocolitis syndrome, eosinophilic disorders and short-bowel syndrome. Enteral foods, except those that are mandated to be covered by law for the therapeutic treatment of phenylketonuria (PKU), branched-chain ketonuria, galactosemia and homocystinuria.

47. Services for the treatment of anti-social personality, conduct disorders and paraphilias. 48. Biofeedback/neurofeedback.

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49. Charges to the extent payment has been made under Medicare or when Medicare is the primary carrier, or under another governmental program, except Medicaid.

50. Charges to the extent payment has been made under a state or federal workers' compensation, employer's

liability or occupational disease law, or local government program. 51. Charges incurred as a result of illness or bodily injury covered by any Workmen’s Compensation Act or

Occupational Disease Law or by United States Longshoreman’s Harbor Worker’s Compensation Act and first party valid and collectible claims covered by a motor vehicle policy issued or renewed pursuant to the Pennsylvania Motor Vehicle Financial Responsibility Law or any applicable federal or state law. This exclusion applies regardless of whether the Member claims the benefit compensation.

52. Alternative and complementary medicine, except as provided in Section CC – Care Coordination,

Subsection F, Alternative Treatment Plan Services. 53. Services performed by a Provider with the same legal residence as a Member or who is a family member,

or Immediate Family member of the persons of the Member’s household, including but not limited to: spouse, brother, sister, parent or child.

54. Charges for Services, use of facilities, or supplies that any covered person has no legal obligation to pay

and for which no charge would have been made in the absence of insurance. 55. Unattended Services, with the exception of at-home sleep studies. 56. Separate charges by interns, residents and other health care professionals who do not have a Participating

Provider Agreement with First Priority Health, who are directly, or indirectly, employed by a Hospital or Facility Other Provider which is a Participating Facility Provider with First Priority Health and makes their Services available.

57. Educational classes, support groups and disease management programs unless sponsored or provided by

the Plan, except as required for diabetes education Services and those that are mandated to be covered as required by law.

58. Copayments, Deductibles, Coinsurance or penalties applied under this Agreement. 59. Screenings, other than those specifically listed on the preventive schedule or recommended by the U.S.

Preventive Services Task Force (USPSTF). 60. Charges in connection with surrogate parenting. 61. Loss sustained or expenses incurred while on active duty as a member of the armed forces of any nation;

or losses sustained or expenses incurred as a result of act of war whether declared or undeclared. 62. Treatment of pervasive developmental disorders such as autism or mental retardation, defects,

deficiencies and learning disabilities. This exclusion does not apply to medical treatment of such Member Persons in accordance with the benefits provided in Section DB – Description of Benefits.

63. For immunizations required for foreign travel or employment. 64. For bariatric surgery including reversal, revision, repeat and staged surgery, except for the treatment of

sickness or injury resulting from such bariatric surgery; 65. Charges for any Prescription Drug or supply, which is not Medically Necessary and appropriate based

on one (1) or more of the following reasons:

1) The indication and/or use of a cosmetic nature or to enhance physical appearance; to enhance athletic performance; or for weight loss.

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2) Based on the Pharmacist’s professional judgment, the Prescription should not be dispensed. 3) The Prescription Drug or supply is subject to Prior Authorization and has not been authorized as

an exception, (based on, and HMO by, medical justification from the Prescriber) for the following reason:

(a) The use of the Prescription Drug or supply is contraindicated due to: overutilization, drug-

drug interaction, drug-disease interaction, therapeutic duplication, adverse reaction, or drug allergy.

(b) The use of the Prescription Drug or supply is subject by First Priority H e a l t h to utilization

review criteria.

4) Charges for any Prescription Drug or supply, unless authorized in accordance with Section GP – General Provisions, Subsection G. of this Policy, which are:

Experimental or Investigative. Not approved for use by the Food and Drug Administration. Not approved for the specific indication by the Food and Drug Administration.

Unless specifically included in Section DB – Description of Benefits, the following are excluded as Covered Pharmacy Expenses:

(1)drugs which do not require a Prescription; (2) drugs which cannot be self-administered; (3) medical supplies; devices and equipment, (4) test agents and devices, except those used for diabetes; (5) smoking-cessation aids, except for those Prescription Drugs and smoking-cessation aids specifically designated as covered by First Priority Health in the Drug Formulary or the Preventive Schedule provided with this Policy; (6) multiple vitamins, except those used for pregnancy and multiple vitamins with fluoride for the prevention of dental caries in children under the age of sixteen (16); (7) the additional charge for a brand-name drug for which there is a Generic Equivalent Drug available; (8) drugs for impotence in excess of four (4) doses per month; (9) allergy extracts for allergen immunotherapy; (10) administration or injection of any drugs; (11) replacement of lost, stolen or damaged drugs; (12) take home drugs dispensed by a Facility Provider or Professional Provider.

66. For the following Services or charges related to pediatric dental Services, except as specifically provided in this

Contract:

a. For treatment started prior to the Member’s Effective Date or after the termination date of coverage under this Contract, (including, but not limited to, multi-visit procedures such as endodontics, crowns, fixed partial dentures, inlays, onlays, and dentures);

b. For house or Hospital calls for dental Services and for hospitalization costs (including, but not limited to,

facility-use fees); c. For Prescription and non-Prescription Drugs, vitamins or dietary supplements; d. Cosmetic in nature as determined by the Plan (including, but not limited to, bleaching, veneer facings,

personalization or characterization of crowns, bridges and/or dentures); e. Elective procedures (including, but not limited to, the prophylactic extraction of third molars); f. For congenital mouth malformations or skeletal imbalances (including, but not limited to, treatment related to

cleft lip or cleft palate, disharmony of facial bone, or required as the result of orthognathic surgery including

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orthodontic treatment). This exclusion does not apply to the treatment of medically diagnosed congenital defects or birth abnormalities of a newborn child or newly adopted children, regardless of age;

g. Diagnostic Services and treatment of jaw joint problems by any method unless specifically covered under this

Contract. Examples of these jaw joint problems are temporomandibular joint disorders (TMD) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to the joint;

h. For treatment of fractures and dislocations of the jaw; i. For treatment of malignancies or neoplasms; j. Services and/or appliances that alter the vertical dimension (including, but not limited to, full-mouth

rehabilitation, splinting, fillings) to restore tooth structure lost from attrition, erosion or abrasion, appliances or any other method;

k. Replacement or repair of lost, stolen or damaged prosthetic or orthodontic appliances; l. Periodontal splinting of teeth by any method; m. For duplicate dentures, prosthetic devices or any other duplicative device; n. Maxillofacial prosthetics; o. For plaque control programs, tobacco counseling, oral hygiene and dietary instructions; p. For treatment and appliances for bruxism (night grinding of teeth); q. For any claims submitted to the Plan by the Member or on behalf of the Member in excess of twelve (12)

months after the date of service; r. Incomplete treatment (including, but not limited to, patient does not return to complete treatment) and

temporary Services (including, but not limited to, temporary restorations); s. Procedures that are:

i) part of a service but are reported as separate Services;

ii) reported in a treatment sequence that is not appropriate; or iii) misreported or which represent a procedure other than the one reported;

t. Specialized procedures and techniques (including, but not limited to, precision attachments, copings and

intentional root canal treatment); u. Service not Dentally Necessary or not deemed to be generally accepted standards of dental treatment. If no

clear or generally accepted standards exist, or there are varying positions within the professional community, the opinion of the Plan will apply;

v. Fees for broken appointments;

w. For other pediatric dental Services not set forth in SECTION DB - DESCRIPTION OF BENEFITS; x. For the following orthodontic Services:

i) Treatments that are primarily for cosmetic reasons;

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ii) Treatments for congenital mouth malformations or skeletal imbalances (including, but not limited to, treatment related to cleft lip or cleft palate, disharmony of facial bone, or required as the result of orthognathic surgery including orthodontic treatment); and

iii) Diagnostic Services and treatment of jaw joint problems by any method unless specifically covered

under the Schedule of Benefits. Examples of these jaw joint problems are temporomandibular joint disorders (TMD) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to the joint;

A. AGREEMENT

1. Entire Agreement

The entire agreement between First Priority Health and the Agreement Holder consists of the Application, this Agreement and any endorsements, riders and schedules, individual Applications of the Members, current Identification Cards of the Members, the Schedule of Benefits, and the applicable premium rate. All statements made by the Group or by any Member shall, in the absence of fraud, be deemed representations and not warranties. No statement made for the purpose of obtaining coverage will result in the termination of coverage or reduction of benefits unless the statement is contained in writing and signed by the Member, and a copy of the same has been furnished to the Member. No change in this Agreement shall be valid until approved by an executive officer of First Priority Health and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this Agreement or to waive any of its provisions.

2. Identification Card

The identification card issued by First Priority Health to a Member pursuant to this Agreement is for identification purposes only. Possession of an identification card confers no right to Services or benefits under this Agreement and misuse of such identification card may be grounds for termination of a Member's coverage pursuant to Section GP – General Provisions, Subsection E, Termination of a Member’s Coverage Under the Agreement, of this Agreement. If the person who misuses the card is the Member, coverage may be terminated for the Member as well as any Dependents. To be eligible for Services or benefits under this Agreement, the holder of the card must be a Member on whose behalf all applicable premium charges under this Agreement have been paid. Any person receiving Services or benefits which he or she is not entitled to receive pursuant to the provisions of this Agreement shall be charged for such Services or benefits at prevailing rates. If any Member permits the use of his or her identification card by any other person, such card may be retained by First Priority Health and all rights of such Member and his or her Dependents, if any, pursuant to this Agreement shall be terminated immediately, subject to the Complaint and Grievance Procedures set forth in Section GP – General Provisions, Subsection L of this Agreement. If a Member terminates coverage with First Priority Health, it is the Agreement Holder's responsibility to obtain the identification cards of the Member and affiliated Members and to return the cards to First Priority Health.

3. Hospital and Facility Other Provider Rules

The Member is subject to all the rules and regulations of each Hospital and Facility Other Provider in which benefits are provided.

SECTION GP – GENERAL PROVISIONS

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4. Reports and Records

First Priority Health will use information reasonably necessary to administer this Agreement subject to all applicable confidentiality requirements as defined in Section GP – General Provisions, Subsection A of this Agreement.

5. Time Limit for Filing Claims

The timely filing of claims is the responsibility of Participating Providers, participating Providers of a Host Blue, and any other Provider who has been authorized by First Priority Health to provide Covered Services to a Member and the Member will have no payment responsibility for any such claim, which is not filed on a timely basis. No payment will be made for any claims filed by a Member unless the Member gives written notice of such claim to First Priority Health within one (1) year of the date of service.

6. Refusal of Treatment

The Member may, for personal reasons, refuse to accept procedures, medicines, or courses of treatment recommended by a participating Physician. If such participating Physician (after a second participating Physician's opinion, if requested by the Member) believes that no professionally acceptable alternative exists, and if after being so advised, the Member still refuses to follow the recommended treatment procedure, the Member will receive no further treatment for the condition involved. In such case neither the Providers nor First Priority Health will have further responsibility to provide any of the benefits available under this Agreement for treatment of such condition. First Priority Health will provide written notice to Member of a decision not to render further treatment for a particular condition. The decision is subject to the Complaint and Grievance Procedures set forth in Section GP – General Provisions, Subsection L of this Agreement. Treatment for the condition involved will be resumed in the event the Member agrees to follow the recommended treatment or procedure.

7. Assignment of Benefits

All rights of Members to receive benefits hereunder are personal to Member and may not be assigned.

8. Legal Action

No action at law or in equity may be maintained against First Priority Health for any expense or bill

unless brought within the statute of limitations for such cause of action. No legal action may be taken to recover benefits within sixty (60) days after Notice of Claim has been given as specified above, and no such action shall be maintained against First Priority Health for any benefits hereunder unless brought within three (3) years after the time written proof of loss is required to be furnished.

9. Physician-Patient Relationship

Participating Physicians maintain the Physician-patient relationship with Members and are solely responsible to the Member for all Medical Services which are rendered by Providers.

10. Inability to Provide Service

In an event due to circumstances not within the control of First Priority Health, including, but not limited to

major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of First Priority Health’s Participating Providers or entities with whom First Priority Health has arranged for Services under this Agreement, or similar causes, the rendition of medical or hospital benefits or other Services provided under this Agreement is delayed or rendered impractical, First Priority Health shall not have any liability or obligation on account of such delay or failure to provide Services, except to refund the amount of the unearned prepaid premiums held by First Priority Health on the date such event occurs. First Priority Health is required only to make a good-faith effort to provide or arrange for the provision of service, taking into account the impact of the event. For purposes of this provision, an event is not within control of First Priority Health if First Priority Health cannot exercise influence or dominion over its occurrence.

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11. Confidentiality

Information contained in the medical records of Members and information received from Physicians,

surgeons, Hospitals or other health professionals incident to the doctor-patient relationship or hospital-patient relationship shall be kept confidential. First Priority Health will use and disclose information according to the HIPAA guidelines. Additionally, this information may be released for use incident to bona fide medical research and education with the administration of this Agreement according to HIPAA guidelines, or in the compiling of aggregate statistical data for First Priority Health or the Agreement Holder for purposes allowed by HIPAA. Any additional release of information and the release of information related to behavioral health service and AIDS require the authorization of the Member.

12. Clerical Records

a. First Priority Health shall keep records of all Members. b. The Agreement Holder shall forward the information required by First Priority Health in Section GP –

General Provisions, Subsection C, Agreement Holder Responsibilities of this Agreement in connection with the administration of this Agreement.

c. All records of the Agreement Holder which are incident to the coverage provided under this Agreement

shall be available for inspection by First Priority Health at any reasonable time and must be maintained for six (6) years.

d. First Priority Health shall not be liable for the fulfillment of any obligation dependent upon such

information prior to its receipt in a form satisfactory to First Priority Health. e. Incorrect information furnished to First Priority Health may be corrected, provided that First Priority Health

has not acted to its prejudice in reliance thereon. Coverage under this Agreement shall not be invalidated by failure of the Agreement Holder due to clerical error, provided all premiums are properly adjusted. The Agreement Holder will only be permitted to retroactively terminate a Member if notice is received by First Priority Health within thirty (30) days of the proposed date of termination and if the Member has not utilized any Services after the proposed date of termination, except as otherwise agreed to by First Priority Health.

13. Limitation of Services

Except in cases of emergency as provided under Section DB – Description of Benefits, Subsection D of this

Agreement, Services are available only from Participating Providers, and First Priority Health shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a Member from any Provider or other person, entity, institution or organization unless prior arrangements are made by First Priority Health. In some parts of the First Priority Health Network, First Priority Health has designated specified Participating Provider sites for Members to obtain certain Services such as Outpatient radiology, including mammographic screenings. First Priority Health will advise affected Members of the designated site at which those Members will be required to receive such Services.

14. Claim Forms/Submission

A Participating Provider will submit the claim to First Priority Health on behalf of a Member, and First Priority Health, upon receipt of a notice of claim, will pay the Participating Provider directly for Covered Services. If Covered Services are performed by Non-Participating Providers, it is the Member’s responsibility to have a claim submitted within one (1) year. Providers generally submit claim forms on the Member’s behalf. If the Provider will not submit the claim, it is the Member’s responsibility to do so by submitting an itemized bill. By submitting an itemized bill, the Member shall be deemed to have complied with the requirements of this Agreement as to proof of loss upon submitting, within the time fixed in the Agreement for filing proofs of loss, the written proof covering the occurrence, nature and the extent of the loss for which the claim is made.

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Once Covered Services are rendered by a Provider, First Priority Health will not honor Member requests not to pay the claims submitted by the Provider. First Priority Health will have no liability to any person because of its rejection of the request. A Participating Provider will submit the claim to First Priority Health on behalf of a Member, and First Priority Health, upon receipt of a notice of claim, will pay the Participating Provider directly for Covered Services. If Covered Services are performed by Non-Participating Providers, it is the Member’s responsibility to have a claim submitted within one (1) year. Providers generally submit claim forms on the Member’s behalf. If the Provider will not submit the claim, it is the Member’s responsibility to do so by submitting an itemized bill. By submitting an itemized bill, the Member shall be deemed to have complied with the requirements of this Agreement as to proof of loss upon submitting, within the time fixed in the Agreement for filing proofs of loss, the written proof covering the occurrence, nature and the extent of the loss for which the claim is made.

15. Payment of Claims

a. First Priority Health will make payments directly to Participating Providers furnishing Covered Services

under this Policy. However, First Priority Health reserves the right to make payments directly to the Member.

b. The right of a Member to receive payment is not assignable, except to the extent required by law, nor

may benefits of this Agreement be transferred either before or after Covered Services are rendered. c. Once Covered Services are rendered by a Provider, First Priority Health will not honor Member requests

not to pay the claims submitted by the Provider. First Priority Health will have no liability to any person because of its rejection of the request.

d. For Covered Services rendered by a Participating Provider and paid at less than 100% of the

Participating Provider allowance, the member is responsible for payment of the difference between 100% of the Preferred Provider allowance and First Priority Health’s payment.

16. Time Limit on Certain Defenses

After three (3) years from the date of issue of this Agreement, no misstatements, except fraudulent misstatements, made by the applicant in the Application for such Agreement shall be used to void the Agreement or to deny a claim for loss incurred or disability commencing after the expiration of such three-year period.

17. Cancellation for Non-Payment of Premium

In the event that this Ag reem en t lapses due solely to nonpayment of premium, an Application is required for re- enrollment during an Open Enrollment Period or Special Enrollment Period.

18. Reinstatement

If this Agreement is terminated due solely to nonpayment of the premium, coverage will be reinstated if the Subscriber, within thirty-six (36) days from the end of the grace period, tenders and the Plan receives payment of the premium required for reinstatement. The Member(s) and the Plan have the same rights under the reinstated Agreement as they had under the Agreement immediately before the due date of the defaulted premium. The right of the Subscriber to have this Agreement reinstated is limited to one (1) reinstatement during any twelve (12)-month period and to two (2) reinstatements during the Subscriber’s lifetime.

When coverage under this Agreement is provided pursuant to enrollment through the Exchange, the right to reinstate coverage shall not apply.

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19. Notice of Claims

First Priority Health will not be liable under this Agreement unless proper written notice is furnished to First Priority Health within twenty (20) days after the occurrence or commencement of any loss covered by the Policy, or as soon thereafter as is reasonably possible. Participating Providers will be responsible for providing written notice to First Priority Health after completion of the Covered Services pursuant to its Provider Agreements with First Priority Health. Should such a Provider fail to provide notice, the Member will not be liable for payment to the Provider for the Covered Services. Notice given by or behalf of the Member or the beneficiary of the Member at:

First Priority Health 19 North Main Street Wilkes-Barre, PA 18711

or to any authorized agent of the Member, with information sufficient to identify the Member, shall be deemed notice to First Priority Health.

An expense will be considered incurred on the date the service or supply was rendered.

20. Proof of Loss

Written proof of loss must be furnished to First Priority Health at its said office in case of claim for loss within ninety (90) days after the date of such loss. Failure to furnish such proof within the time period required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity later than one (1) year from the time proof is otherwise required.

21. Time of Payment of Claims

Claim payment for benefits payable under this Agreement will be processed immediately upon receipt of due written proof of such loss.

22. Physical Examination and Autopsy

First Priority Health at its own expense shall have the right and opportunity to examine the person of the Member when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

23. Applicable Law

This Agreement is entered into and is subject to the laws of the Commonwealth of Pennsylvania. The invalidity or unenforceability of any terms or conditions hereof shall in no way affect the validity or enforceability of any other terms or provisions. The waiver by either party of a breach or violation of any provision of this Agreement shall not operate as or be construed to be a waiver of any subsequent breach or violation thereof.

B. COORDINATION OF BENEFITS WITH OTHER HEALTH PLANS None of these coordination of benefits rules will serve as a barrier to the Member first receiving direct health

Services from First Priority Health which are covered under this Agreement. All benefits provided under this Agreement are subject to this provision and will not be increased by virtue of this provision.

1. Definitions - In addition to the Definitions of this Agreement, the following definitions only apply to this

provision:

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a. “Plan” means any individual coverage or group arrangement providing health care benefits or Covered

Services through:

1) individual, group, blanket (except student accident) or franchise insurance coverage; 2) Blue Cross, Blue Shield, First Priority Health, health maintenance organization, group practice, and

other prepayment coverage; 3) coverage under labor management trusteed plans, union welfare plans, employer organization plans,

or employee benefit organization plans; and 4) coverage under any tax-supported or government program to the extent permitted by law, except a

state plan under Medicaid, or a governmental Plan which, by law, provides benefits that are in excess of those of any private insurance plan or other non-governmental

plan; and 5) coverage under a hospital indemnity plan of more than $100 per day.

a. “Dependent” means, for any Plan, any person who qualifies as a Dependent under that Plan.

b. “Allowable Benefits” means the charge for Covered Services.

c. “Benefits Paid or Payable” means the amounts actually paid for Covered Services.

2. Effect on Benefits

a. This provision shall apply in determining the benefits of this Agreement if, for Covered Services received,

the sum of the Benefits Payable under this Agreement and the Benefits Payable under other Plans would exceed the Allowable Benefits.

b. Except as provided in item c. of this Section, the Benefits Payable under this Agreement for Covered

Services will be reduced so that the sum of the reduced benefits and the Benefits Payable for Covered Services under other Plans does not exceed the total of Allowable Benefits.

c. If,

1) the other Plan contains a provision coordinating its benefits with those of this Agreement, and its rules require the benefits of this Agreement to be determined first, and

2) the rules set forth in item e. of this Section require the benefits of this Agreement to be determined

first, and then the benefits of the other Plan will be ignored in determining the benefits under this Agreement.

d. If the other Plan does not include a Coordination of Benefits provision, such Plan will be primary. e. If the other Plan does include a Coordination of benefits provision:

1) The Plan covering the patient other than as a Dependent will be the primary Plan. 2) Where both Plans cover the patient as a Dependent child, the Plan covering the patient as a

Dependent child of a parent whose date of birth, excluding year of birth, occurs earlier in a Calendar Year shall be the primary Plan. But, if both parents have the same birthday, the Plan which covered the parent longer will be the primary Plan. If the parents are separated or divorced, the following will apply:

a.) The Plan which covers the child as a Dependent of the parent with custody will be the primary

Plan.

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b.) If the parent with custody has remarried, the Plan which covers the child as a Dependent of the stepparent with custody will determine its benefits before the Plan covering the child as a Dependent of the parent without custody.

c.) Where there is a court decree which establishes financial responsibility for the health care

expenses of the Dependent child, the Plan which covers the child as a Dependent of the parent with such financial responsibility will be the primary Plan as long as the Plan of that parent has actual knowledge of the court decree.

d.) If the specific terms of the court decree state that the parents shall share joint custody, without

stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined in the first paragraph of 2.e.2).

In the event this Agreement is coordinating with a Plan that uses the male/female rule regarding dependent children, the first paragraph of Section B. Coordination of Benefits with Other Health Plans, Effect on Benefits, 2.e.2) defaults to the following: "Where both Plans cover the patient as a dependent child, the Plan covering the patient as a dependent child of a male will be the primary Plan, except that if the parents are separated or divorced, the following will apply:"

3) Where the determination cannot be made in accordance with e.1) or 2) above, the Plan which has

covered the patient for the longer period of time will be the primary plan; provided that, a.) the benefits of a plan covering the person as an Employee or Member other than a laid-off or

retired Employee or Member or as the Dependent of such person shall be determined before the benefits of a plan covering the person as a laid-off or retired Employee or Member or as a Dependent of such person; and

b.) if the other plan does not have a provision and if, as a result, the plans do not agree on the

order of benefits, this provision 3.a) shall be ignored.

3. Facility of Payment - Whenever payments should have been made under this Agreement in accordance with this provision, but the payments have been made under any other Plan, First Priority Health has the right to pay to any organization that has made such payment any amount it determines to be warranted to satisfy the intent of this provision. Amounts so paid shall be deemed to be Benefits Paid under this Agreement and to the extent of the payments for Covered Services, First Priority Health shall be fully discharged from liability under this Agreement.

4. Right of Recovery

a. Whenever payments have been made by First Priority Health for Covered Services in excess of the

maximum amount of payment necessary at that time to satisfy the intent of these provisions, irrespective of to whom paid, First Priority Health shall have the right to recover the excess from among the following, as First Priority Health shall determine: any person to or for whom such payments were made, any insurance company or any other organization.

b. The Member, personally and on behalf of family members shall, upon request, execute and deliver

such documents as may be required and do whatever else is reasonably necessary to secure First Priority Health’s rights to recover the excess payments.

5. First Priority Health shall not be required to determine the existence of any Plan or amount of Benefits

Payable under any Plan except this Agreement, and the payment of benefits under this Agreement shall be affected by the Benefits Payable under any and all other Plans only to the extent that First Priority Health is furnished with information relative to such other Plans by the Employer or Employee or any other insurance company or organization or person.

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When the benefits are reduced under the Primary Plan because a Member does not comply with the Plan provisions, the amount of such reduction will not be considered an Allowable Benefit. Examples of such provisions are those related to second surgical opinions and Prior Authorization of admissions and Services.

C. TERMINATION OF A MEMBER’S COVERAGE UNDER THE AGREEMENT

1. This Agreement may be terminated by the Subscriber by giving appropriate written notice to the Plan. Notice shall be given no less than fourteen (14) days prior to the requested termination date.

2. This Agreement is guaranteed renewable and cannot be terminated without consent of the Subscriber except

in the following instances:

a. If payment of the appropriate premium is not made when due, or during the grace period, coverage will terminate on the last day of the grace period unless an earlier date is required by law.

When coverage under this Agreement is provided pursuant to enrollment through the Exchange and the Subscriber receives APTCs, failure of the Plan to receive payment of APTCs shall not be grounds for terminating this Agreement when the Subscriber has made payment of his or her portion of the premium when due.

b. If a Subscriber in obtaining coverage, or in connection with coverage hereunder, has performed an act

or practice constituting fraud or intentional misrepresentation of a material fact (e.g., misuse of the Member Identification Card), coverage will terminate immediately. However, the Plan will not terminate this Agreement because of a Subscriber’s Medically Necessary and Appropriate utilization of Services covered under this Agreement.

c. Coverage will terminate upon ninety (90) days notice to the Subscriber when the Plan discontinues this

coverage, and offers to each individual the option to purchase any other individual health insurance coverage then available from the Plan in the geographic area where the Subscriber resides, or upon one hundred eighty (180) days notice to the Member when the Plan discontinues all individual coverage within the Service Area.

d. In the event the Subscriber no longer lives in the Network Service Area, coverage will terminate on the

last day of the month for which the premium has been accepted.

e. The end of the month in which either of the following events occurs:

i) a child ceases to meet any of the requirements for Dependent coverage set forth in SECTION SE - SCHEDULE OF ELIGIBILITY of this Agreement; or

ii) a spouse becomes divorced from the Subscriber; or iii) the Domestic Partnership terminates.

However, if the Plan accepts payment of the premium for coverage extending beyond the date determined in this Subparagraph e, then coverage as to such person shall continue during the period for which an identifiable premium was accepted, except where such acceptance was predicated on a misstatement of age.

3. When coverage provided under this Agreement is provided pursuant to enrollment through the Exchange,

coverage will terminate in the following additional circumstances:

a. The Subscriber is no longer eligible for coverage through the Exchange in which case coverage will terminate effective:

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i) the last day of the month following the month in which notice of ineligibility is sent by the Exchange, unless an earlier termination date is requested by the Member; or

ii) in the case where the Subscriber is determined to be newly eligible for Medicaid, CHIP or basic

health plan coverage, the last day of coverage under this Agreement shall be the day before such new coverage begins.

b. The Qualified Health Plan through which coverage under this Agreement is provided terminates or is

decertified.

c. The Subscriber elects to enroll in a different Qualified Health Plan during an applicable Annual Open Enrollment Period, Limited Open Enrollment Period or Special Enrollment Period in which case coverage under this Agreement will terminate the day before coverage under the new Qualified Health Plan begins.

If this Agreement is terminated at the option of either party, the Plan shall refund to the Subscriber the amount of any unearned prepaid premium held by the Plan. Unearned prepaid premium in any amount less than one ($1.00) dollar shall not be refunded unless specifically requested by the Subscriber.

D. BENEFITS AFTER TERMINATION OF COVERAGE

If the Member is an Inpatient on the date coverage terminates, the benefits of this Agreement for Inpatient Covered Services shall be provided:

1. until the Inpatient stay ends; or 2. until the maximum amount of benefits has been paid; or 3. until the Member becomes covered without limitation as to the condition for which he is receiving Inpatient

care under any other group coverage; or 4. up to the end of the Benefit Period.

whichever occurs first.

If the Member is continuously disabled on the date this Agreement is terminated, for reasons other than fraud, intentional misrepresentation of a material fact, and the Member incurs charges for the disabling cause while the Member remains so disabled, the Member shall be entitled to benefits under the terms of this Agreement.

Benefits will be provided, for charges incurred for the disabling cause, until the earlier of: (1) the end of the Benefit Period; or (2) the exhaustion of benefits. Any such continuation of benefits after the date this Agreement is terminated is conditioned upon the continuous disability of the Member.

E. REINSTATEMENT In the event that this Agreement lapses due solely to nonpayment of premium, an Application is required for

reinstatement. If premium is received from the Agreement Holder with an Application, the Plan shall issue a conditional receipt for premium paid and the Agreement shall be reinstated only upon approval of such Application, or lacking such approval, on the forty-fifth (45) day following the date of such conditional receipt, unless the Plan has previously notified the Agreement Holder in writing of its disapproval of such Application. The Agreement Holder and the Plan shall have the same rights as they had under the Agreement before the due date of the defaulted premium.

F. MILITARY SERVICE The Agreement provides for suspension of coverage upon entry of the Member into full-time active duty in the

military service. Upon written request from the Member, First Priority Health will refund unearned premiums for

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the period of the suspension. The Agreement will be reinstated without evidence of insurability upon written request from the Member received within sixty (60) days of termination of military service.

G. EXPERIMENTAL OR INVESTIGATIVE SERVICES A Medical Director of First Priority Health shall determine whether the use of any treatment, procedure, Provider,

equipment, drug, device, or supply (each of which is hereinafter called a “Services”) is Experimental or Investigative (that is not supported by evidence-based medicine).

1. If, in making that determination, a Medical Director of First Priority Health finds that the Services, for which a

claim for benefits is made, is either: (1) the subject of a written investigational or research protocol used by the treating facility or of a written investigational or research protocol of another facility studying substantially the same Service; or (2) the subject of a written informed consent used by the treating facility which refers to the Service as experimental, investigative, educational, or research.

2. If, in making that determination, a Medical Director of First Priority Health finds that neither a protocol nor an

informed consent, as described above, exist, then a Medical Director of First Priority Health may require that demonstrated evidence exists, as reflected in the published Peer Reviewed Medical Literature that:

a. the technology must have final approval from the appropriate governmental regulatory bodies; b. the scientific evidence must permit conclusions concerning the effect of the technology on health

outcomes; c. the technology must improve the net health outcome; d. the technology must be as beneficial as any established alternatives; and e. the improvement must be attainable outside the investigational settings.

PEER REVIEWED MEDICAL LITERATURE means two (2) or more U.S. scientific publications which require that manuscripts be submitted to acknowledged experts inside or outside the editorial office in their considered opinions or recommendations regarding publication of the manuscript. Additionally, in order to qualify as Peer Reviewed Medical Literature, the manuscript must actually have been reviewed by acknowledged experts before publication.

3. If, in making the determination, First Priority Health finds that a drug, a device, a supply, or equipment has

not received marketing approval (permission for commercial distribution) by the United States Food and Drug Administration: (1) at the time the service is received; and (2) for the purpose for which it is rendered; and (3) for the manner in which it is rendered, the drug, device, supply or equipment shall be deemed to be Experimental or Investigative.

H. SUBROGATION

1. To the extent that benefits for Covered Services are provided or paid under this Agreement, First Priority Health shall be subrogated and succeed to any rights of recovery of a Member for expenses incurred against any person or organization except insurers on policies of health insurance issued to and in the name of the Member. Acceptance of benefits under this Agreement will constitute consent and notice of the provisions of this section.

2. The Member shall pay First Priority Health all amounts recovered by suit, settlement, or otherwise from any

third party or his insurer to the extent of the benefits provided or paid under this Agreement, and to the extent permitted by law. The reimbursement is required even if the Member is not fully compensated or made whole for the injuries sustained.

3. The Member shall take such action, furnish such information and assistance, and execute such papers as

First Priority Health may reasonably require to facilitate enforcement of its rights, and shall take no action

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prejudicing the rights and interests of First Priority Health under this Agreement. The Member shall promptly notify First Priority Health as to how, when and where an accident or incident resulting in personal injuries to the Member occurred and all necessary information regarding persons involved and applicable insurance coverages. If any legal action or proceeding is commenced against any person or organization for personal or bodily injuries sustained by the Member, the Member shall promptly notify First Priority Health.

4. These provisions shall not apply where subrogation is specifically prohibited by law.

I. RELATIONSHIP TO BLUE CROSS AND BLUE SHIELD PLANS This Agreement is between the Agreement Holder, on behalf of itself and the Members and First Priority Health

only. First Priority Health is an independent corporation operating under a license from the Blue Cross Blue Shield Association (“the Association”), which is an association of independent Blue Cross and Blue Shield Plans. Although all of these independent Blue Cross and Blue Shield Plans operate from a license with the Association, each of them is a separate and distinct corporation. The Association allows First Priority Health to use the familiar Blue words and symbol. First Priority Health, which is entering into this Agreement, is not contracting as an agent of the Association. Only First Priority Health shall be liable to the Agreement Holder, on behalf of itself and the Members, for any of First Priority Health’s obligations under this Agreement. This paragraph does not add any obligations to this Agreement.

J. COMPLAINT AND GRIEVANCE/APPEAL PROCEDURES

First Priority Health’s complaint and grievance procedures assure that you receive fair and confidential treatment. The procedures to file a complaint or grievance are listed below. It explains how you can file, your right to appeal a decision, and to designate a representative to assist you. All disputes involving denial of payment for a health care service on the basis of Medical Necessity and appropriateness will be reviewed by qualified personnel with experience in the same or similar scope of practice and all notices of decisions will include information regarding the basis for the determination. You have 180 days to file a complaint or grievance from the date of the occurrence of the issue being complained about, or the date of your receipt of notice of First Priority Health’s decision. You may also designate a representative to act on your behalf. First Priority Health must receive this designation in writing. A form will be provided at your request by contacting our Service Representatives at 1-800-822-8753 weekdays during normal business hours. The initial complaint will be promptly investigated by an Initial Review Committee comprised of one or more First Priority Health employees who may not have been involved in the prior decision to deny your complaint and is not the subordinate of such individual. You will be provided, free of charge, with any new or additional evidence or rationale considered, relied upon, or generated by First Priority Health related to your complaint. Before a decision is rendered, you will be provided with the opportunity to respond to the evidence or rationale provided to you. If the complaint involves Services that have not yet been rendered (pre-service), the committee will provide you with a response within fifteen (15) days of receipt of the complaint. If the complaint involves Services that have already been rendered (post-service), the committee will provide you with a response within thirty (30) days of receipt of the complaint. The notice will include the basis for the decision and the procedure to file a request for a second internal level review of the decision. When required, First Priority Health will provide written notification in a culturally and linguistically appropriate manner. First Priority Health has established the following complaint and grievance procedures for your use if you are in any way dissatisfied with First Priority Health, a practitioner or Provider. Complaint - If you have a dispute or objection regarding a Participating Provider; coverage issues including agreement exclusions, limitations and non-covered benefits; or the operations and management policies of First Priority Health, you should contact a Member Service Representative. You or your designated representative may file a written or verbal complaint to First Priority Health as well as written data, testimony, or other information in support of the complaint. You may also request copies of all documents, records and other information in support of the complaint. A complaint does not include a grievance.

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Upon receipt of the complaint, First Priority Health will provide written confirmation to you, that the request has been received, and that First Priority Health has classified it as a complaint for purposes of internal review. If you disagree with this classification, you can contact the Department of Health directly for consideration and intervention.

The initial complaint will be promptly investigated by an Initial Review Committee comprised of one or more First Priority Health employees who may not have been involved in the prior decision to deny your complaint and is not the subordinate of such individual. You will be provided, free of charge, with any new or additional evidence or rationale considered, relied upon, or generated by First Priority Health related to your complaint. Before a decision is rendered, you will be provided with the opportunity to respond to the evidence or rationale provided to you. If the complaint involves Services that have not yet been rendered (pre-service), the committee will provide you with a response within fifteen (15) days of receipt of the complaint. If the complaint involves Services that have already been rendered (post-service), the committee will provide you with a response within thirty (30) days of receipt of the complaint. The notice will include the basis for the decision and the procedure to file a request for a second internal level review of the decision. When required, First Priority Health will provide written notification in a culturally and linguistically appropriate manner.

Each appeal will be promptly investigated and the Plan will provide written notification of its decision within the following time frames:

i.) When the appeal involves a non-urgent care Pre-service Claim, within a reasonable period of time

appropriate to the medical circumstances involved not to exceed thirty (30) days following receipt of the appeal;

ii.) When the appeal involves an Urgent Care Claim, as soon as possible taking into account the

medical exigencies involved but not later than seventy-two (72) hours following receipt of the appeal; or

iii.) When the appeal involves a Post-service Claim or a decision by the Plan to rescind coverage, within

a reasonable period of time not to exceed thirty (30) days following receipt of the appeal.

The notice will include the basis for the decision and any additional rights you may have. You will be provided, free of charge, with any new or additional evidence or rationale considered, relied upon, or generated by First Priority Health related to your complaint. Before a decision is rendered, you will be provided with the opportunity to respond to the evidence or rationale provided to you. At any stage of the complaint process, you have the right to request that First Priority Health appoint a member of its staff who has had no direct involvement in the case to aid you in preparing your complaint. Such assistance may be particularly useful to you in preparing a succinct, factual, supportable presentation. In the complaint process, you should be as specific as possible as to the remedy being sought from First Priority Health. Expedited Complaint Process - If you believe that the timeframe for the Standard Value complaint process could seriously jeopardize your life, health or ability to regain maximum functioning, or, in the opinion of your physician, you experience pain that cannot be adequately controlled while you wait for a decision, you may request an expedited complaint. In order for a complaint to be expedited, you must provide First Priority Health with a written certification from your Physician stating that your life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the regular review process. The certification must include clinical rationale and facts to support the Physician’s opinion. First Priority Health will arrange to have the complaint reviewed by our Second Level Review Committee within seventy-two (72) hours, unless additional information is needed, and the Committee will inform you of the decision both verbally and in writing. If the Committee’s decision is adverse, you have two (2) Business Days from the receipt of the expedited internal review decision to contact First Priority Health and request an expedited external review.

The Initial Review Committee decision will be binding, unless you appeal the decision.

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The appeal of the initial complaint shall go to the Second Level Review Committee established by First Priority Health’s board of directors. You or your designated representative may file a written or verbal complaint to First Priority Health as well as written data, testimony, or other information in support of the complaint. The Second Level Review Committee will consist of three or more individuals who did not participate in the initial review and are not subordinates of the individual(s). At least one third of the committee members shall not be employed by First Priority Health. The committee will hold an informal hearing to consider your complaint. You have the right, but are not required, to attend the hearing. When arranging the hearing, First Priority Health will notify you in writing of the hearing procedures and your rights at such hearing. When possible, you will be notified fifteen (15) days in advance of the hearing date. If the complaint involves Services that have not yet been rendered (pre-service), the voluntary second level internal review will be completed within fifteen (15) days of receipt of a request for such review. Written notification to you regarding the decision of the Second Level Review Committee will be mailed to you within five (5) business days of the decision, but no later than fifteen (15) days of receipt. If the complaint involves Services that have already been rendered (post-service), the voluntary second level review internal review will be completed within thirty (30) days of receipt of a request for such review. Written notification to you regarding the decision of the Second Level Review Committee will be mailed to you within five (5) business days of the decision, but no later than thirty (30) days of receipt. The notice shall include the basis for the decision and any additional rights you may have.

The Second Level Review Committee decision will be binding, unless you appeal the decision within fifteen (15) days from receipt of the notice of the decision from the Second Level Review Committee. The appeal of the Second Level Review Committee decision shall be to the Department of Health or the Insurance Department. Upon receipt of your request to file to the Department of Health or the Insurance Department, First Priority Health will transmit all first and second level records to the appropriate department for review. You, your Provider or First Priority Health may submit additional information related to the complaint. The appropriate department will review your complaint. You may be represented by an attorney or other individual before the department. The department shall make the decision based on the written record. This is the final level of the First Priority Health member complaint process. At any stage of the complaint process, you have the right to request that First Priority Health appoint a member of its staff who has had no direct involvement in the case to aid you in preparing your complaint. Such assistance may be particularly useful to you in preparing a succinct, factual, supportable presentation. In each step of the complaint process, you should be as specific as possible as to the remedy being sought from First Priority Health. Grievance - A request by you or a Provider with your written consent, to have First Priority Health or an Independent Review Organization review the denial of a health care service based on Medical Necessity and appropriateness. This includes cases in which First Priority Health denies full or partial payment for requested health care Services, approves the provision of a requested health care service for a lesser scope or duration than requested, or denies payment of the provision of a requested service but approves payment for the provision of an alternative health care service. A grievance does not include a complaint. If you have a grievance request, you should contact a Member Service Representative. First Priority Health will accept both verbal and written grievance requests from you or your designated representative. We will also accept written data, testimony or other information in support of the grievance. You may request copies of all documents, records, and other information relevant to your grievance. Upon receipt of the grievance, First Priority Health will provide written communication to you, that the request has been received, and that First Priority Health has classified it as a grievance for purposes of internal review. If you disagree with this classification, you can contact the Department of Health directly for consideration and intervention.

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The initial grievance will be promptly investigated by an Initial Grievance Review Committee composed of one or more persons selected by First Priority Health who did not previously participate in the decision to deny payment for the health care service and who is not the subordinate of such individual. This review will include a licensed Physician or, where appropriate, a licensed Psychologist/psychiatrist in the same or similar specialty that typically manages or consults on the heath care service being reviewed. You will be provided, free of charge, with any new or additional evidence or rationale considered, relied upon, or generated by First Priority Health related to your grievance. Before a decision is rendered, you will be provided with the opportunity to respond to the evidence or rationale provided to you. When required, First Priority Health will provide written notification in a culturally and linguistically appropriate manner. Each appeal will be promptly investigated and the Plan will provide written notification of its decision within the following time frames:

i.) When the appeal involves a non-urgent care Pre-service Claim, within a reasonable period of time

appropriate to the medical circumstances involved not to exceed thirty (30) days following receipt of the appeal;

ii.) When the appeal involves an Urgent Care Claim, as soon as possible taking into account the

medical exigencies involved but not later than seventy-two (72) hours following receipt of the appeal; or

iii.) When the appeal involves a Post-service Claim or a decision by the Plan to rescind coverage, within

a reasonable period of time not to exceed thirty (30) days following receipt of the appeal.

If the grievance involves Services that have not yet been rendered (pre-service), the committee will provide you and your Provider with a response within fifteen (15) days of receipt of the grievance. If the grievance involves Services that have already been rendered (post-service), the committee will provide you and your Provider with a response within thirty (30) days of receipt of the grievance. The notice shall include the basis and clinical rationale for the decision and the procedure to file a request for a second internal level review of the decision. Expedited Grievance Process - If you believe that the timeframe for the Standard Value grievance process could seriously jeopardize your life, health or ability to regain maximum functioning, or, in the opinion of your physician, you experience pain that cannot be adequately controlled while you wait for a decision, you may request an expedited grievance. In order for a grievance to be expedited, you must provide First Priority Health with a written certification from your Physician stating that your life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the regular review process. The certification must include clinical rationale and facts to support the Physician’s opinion. First Priority Health will arrange to have the grievance reviewed by the Second Level Review Committee within seventy-two (72) hours and the Committee will inform you of the decision both verbally and in writing. This review will include a licensed Physician or, where appropriate, a licensed Psychologist/ psychiatrist in the same or similar specialty that typically manages or consults on the heath care service being reviewed. If the Committee’s decision is adverse, you have two (2) Business Days from the receipt of the expedited internal review decision to contact First Priority Health and request an expedited external review. Individuals in urgent care situations and individuals receiving an ongoing course of treatment may be allowed to proceed with expedited external review at the same time as the internal appeals process. The Initial Grievance Review Committee decision will be binding, unless you appeal the decision. The appeal of the initial grievance will go to the Second Level Review Committee established by First Priority Health’s board of directors. The Second Level Review Committee will consist of at least three or more individuals who did not participate in the decision to deny payment for the health care service and who are not subordinates of such individual. This committee review shall include a licensed Physician or, where appropriate, a licensed Psychologist/psychiatrist, in the same or similar specialty that typically manages or consults on the health care service being reviewed.

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The committee will hold an informal hearing to consider your grievance. You have the right, but are not required, to attend the hearing. When arranging the hearing, First Priority Heath will notify you in writing of the hearing procedures and your rights at such hearing. When possible, you will be notified fifteen (15) days in advance of the hearing date.

If the grievance involves Services that have not yet been rendered (pre-service), the voluntary second level internal review will be completed within fifteen (15) days of receipt of a request for such review. Written notification to you regarding the decision of the Second Level Review Committee will be mailed to you within five (5) business days of the decision, but no later than fifteen (15) days of receipt. If the grievance involves Services that have already been rendered (post-service), the voluntary second level review internal review will be completed within thirty (30) days of receipt of a request for such review. Written notification to you regarding the decision of the Second Level Review Committee will be mailed to you within five (5) business days of the decision, but no later than thirty (30) days of receipt. The notice shall include the basis and clinical rationale for the decision and the procedure for appealing the decision. The Second Level Review Committee decision will be binding, unless you appeal the decision within four (4) months from receipt of the notice of the decision from the Second Level Review Committee. External Review - The appeal of the Second Level Review Committee decision shall be to an independent review organization randomly assigned by First Priority Health. Any external grievance shall be filed with First Priority Health within four (4) months of receipt of a notice of denial resulting from the internal grievance process. The filing of the external grievance will include any additional material justification and all reasonably necessary supporting information. First Priority Health will notify you or your Provider of the name, address and telephone number of the independent review organization within five (5) Business Days of receipt. First Priority Health will then transmit all first and second internal level records to the appropriate independent review organization within fifteen (15) days of receipt of the request.

The initial Review Committee decision will be binding, unless you appeal the decision within four (4) months from receipt of the notice of the decision.

The appeal of the Initial Review Committee decision shall be to First Priority Health. Upon receipt of your request, your grievance will be assigned to a randomly selected Independent Review Organization. First Priority Health will transmit all records to the assigned Independent Review Organization. You, your Provider or First Priority Health may submit additional information related to your grievance.

Within forty-five (45) days of receipt of the external grievance by the Independent Review Organization, the Independent Review Organization shall issue a written decision to you and First Priority Health, based on the records submitted. Written notice of the decision shall provide, among other information, a statement of the principal reasons for the decision including the rationale and Standard Values relied upon by the IRO, a statement that judicial review may be available to the Member and current contact information for the Pennsylvania Insurance Department Office of Consumer Services or such other applicable office of health insurance consumer assistance or ombudsman. This is the final level of the First Priority Health Member grievance process.

Within forty-five (45) days of receipt of the external grievance by the independent review organization, the independent review organization shall issue a written decision to First Priority Health, you and your Provider, including the basis and clinical rationale for the decision. The external grievance decision shall be subject to appeal to a court of competent jurisdiction within sixty (60) days of receipt of notice of the external grievance decision. At any stage of the grievance process, you have the right to request that First Priority Health appoint a member of its staff who has had no direct involvement in the case to aid you in preparing your grievance. Such assistance may be particularly useful to you in preparing a succinct, factual, supportable presentation. In each step of the grievance process, you should be as specific as possible as to the remedy being sought from First Priority Health.

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The Pennsylvania Department of Health and the Pennsylvania Insurance Department are responsible for monitoring First Priority Health’s compliance with the internal complaint and grievance procedures. They can be contacted at the following addresses:

Pennsylvania Department of Health Pennsylvania Insurance Dept. Bureau of Managed Care Bureau of Consumer Services Room 912 Health & Welfare Building Room 1209, Strawberry Square 625 Forster Street Harrisburg, PA 17120 Harrisburg, PA 17120-0701

If you have any questions concerning the filing status of a complaint or grievance, you can call a Member Service Representative toll-free at (800) 822-8753 weekdays during normal business hours.

K. RELEASE AND PROTECTION OF MEMBER INFORMATION

All personally identifiable information about individual Members (“Protected Health Information”) is subject to various statutory privacy Standard Values, including state insurance regulations implementing Title V of the Gramm-Leach-Bliley Act and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and regulations adopted thereunder by the Department of Health and Human Services (45 CFR Parts 160, 162, 164). In accordance with those Standard Values, First Priority Health may use and disclose Protected Health Information to facilitate payment, treatment and health care operations as described in First Priority Health’s Notice of Privacy Practices (“NPP”). Copies of First Priority Health’s current NPP are available on First Priority Health’s internet site, or from First Priority Health’s Privacy Office.

At its sole discretion, First Priority Health may make available, either directly or through a designated vendor, Member identity theft protection Services. Any decision to accept or not accept such Services will not affect the continued eligibility, benefits, premiums or cost-sharing of the Member under this Agreement. First Priority Health shall not be liable for, and the Member shall hold First Priority Health harmless from, any matters arising from or relating to such Services. Each Member may authorize, in writing, that any person or organization furnishing Services or supplies to him provide First Priority Health with requested information and records. Each Member may authorize that any person or entity having information relating to an illness or injury for which benefits are claimed under this Agreement may furnish it to First Priority Health (including copies of records). In addition, First Priority Health may furnish such information to other entities providing similar benefits at their request.

L. MEMBER/PROVIDER RELATIONSHIP

a. The choice of a Provider is solely the Member's.

b. First Priority Health does not furnish Covered Services but only makes payment for Covered Services

received by Members. First Priority Health is not liable for any act or omission of any Provider. First Priority Health has no responsibility for a Provider's failure or refusal to render Covered Services to a Member.

c. The use or non-use of an adjective such as P a r t i c i p a t i n g or Non-Participating in modifying any

Provider is not a statement as to the ability of the Provider. M. MATERIALS PROVIDED TO MEMBER PERSONS

First Priority Health will provide to the Member the Agreem ent and materials that describe this Ag reem en t ’ s benefits, explain how to access benefits and claims filing instructions, and include the rights and responsibilities of the Member. In the event of a conflict between the Agreement and such materials, the Agreement shall prevail.

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N. RIGHTS OF THE MEMBER

A Member shall have no rights or privileges as to the benefits provided under this Agreement, except as specifically provided herein.

O. NOTICE

Any notice required under this Agreement or a booklet must be in writing. Notice given to First Priority Health will be sent to First Priority Health at:


19 North Main Street Wilkes-Barre, PA 18711

Notice given to a Member will be sent to the Member's address as it appears on the records of First Priority Health. First Priority Health or a Member may, by written notice, indicate a new address for giving notice.

P. PAYMENT OF PREMIUMS

1. Premium Modification

a. Each Agreement is maintained at a premium for which the Member is eligible. b. The amount of the premium for the Member, if applicable, at any time is the rate set forth in the

schedule of rates on file with and approved by the Insurance Department of the Commonwealth of Pennsylvania.

c. The premium is payable in advance directly to First Priority Health. d. The M e m b e r rate is subject to change upon approval of the Pennsylvania Insurance

Department. The Member shall be given at least thirty (30) days advanced written notice prior to any change in the premium rate. First Priority Health reserves the right to change the premium rates for the agreement on a class basis.

e. Any notice shall be considered to have been given when mailed to the M e m b e r at the address

on the records of First Priority Health.

2. Grace Period A grace period of thirty (30) days from the due date will be granted for the payment of each premium. During the grace period, the Agreement will stay in force; however, no benefits will be paid for Services Incurred subsequent to the end of the grace period, subject to the BENEFITS AFTER TERMINATION Subsection of this Section. If appropriate payment is not received within the grace period, this Agreement automatically terminates at the end of the grace period without written notification to the Member. The Plan has the right to collect all outstanding premiums, including the premium for the grace period, from the Subscriber. Notwithstanding the above, when coverage under this Agreement is provided pursuant to enrollment through the Exchange and the Subscriber:

a. is receiving APTCs; and

b. has made payment of at least one full monthly premium;

a grace period of three (3) consecutive months shall be provided under this Agreement for the payment of premium. Benefits will only be provided by the Plan under this Agreement for Covered Services received during the first (1st) month, or the first thirty (30) days, if greater, of the three (3) month grace period if

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payment of the appropriate premium amount by the Member is not received prior to the end of the grace period.

3. Adjustment of Premiums

a. Each Agreement is maintained at a premium for which the Member is eligible.

b. The amount of the premium for the Member, if applicable, at any time is the rate set forth in the schedule of rates on filed with and approved by the Insurance Department of the Commonwealth of Pennsylvania.

c. The premium is payable in advance directly to First Priority Health.

d. The Member rate is subject to change upon approval of the Pennsylvania Insurance Department.

The Member shall be given at least thirty (30) days advanced written notice prior to any change in the premium rate. First Priority Health reserves the right to change the premium rates for Agreement on a class basis.

Any notice shall be considered to have been given when mailed to the Member at the address on the records of First Priority Health. Q. COMPLIANCE WITH LAW; AMENDMENT

Anything contained herein to the contrary notwithstanding, the Plan shall have the right to modify this Agreement, including any endorsements hereto, at any time during the term of this Agreement, for the following purposes: a. to comply with the provisions of any law, regulation or lawful order; and/or b. to reflect the loss or discontinuation of payments made or to be made by the federal government or any state

or local government. These amendments may include, but are not limited to, the modification of premium rates and the increase, reduction or elimination any of the benefits provided for any one (1) or more eligible Members enrolled under the terms of this Agreement Each party hereby agrees to any amendment of this Agreement which is necessary in order to accomplish such purpose.

R. CONTINUATION UPON DEATH OF SUBSCRIBER OR TERMINATION OF SUBSCRIBER’S COVERAGE

Unless coverage under this Agreement is provided pursuant to enrollment through the Exchange, coverage may continue under this Agreement for the covered Dependents upon termination of the Subscriber’s coverage under this Agreement due to enrollment in a Medicare Supplemental or Medicare Advantage plan, or due to the death of the Subscriber, for any period for which premium has already been paid. The Subscriber’s spouse or Domestic Partner, if covered under this Agreement, shall thereafter become the Subscriber upon notice to the Plan of the termination of the Subscriber’s coverage or the Subscriber’s death. If the Subscriber’s spouse or Domestic Partner was not covered under this Agreement, a Dependent child may become a Subscriber but only under his or her own agreement.

S. THIRD PARTY PAYMENTS

The Subscriber has an ongoing obligation under this Agreement to disclose to the Plan any full or partial premium payment made, directly or indirectly, by third party payers on behalf of the Subscriber or any Dependent. These payments, referred to as “third party payments” are those made by any means including, but not limited to, cash, check, money order, pre-paid debit card, credit card and electronic fund transfers.

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The Plan, in its sole discretion and in accordance with applicable law and regulatory guidance, reserves the right to refund and/or refuse to accept premium payments made by ineligible third party payers. “Ineligible third party payers” include any person or entity from which the Plan is not required by law to accept such third party payments. The Subscriber remains liable for all premium payments due under this Agreement for which a disallowed third party payment was made or attempted to be made on behalf of the Subscriber or any Dependent.

First Priority Health is a subsidiary of Highmark Blue Cross Blue Shield, both of which are independent licensees of the Blue Cross Blue Shield Association.

Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, First Priority Life Insurance Company or First Priority Health, all of which are independent licensees of the Blue Cross Blue Shield Association. Health care plans are subject to terms of the benefit agreement.

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