Providing Essential Health Benefits in West Virginia

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West Virginia Offices of the Insurance Commissioner Bulletins and Informational Letters › Providing Essential Health Benefits in West Virginia

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[LOGO]

STATE OF WEST VIRGINIA

Offices of the Insurance Commissioner

Earl Ray Tomblin

Governor

Michael D. Riley

Insurance Commissioner

# FEBRUARY 2016

# WEST VIRGINIA INFORMATIONAL LETTER

NO. 186A

TO: All Insurance Companies Authorized to Sell Health Insurance Plans in West Virginia's Small Group and Individual Markets

RE: Providing Essential Health Benefits in West Virginia

In March 2010, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 were signed into law. The two laws are collectively referred to as the Affordable Care Act ("ACA"). As part of an amendment to the Public Health Services Act, the ACA requires all qualified health plans, as well as all health care plans sold in the United States in the small group or individual markets, to include "essential health benefits" ("EHB"), defined as ten (10) categories of benefits. (See ACA §2707 codified at 42 USC §300gg-6; ACA §1301 codified at 42 USC §18021.) Aside from the ten basic categories, discretion on how to define EHB was left to the U.S. Department of Health and Human Services ("HHS"). HHS ultimately used a "benchmark" approach, permitting each state to select a benchmark plan from various options of plans offered in the state or federal plans. West Virginia's benchmark plan for 2017 is "Highmark Blue Cross Blue Shield West Virginia $1000 Deductible Gold Shared Cost PPO 1000 Plan."

The purpose of this informational letter is to provide all health insurance carriers in West Virginia that issue policies in the small group and individual market specific guidance as to how to comply with the ACA EHB requirement based on West Virginia's benchmark. The final EHB regulation promulgated by HHS clarifies that for a health care policy to be deemed to provide EHB, it must generally "provide benefits that ..

formational letter is to provide all health insurance carriers in West Virginia that issue policies in the small group and individual market specific guidance as to how to comply with the ACA EHB requirement based on West Virginia's benchmark. The final EHB regulation promulgated by HHS clarifies that for a health care policy to be deemed to provide EHB, it must generally "provide benefits that ... [a]re substantially equal to the EHB benchmark plan including: (i) Covered benefits; [and] (ii) Limitations on coverage including coverage of benefit amount, duration and scope ..." See 45 CFR §156.115. Following the publication of this final regulation, the West Virginia Offices of the Insurance Commissioner ("OIC") had communications with officials from HHS to seek clarity on what "substantially equal" means. HHS clarified that the purpose of the language was to permit some flexibility among various plans as compared to the benchmark within the states' discretion. HHS also clarified, however, that the "starting point" for EHB was the actual language of the benchmark policy, not just the general guidelines of the benchmark set forth in the EHB regulation (the EHB regulation has a matrix of each state's benchmark with some information as to each).

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WVIL 186A

Executive Office

Post Office Box 50540

Charleston, West Virginia 25305-0540

"We are an Equal Opportunity Employer"

[LOGO]

Telephone (304) 558-3354

Facsimile (304) 558-0412

www.wvinsurance.gov

, not just the general guidelines of the benchmark set forth in the EHB regulation (the EHB regulation has a matrix of each state's benchmark with some information as to each).

Page 1 of 1

WVIL 186A

Executive Office

Post Office Box 50540

Charleston, West Virginia 25305-0540

"We are an Equal Opportunity Employer"

[LOGO]

Telephone (304) 558-3354

Facsimile (304) 558-0412

www.wvinsurance.gov

Accordingly, the OIC directs all applicable health insurance carriers to use, as a starting point for determining how to provide EHB, the benefits as outlined in the “Highmark Blue Cross Blue Shield West Virginia $1000 Deductible Gold Shared Cost PPO 1000 Plan” Certificate of Coverage, attached to this letter as Appendix 1. However, pursuant to the goal of flexibility embedded in the term “substantially equal,” some deviation is permitted. For example, a carrier may want to slightly alter the number of visits or treatments permitted within a certain benefit type.¹ As long as the deviation is deemed by the OIC to be “substantially equal,” it would be permissible. The OIC will ultimately address whether deviations from the benchmark are “substantially equal” on a case-by-case basis.

In addition to the above, carriers who issue EHB compliant policies need to also be aware of “backfills,” which pertain to benefits not currently found in the West Virginia benchmark plan but become required due to enactments of the West Virginia Legislature. Should backfills become necessary, the OIC will issue a supplemental informational letter.

Questions regarding this informational letter should be directed to Director, Health Policy at Health.Policy@wvinsurance.gov or 304-558-6279.

Michael D. Riley

Insurance Commissioner

currently found in the West Virginia benchmark plan but become required due to enactments of the West Virginia Legislature. Should backfills become necessary, the OIC will issue a supplemental informational letter.

Questions regarding this informational letter should be directed to Director, Health Policy at Health.Policy@wvinsurance.gov or 304-558-6279.

Michael D. Riley

Insurance Commissioner

¹ As evidenced by the example, this is referring to deviating in amount, duration and scope within a specific type of benefit. In addition to this, the federal EHB regulation also permits deviation between benefit types within an EHB category as long as changes provide actuarially equivalent benefits to the benchmark. For example, a carrier could potentially greatly reduce or eliminate benefit type A within an EHB category if they provided a new benefit type and/or grossly increased an existing benefit type in a manner that was actuarially equivalent to the reduction in the other benefit type. Deviation between benefits types such as this must be justified actuarially.

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WVIL 186A

![img-0.jpeg](img-0.jpeg)

An Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

## WV GROUP GOLD

## SHARED COST PPO 1000

## HEALTH CARE CERTIFICATE

Appendix 1 – WVIL186A

WVIL 186A

![img-0.jpeg](img-0.jpeg)

An Independent Licensee of the Blue Cross and Blue Shield Association

Blue Cross, Blue Shield and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

## WV GROUP GOLD

## SHARED COST PPO 1000

## HEALTH CARE CERTIFICATE

Appendix 1 – WVIL186A

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# YOUR HEALTH CARE BENEFITS

AND

HOW TO USE THEM

WV Group Gold Shared Cost PPO 1000

Health Care Certificate

1. 2017年，公司与上海浦东发展银行股份有限公司签订了《关于使用部分闲置募集资金进行现金管理的协议》。

# TABLE OF CONTENTS

# I. I. WV Group Gold Shared Cost PPO 1000 Health Care Certificate ...1

- Group Contract and Certificate ...1

- Financing Arrangement...1

- Important Information About This Coverage...1

# II. How To Use Your Certificate...4

- Summary of Benefits ...4

- Eligibility ...4

- Benefits ...4

- Exclusions...4

- Coordination of Benefits, Right of Recovery, and Right of Reimbursement/Subrogation ...4

- General Provisions...4

- Definitions...4

- Prescription Drug Benefits...4

- Statement of ERISA Rights ...4

- Plan Information ...4

# III. WV Group Gold Shared Cost PPO 1000 Summary of Benefits...5

- Provider Networks and Directory ...5

- Medical Cost-Sharing Provisions (Member Liability) ...5

- Benefits Summary...7

# IV. Eligibility...15

f Recovery, and Right of Reimbursement/Subrogation ...4

- General Provisions...4

- Definitions...4

- Prescription Drug Benefits...4

- Statement of ERISA Rights ...4

- Plan Information ...4

# III. WV Group Gold Shared Cost PPO 1000 Summary of Benefits...5

- Provider Networks and Directory ...5

- Medical Cost-Sharing Provisions (Member Liability) ...5

- Benefits Summary...7

# IV. Eligibility...15

- Applying For Coverage...15

- Eligible Employees ...15

- Eligible Dependents...15

- Enrollment Upon Initial Eligibility ...16

- Eligibility Changes and Special Enrollment Procedures...17

- Open Enrollment...19

- Effective Date ...19

- Identification Cards (ID Cards)...19

- Medicare Eligibility ...19

- Non-Medicare Retirees ...20

- How and When Your Benefits May Change...20

- How and When Your Coverage Stops ...20

- Continuation Coverage - COBRA ...21

- Continuation Coverage - Mini-COBRA ...22

- Military Service ...23

- Inpatient Benefits Incurred at and Exceeding Term of Contract...23

- Conversion Privilege...23

# V. Health Care Benefits ...25

- Medical Necessity Requirement and Member Liability...25

- Prior Authorization ...25

- Allergy Tests and Treatments ...25

- Ambulance Services...25

- Autism Spectrum Disorder...26

- Bone Marrow Procedures...26

- Clinical Trials Coverage ...27

- Cost Effective Non-Covered Services...27

-i-

• Dental Services for an Accidental Injury ...27

• Diagnostic Services...27

• Emergency Services...27

• Home Health Care Services ...28

• Home, Office and Other Outpatient Visit ...29

• Hospice Services ...29

• Hospital-Based Clinics...29

• Injectable Drugs ...30

• Inpatient Services...30

• Maternity Services ...31

• Medical Supplies and Equipment...31

• Mental Health Care and Substance Abuse (Drug and Alcohol) Coverage...32

• Organ Transplant Services ...32

• Prescription Drug Claims...35

• Preventive Care Services ...35

• Private Duty Nursing Services ...36

• Rehabilitation Services ...36

• Skilled Nursing Facility Services...37

• Special Services ...37

nt Services...30

• Maternity Services ...31

• Medical Supplies and Equipment...31

• Mental Health Care and Substance Abuse (Drug and Alcohol) Coverage...32

• Organ Transplant Services ...32

• Prescription Drug Claims...35

• Preventive Care Services ...35

• Private Duty Nursing Services ...36

• Rehabilitation Services ...36

• Skilled Nursing Facility Services...37

• Special Services ...37

• Specialist Virtual Visits ...38

• Surgical Services...38

• Temporomandibular Disorders (TMD)/Craniomandibular Disorders ...39

• Therapy Services...40

• Well Child Care and Immunization Services ...40

# VI. Exclusions / What Is Not Covered ...41

# VII. Coordination of Benefits, Right of Recovery, Right of Reimbursement/Subrogation and Work Related Injuries or Illnesses ...44

• Order of Benefit Determination Rules ...44

• Facility of Payment ...46

• Right of Recovery ...46

• Right of Reimbursement and Subrogation...46

• Work Related Injury and Illness ...48

# VIII. General Provisions ...49

• What Is A Claim and How To Apply For Benefits ...49

• Pre-Service Claim Conditions...51

• Claims Process For Initial Claims For Benefits ...52

• Notice of Adverse Claim/Appeal Decisions ...53

• Appeal Procedures For Adverse Benefit Determinations ...53

• Informal Dissatisfaction Resolution...56

• Designating An Authorized Representative...56

• Treatment Plans ...56

• Our Right To Review Claims...57

• Provider Services ...57

• How Claims are Paid...57

• How to Report Fraud...60

• Limitations of Actions and Venue ...61

• Non-Waiver Provision ...61

• Severability ...61

• Governing Law ...61

-ii-

IX. Definitions ...62

X. Prescription Drug Benefits ...73

- Prescription Drug Benefits ...73

- Formulary ...75

- Retail and Mail Order Prescription Drug Management ...76

- Exclusions and Limitations Specific to Prescription Drugs ...76

- Definitions ...77

XI. Statement of ERISA Rights ...79

Actions and Venue ...61

• Non-Waiver Provision ...61

• Severability ...61

• Governing Law ...61

-ii-

IX. Definitions ...62

X. Prescription Drug Benefits ...73

- Prescription Drug Benefits ...73

- Formulary ...75

- Retail and Mail Order Prescription Drug Management ...76

- Exclusions and Limitations Specific to Prescription Drugs ...76

- Definitions ...77

XI. Statement of ERISA Rights ...79

- Receive Information About Your Plan and Benefits ...79

- Continue Group Health Plan Coverage ...79

- Prudent Actions by Plan Fiduciaries ...79

- Enforce Your Rights ...79

- Assistance with Your Questions ...80

XII. Group Health Plan Information ...81

-iii-

# I. WV Group Gold Shared Cost PPO 1000 Health Care Certificate

# A. GROUP CONTRACT AND CERTIFICATE

This Certificate describes the health care benefits available to you as part of a Group Contract (or "Contract"). It is part of and subject to the terms and conditions of the Group Contract.

The actual Group Contract is between Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield West Virginia ("Highmark WV") and the employer or organization that pays or forwards the premiums and any administrative costs for your coverage with Highmark WV. Highmark WV may be referred to throughout this Certificate as we, us, or our. The employer or organization will be called the Group, Plan, Plan Sponsor, or Plan Administrator. The benefits provided under the Contract are referred to as Plan or Group Health Plan. All persons who meet eligibility criteria in this Certificate are eligible for coverage under the Group Contract. They are referred to as Covered Persons, you or your. They must:

- Apply for coverage under the Group Contract;

- Pay a portion of the premium if necessary;

- Satisfy the conditions specified in Section IV; and

- Be approved by us.

ontract are referred to as Plan or Group Health Plan. All persons who meet eligibility criteria in this Certificate are eligible for coverage under the Group Contract. They are referred to as Covered Persons, you or your. They must:

- Apply for coverage under the Group Contract;

- Pay a portion of the premium if necessary;

- Satisfy the conditions specified in Section IV; and

- Be approved by us.

Certain words used in this Certificate have special meaning. They will be capitalized throughout the text so that you will pay special attention to them. They are either defined in Section IX, or where used in the text.

Premiums are computed in accordance with Highmark WV's rating formula; which reflects, among other things, costs and charges associated with the selected benefit policy.

The Group shall have the right to return the Contract within 10 days of its delivery and to have the premium refunded if, after examination of the Contract, the Group is not satisfied for any reason. In the event the Group exercises this right, Highmark WV shall not be obligated to pay any benefits under the Group Health plan for Claims submitted to Highmark WV during such 10-day period.

# B. FINANCING ARRANGEMENT

The benefits are underwritten and insured by Highmark WV through the Contract with your Group. Highmark WV also performs administrative functions related to payment and processing of Claims and provides Network access.

# C. IMPORTANT INFORMATION ABOUT THIS COVERAGE

any benefits under the Group Health plan for Claims submitted to Highmark WV during such 10-day period.

# B. FINANCING ARRANGEMENT

# C. IMPORTANT INFORMATION ABOUT THIS COVERAGE

1. Not a Provider of Services. We do not furnish Services. We only pay for Covered Services you receive from Providers. We are not liable for any act or omission of any Provider, and we have no responsibility for a Provider's failure or refusal to give Services to you. Any decision to receive care is solely between you and your Provider. Any action by Highmark WV pursuant to any utilization management, referral management, discharge planning, Medical Necessity determination or other functions in no way absolves the Provider of the responsibility to provide appropriate Medical Care to the Covered Person.

2. Precertification Review. This Certificate contains a Precertification Review limitation. It is described in Sections III and Section VIII Precertification Review is limited solely to determining Medical Necessity. It is not a guarantee of coverage or payment. Remember, in an emergency, always go to the nearest appropriate medical facility.

3. **Mastectomy Benefits.** This Group Health Plan provides certain reconstructive services for mastectomy benefits. See Section V for more information.

4. **Ministerial Duties of Highmark WV**

ecertification Review is limited solely to determining Medical Necessity. It is not a guarantee of coverage or payment. Remember, in an emergency, always go to the nearest appropriate medical facility.

3. **Mastectomy Benefits.** This Group Health Plan provides certain reconstructive services for mastectomy benefits. See Section V for more information.

4. **Ministerial Duties of Highmark WV**

Highmark WV shall, in accordance with the Group Health Plan and Contract, perform the following ministerial duties: (a) determine questions of eligibility; (b) determine the amount and type of benefits payable under the Group Health Plan; and (c) implement claim and appeal procedures established by the Department of Labor under Claim Rules set forth in 29 CFR Part 25607. In carrying out these functions, Highmark WV shall have the exclusive right to apply the terms and provisions of the Group Health Plan and this Contract and to determine any and all questions arising under the Group Health Plan or this Contract, or in connection with these functions, including, without limitation, the right to remedy or resolve possible ambiguities, disputes, inconsistencies, or omissions by general rule or particular decision. Highmark WV shall have the exclusive right and authority to make any findings necessary or appropriate for the purpose of these functions, including, but not limited to, the determination of the eligibility for, and the amount, manner, and time of payment of, any benefit payable under the Group Health Plan or this Contract. Benefits will be paid only if Highmark WV decides, in accordance with the Group Health Plan and this Contract, that the claimant is entitled to them

5. **Blue Cross and Blue Shield Association**

these functions, including, but not limited to, the determination of the eligibility for, and the amount, manner, and time of payment of, any benefit payable under the Group Health Plan or this Contract. Benefits will be paid only if Highmark WV decides, in accordance with the Group Health Plan and this Contract, that the claimant is entitled to them

5. **Blue Cross and Blue Shield Association**

The Group, on behalf of itself and all Certificate Holders, hereby expressly acknowledges its understanding that this agreement constitutes a Contract solely between the Group and Highmark WV Blue Cross & Blue Shield (Highmark WV), which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the "Association"), permitting Highmark WV to use the Blue Cross and Blue Shield Service Marks in the State of West Virginia and Washington County, OH, and that Highmark WV is not contracting as the agent of the Association.

The Group, on behalf of itself and its Certificate Holders, further acknowledges and agrees that it has not entered into this agreement based upon representations by any person or entity, other than Highmark WV and that no person, entity or organization other than Highmark WV shall be held accountable or liable to the Group for any of Highmark WV's obligations to the Group created under this agreement. This paragraph shall not create any additional obligations whatsoever on the part of Highmark WV other than those obligations created under other provisions of this agreement.

6. **Address**

Highmark Blue Cross Blue Shield West Virginia

614 Market Street

Parkersburg, WV 26101

7. **Member Services**

If you have questions about your coverage or are directed to contact Highmark WV, you should contact Member Services, unless directed otherwise. Member Services can be reached using the number and address located on the back of your ID Card.

8. **Information for Non-English Speaking Members**

k Blue Cross Blue Shield West Virginia

614 Market Street

Parkersburg, WV 26101

7. **Member Services**

8. **Information for Non-English Speaking Members**

Members who do not speak English can call the toll-free number on the back of their ID Card to be connected to the language services interpreter line. Member Services representatives are trained to make this connection.

# 9. Member Rights and Responsibilities

You have the right to:

a. Receive information about Highmark WV, its products and its services, its practitioners and providers, and your rights and responsibilities.

b. Be treated with respect and recognition of your dignity and right to privacy.

c. Participate with practitioners in decision-making regarding your health care. This includes the right to be informed of your diagnosis and treatment plan in terms that you understand and participate in decisions about your care.

d. Have a candid discussion of appropriate and/or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage.

e. Voice a complaint or file an appeal about Highmark WV or the care provided and receive a reply within a reasonable period of time.

f. Make recommendations regarding the Highmark WV Members' Rights and

g. Responsibilities policies.

# You have a responsibility to:

discussion of appropriate and/or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage.

e. Voice a complaint or file an appeal about Highmark WV or the care provided and receive a reply within a reasonable period of time.

f. Make recommendations regarding the Highmark WV Members' Rights and

g. Responsibilities policies.

# You have a responsibility to:

a. Supply to the extent possible, information that the organization needs in order to make care available to you, and that its practitioners and providers need in order to care for you.

b. Follow the plans and instructions for care that you have agreed on with your practitioners. Communicate openly with the physician you choose. Ask questions and make sure you understand the explanations and instructions you are given, and participate in developing mutually agreed upon treatment goals. Develop a relationship with your doctor based on trust and cooperation.

# 10. How We Protect Your Right to Confidentiality

We have established policies and procedures to protect the privacy of our members' protected health information ("PHI") in all forms, including oral PHI, from unauthorized or improper use. Some of the ways we protect your privacy include not discussing PHI outside of our offices, e.g., in hallways, elevators, as well as verifying your identity before we discuss PHI with you over the phone. As permitted by law, we may use or disclose protected health information for treatment, payment and health care operations, such as: claims management, routine audits, coordination of care, quality assessment and measurement, case management, utilization review, performance measurement, customer service, credentialing, medical review and underwriting. With the use of measurement data, we are able to manage members' health care needs, even targeting certain individuals for quality improvement programs, such as health, wellness and disease management programs.

ts, coordination of care, quality assessment and measurement, case management, utilization review, performance measurement, customer service, credentialing, medical review and underwriting. With the use of measurement data, we are able to manage members' health care needs, even targeting certain individuals for quality improvement programs, such as health, wellness and disease management programs.

If we ever use your protected health information for non-routine uses, we will ask you to give us your permission by signing a special authorization form, except with regard to court orders and subpoenas.

You have the right to access the information your doctor has been keeping in your medical records, and any such request should be directed first to your network physician.

You benefit from the many safeguards we have in place to protect the use of data we maintain. This includes requiring our employees to sign statements in which they agree to protect your confidentiality, using computer passwords to limit access to your protected health information, and including confidentiality language in our contracts with physicians, hospitals, vendors and other health care providers.

Our Privacy Department reviews and approves policies regarding the handling of confidential information.

## II. How To Use Your Certificate

This Certificate gives you the details you need in order to understand your health care benefits. We have tried to write it in simple terms that are easy to understand. Please read this Certificate carefully and completely to understand the benefit coverage. It is important that you keep a copy of this Certificate and refer to it if you have any questions about the benefits. Please refer to www.mybenefitshome.com to assure you have the most current version. You may also call Member Services to have a new Certificate sent to you.

### III. Summary of Benefits

and. Please read this Certificate carefully and completely to understand the benefit coverage. It is important that you keep a copy of this Certificate and refer to it if you have any questions about the benefits. Please refer to www.mybenefitshome.com to assure you have the most current version. You may also call Member Services to have a new Certificate sent to you.

### III. Summary of Benefits

This Section briefly describes how and when your benefits pay. It provides additional information such as the amount of Deductibles, Fees, Coinsurances, and benefit limits.

### IV. Eligibility

This Section outlines how and when you become eligible for coverage. It also describes how and when your coverage becomes effective and when it terminates.

### V. Benefits

This Section explains types of health care benefits in your coverage.

### VI. Exclusions

This Section lists what Services and Supplies are not covered. Please review this section carefully

### VII. Coordination of Benefits, Right of Recovery, and Right of Reimbursement/Subrogation

This Section describes when and how your benefits may coordinate with other coverage. It also describes certain obligations you have to us for overpayments or when benefits are the responsibility of another party.

### VIII. General Provisions

This Section tells you such things as: how to apply for benefits, how Claims are paid and other important but general information.

### IX. Definitions

If a word or phrase starts with a capital letter, it either has a special meaning or is a title. If the word or phrase has a special meaning, it is defined in this Section or where used in the text.

### X. Prescription Drug Benefits

This Section describes your coverage for Prescription Drugs.

### XI. Statement of ERISA Rights

This Section explains your rights under the Employee Retirement Security Act of 1974 (ERISA) if your benefits are subject to ERISA.

### XII. Group Health Plan Information

word or phrase has a special meaning, it is defined in this Section or where used in the text.

### X. Prescription Drug Benefits

This Section describes your coverage for Prescription Drugs.

### XI. Statement of ERISA Rights

This Section explains your rights under the Employee Retirement Security Act of 1974 (ERISA) if your benefits are subject to ERISA.

### XII. Group Health Plan Information

This Section provides important information about your Group Health Plan, Plan Administrator and applicable contacts.

### III. WV Group Gold Shared Cost PPO 1000

Summary of Benefits

IMPORTANT - Read this Section carefully. See Section V for a detailed description of benefits. Section X describes Prescription Drug benefits if such are provided under this Policy.

This Section indicates the amounts for Coinsurances, Deductible, Fees, reimbursement percentages, and Benefit Maximums. You will receive notification if your benefits change. Please refer to www.mybenefitshome.com to assure you have the most current version. You may contact Member Services to request an updated Policy.

# A. PROVIDER NETWORKS AND DIRECTORY

The choice of a Provider is solely yours. All Providers are designated as either Network or Non-Network. The amount of benefits that you will receive for Covered Services will vary depending upon whether the Provider is in the Network. Your financial responsibility will also vary between these Provider designations.

Examples of Providers include, but are not limited to the following: primary care physicians; specialists; mental health and substance abuse providers; community and specialty hospitals; and laboratories. You have access to care 24 hours a day/7 days a week. If you have Covered Services outside of your primary care physician's hours, you should follow up with them after receiving care.

You will receive greater benefits by seeking Covered Services from Network Providers. This section tells you how much we will pay for Covered Services at Network and Non-Network Providers.

spitals; and laboratories. You have access to care 24 hours a day/7 days a week. If you have Covered Services outside of your primary care physician's hours, you should follow up with them after receiving care.

You will receive greater benefits by seeking Covered Services from Network Providers. This section tells you how much we will pay for Covered Services at Network and Non-Network Providers.

Remember, in an emergency, always go to the nearest appropriate medical facility.

Network Provider online directory information is available by accessing www.highmarkbcbswv.com or you may also obtain such information by logging on to www.mybenefitshome.com or www.bcbs.com/healthtravel/finder/html. The Network status of Providers listed in a directory may change from time to time. You should be sure of the status of the Provider before receiving Services. To request a copy of the Provider Directory or check the status of a Provider, you may call the number on your ID Card. If you are outside of our Service Area, you may also call 1-800-810-BLUE. See Section VIII for more information on the meaning of Provider status.

# B. MEDICAL COST-SHARING PROVISIONS (MEMBER LIABILITY)

The expenses you may incur include, but are not limited to, those briefly defined and described below. Further detail is provided later in this Section III, Section V, and throughout this Certificate. The Network Provider may request that you pay any applicable unmet Deductible, Coinsurance or Fee for the Covered Services at the time Covered Services are rendered.

Note: You may be responsible for a facility fee, clinic charge, or similar fee or charge in addition to the Physician's charge if the Service is provided at a Physician's office, a Hospital or Facility Other Provider, Ancillary Provider, Retail Clinic or Urgent Care Center.

pay any applicable unmet Deductible, Coinsurance or Fee for the Covered Services at the time Covered Services are rendered.

1. Benefit Accumulation. Some employers may offer more than one health insurance policy through Highmark WV. Should you decide to change policies within the same company and within the same Benefit Period, for example, from a $500 Deductible to a $1,000 Deductible option, any Deductibles and Coinsurances earned on the $500 Deductible option shall apply to the $1,000 Deductible option. This provision does not apply if you change employment and both employers offer group health insurance through Highmark WV. If you have any questions about this provision, contact Member Services.

2. Benefit Maximums. Once the Benefit Maximum is met for a Covered Service(s) within the Benefit Period, any additional Charges Incurred will be your responsibility. Charges for Services above a Benefit Maximum will not apply to Fees, Deductibles, Network and Non-Network Coinsurances, or other Covered Person responsibilities. In some circumstance, the Benefit Maximums are combined for Network and Non-Network Services.

3. Coinsurance and Coinsurance Limits. This is a percentage of the Plan Allowance after your Deductible has been satisfied. Network Coinsurance percentages generally are less than Non-Network Coinsurance. Normally you receive greater benefits from Network Providers. There are separate limits for Network Coinsurance (Network Coinsurance Limits) and Non-Network Coinsurance (Non-Network Coinsurance Limits).

Except as otherwise specified, after you have paid any applicable Deductibles or Fees, Covered Services will be paid at the percentage applicable to the Provider Network status.

twork Coinsurance. Normally you receive greater benefits from Network Providers. There are separate limits for Network Coinsurance (Network Coinsurance Limits) and Non-Network Coinsurance (Non-Network Coinsurance Limits).

Except as otherwise specified, after you have paid any applicable Deductibles or Fees, Covered Services will be paid at the percentage applicable to the Provider Network status.

Non-Network Coinsurance and Liability Limits. The Non-Network Coinsurance is in addition to your Network Coinsurance Limit. Also, Non-Network Liability amounts will not be applied toward satisfying either your Network or Non-Network Coinsurance Limits.

After your Network Coinsurance Limit is satisfied, benefits for Covered Services provided by a Network Provider are payable by Highmark WV at 100% of the Plan Allowance, unless otherwise stated.

After your Non-Network Coinsurance Limit is satisfied, benefits for Covered Services provided by a Non-Network Provider are payable by Highmark WV at 100% of the Plan Allowance, unless otherwise indicated. You are responsible for payment of some or all of the Provider Charges in excess of the Plan Allowance for Covered Services received from a Non-Network Provider (Non-Network Liability).

4. Co-Pay or Copayment. An upfront set amount that is the responsibility of the Covered Person for Office Visits and other Services as specified in this section or on your ID Card.

5. Deductible. A specified dollar amount you must pay for Covered Services each Benefit Period before we begin to provide payment for benefits. You may be required to pay any applicable Deductible at the time you receive care from a Provider. The copayment is typically payable at the time Covered Services are rendered.

6. Maximum Out-of-Pocket. The maximum amount of expenses Incurred for Deductibles, Copayments and Coinsurances for Covered Services for a Benefit Period per individual or family. The Maximum Out-of-Pocket does not include Non-Network Liability.

pay any applicable Deductible at the time you receive care from a Provider. The copayment is typically payable at the time Covered Services are rendered.

7. Non-Covered Services. Certain Services that may be Incurred or recommended by a Provider may not be a Covered Service under your Policy. As a result, you will be responsible for the cost of such Services. These Services will not apply towards any Fees, Deductibles, and Coinsurances.

8. Non-Network Liability. In addition to any Deductible and Non-Network Coinsurance, you may be responsible for some, or all, of the amount of Actual Charges in excess of our agreed Plan Allowance, when you obtain Services from Non-Network Providers.

9. Office Visit Fees. An upfront charge, usually stated in dollars, for Office Visits with Physicians and Professional Other Providers. The Office Visit Fee applies to Charges for the Office Visit only. This Fee does not apply to other Services received during a Visit, except as specified. Office Visit Fees are in addition to, and do not apply toward any other Deductibles, Fees or Coinsurances. The Office Visit Fee applies per Visit and is payable at the time Covered Services are received.

10. **Precertification Review Penalty.** A financial penalty that you are required to pay for most Inpatient Admissions if you do not contact us as required in Section VIII.

cept as specified. Office Visit Fees are in addition to, and do not apply toward any other Deductibles, Fees or Coinsurances. The Office Visit Fee applies per Visit and is payable at the time Covered Services are received.

10. **Precertification Review Penalty.** A financial penalty that you are required to pay for most Inpatient Admissions if you do not contact us as required in Section VIII.

11. **Waivers.** In some instances, a Network Provider may ask you to sign a “waiver” or other document prior to receiving care. This waiver may state that you accept responsibility for the Charges above the applicable Plan Allowance with Highmark WV or for Services deemed not Medically Necessary by Highmark WV. Generally, Network Providers are prohibited from this practice. See Section V. for circumstances where you may be responsible for non-Medically Necessary Services.

C. **SUMMARY OF BENEFITS DESCRIPTIONS** The following pages provide details regarding specific benefit amounts and limits.

# WV Group Gold Shared Cost PPO 1000

## SUMMARY OF BENEFITS¹

IMPORTANT: PLEASE READ THE SUMMARY OF BENEFITS SECTION. THIS IS PART OF YOUR POLICY AND SUBJECT TO CHANGE. FOR FURTHER EXPLANATION REFER TO YOUR POLICY.

| Benefit | Network | Out-of-Network |

| --- | --- | --- |

| **General Provisions** | | |

| **Benefit Period(1)** | Contract Year | |

| Deductible (per benefit period) Individual Family | $1,000 $2,000 | $2,000 $4,000 |

| Plan Pays – payment based on the plan allowance | 80% after deductible | 60% after deductible |

| Out-of-Pocket Maximums (Includes deductible, coinsurance and copayments

it | Network | Out-of-Network |

| --- | --- | --- |

| **General Provisions** | | |

| **Benefit Period(1)** | Contract Year | |

| Deductible (per benefit period) Individual Family | $1,000 $2,000 | $2,000 $4,000 |

| Plan Pays – payment based on the plan allowance | 80% after deductible | 60% after deductible |

| Out-of-Pocket Maximums (Includes deductible, coinsurance and copayments. Once met, plan pays 100% for the rest of the benefit period.) Individual Family | $3,000 $6,000 | $6,000 $12,000 |

| **Office/Clinic/Urgent Care Visits** | | |

| Retail Clinic Visits | 80% after deductible | 60% after deductible |

| Primary Care Provider Office Visits | 100% after $25 copayment | 60% after deductible |

| Specialist Office & Virtual Visits | 100% after $35 copayment | 60% after deductible |

| Virtual Visit Originating Site Fee | 80% after deductible | 60% after deductible |

| Urgent Care Center Visits | 100% after $35 copayment | 60% after deductible |

| Telemedicine Service(2) | 100% after $10 copayment | |

| **Preventive Care(3)** | | |

| Routine Adult | | |

| Adult immunizations | 100% (deductible does not apply) | Not Covered |

| Colorectal cancer screening | 100% (deductible does not apply) | Not Covered |

| Diagnostic services and procedures | 100% (deductible does not apply) | Not Covered |

| Mammograms, annual routine and medically necessary | 100% (deductible does not apply) | Not Covered |

| Physical exams | 100% (deductible does not apply) | Not Covered |

| Routine gynecological exams, including a Pap Test | 100% (deductible does not apply) | Not Covered |

| Routine adult vision exam | 100% (deductible does not apply) | Not Covered |

| Routine Pediatric | | |

| Diagnostic services and procedures | 100% (deductible does not apply) | Not Covered |

| Pediatric immunizations | 100% (deductible does not apply) | Not Covered |

| Physical exams | 100% (deductible does not apply) | Not Covered |

| Pediatric Vision(4) | | |

| Exam (including

Routine adult vision exam | 100% (deductible does not apply) | Not Covered |

| Routine Pediatric | | |

| Diagnostic services and procedures | 100% (deductible does not apply) | Not Covered |

| Pediatric immunizations | 100% (deductible does not apply) | Not Covered |

| Physical exams | 100% (deductible does not apply) | Not Covered |

| Pediatric Vision(4) | | |

| Exam (including dilation, as professionally indicated) | 100% (deductible does not apply) | Not Covered |

| Pediatric frame selection | 100% (deductible does not apply) | Not Covered |

| Standard eyeglass lenses (per pair) | 100% (deductible does not apply) | Not Covered |

| Pediatric Dental(4) | | |

| Exam and Cleanings | 100% (deductible does not apply) | Not Covered |

| Basic Services (Fluoride treatments, sealants, consultations) | 50% (deductible does not apply) | Not Covered |

| Major Services (Radiographs (all x-rays), space maintainers, amalgam restorations (metal fillings), resin based composite fillings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.)) | 50% (deductible does not apply) | Not Covered |

| Orthodontics(5) (Medically necessary with prior approval. Waiting limits apply.) | 50% (deductible does not apply) | Not Covered |

| Hospital and Medical/Surgical Expenses (including maternity) | | |

| --- | --- | --- |

| Hospital Inpatient | 80% after deductible | 60% after deductible |

| Hospital Outpatient | 80% after deductible | |

| Maternity (non-preventive facility & professional services) including dependent daughter | 80% after deductible | |

| Medical Care (including inpatient visits and consultations)/Surgical Expenses | 80% after deductible | |

| Emergency Services | | |

| Emergency Room Services | 80% after deductible | |

| Emergency Room Services – Non-Emergency | 80% after deductible | 60% after deductible |

| Ambulance | 80% after deductible | |

| Ambulance – Non-Emergency | 80% after deductible | 60% after de

Medical Care (including inpatient visits and consultations)/Surgical Expenses | 80% after deductible | |

| Emergency Services | | |

| Emergency Room Services | 80% after deductible | |

| Emergency Room Services – Non-Emergency | 80% after deductible | 60% after deductible |

| Ambulance | 80% after deductible | |

| Ambulance – Non-Emergency | 80% after deductible | 60% after deductible |

| Therapy, Rehabilitative and Habilitative Services | | |

| Occupational Therapy (Rehabilitative and Habilitative) | 80% after deductible Limit: 30 combined rehabilitative/habilitative visits/benefit period | 60% after deductible |

| Physical Therapy (Rehabilitative and Habilitative) | 80% after deductible Limit: 30 combined rehabilitative/habilitative visits/benefit period | 60% after deductible |

| Respiratory Therapy | 80% after deductible | 60% after deductible |

| Speech Therapy (Rehabilitative and Habilitative) | 80% after deductible | 60% after deductible |

| Spinal Manipulations (Rehabilitative and Habilitative) | 80% after deductible Limit: 30 combined rehabilitative/habilitative visits/benefit period | 60% after deductible |

| Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) | 80% after deductible | 60% after deductible |

| Mental Health/Substance Abuse | | |

| Inpatient | 80% after deductible | 60% after deductible |

| Inpatient Detoxification/Rehabilitation | 80% after deductible | |

| Outpatient | 100% after $35 copayment | |

| Other Services | | |

| Allergy Extracts and Injections | 80% after deductible | 60% after deductible |

| Assisted Fertilization Procedures | Not Covered | |

| Dental Services Related to Accidental Injury | 80% after deductible | 60% after deductible |

| Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) | 80% after deductible | 60% after deductible |

| Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) | 80% aft

after deductible |

| Assisted Fertilization Procedures | Not Covered | |

| Dental Services Related to Accidental Injury | 80% after deductible | 60% after deductible |

| Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) | 80% after deductible | 60% after deductible |

| Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) | 80% after deductible | 60% after deductible |

| Durable Medical Equipment, Orthotics and Prosthetics | 80% after deductible | 60% after deductible |

| Home Health Care | 80% after deductible 100 visits per benefit period, aggregated with Visiting Nurse | 60% after deductible |

| Hospice | 80% after deductible | 60% after deductible |

| Infertility Counseling, Testing and Treatment(6) | 80% after deductible | 60% after deductible |

| Private Duty Nursing | 80% after deductible 35 visits per benefit period | 60% after deductible |

| Skilled Nursing Facility Care | 80% after deductible | 60% after deductible |

| Transplant Services | 80% after deductible | 60% after deductible |

| Precertification Requirements(7) | Yes | |

| Prescription Drugs | |

| --- | --- |

| **Prescription Drug Deductible** Individual Family | None None |

| **Prescription Drug Program**(8) Soft Mandatory Generic *Defined by the Premier 2012 Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered.* *Your plan uses the Comprehensive Formulary with an Incentive Formulary Benefit Design.* | **Retail Drugs (34 -day Supply)** $4 generic copayment $40 formulary brand copayment $70 non-formulary copayment **Maintenance Drugs through Mail Order (90-day Supply)** $10 generic copayment $100 formulary brand copayment $175 non-formulary brand copayment |

lled at a non-network pharmacy are not covered.* *Your plan uses the Comprehensive Formulary with an Incentive Formulary Benefit Design.* | **Retail Drugs (34 -day Supply)** $4 generic copayment $40 formulary brand copayment $70 non-formulary copayment **Maintenance Drugs through Mail Order (90-day Supply)** $10 generic copayment $100 formulary brand copayment $175 non-formulary brand copayment |

(1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact your employer to determine the effective date applicable to your program.

(2) Services must be performed by a Highmark approved telemedicine provider.

(3) Services are limited to those listed on the Preventive Schedule (Women's Health Preventive Schedule may apply). Gender, age and frequency limits may apply.

(4) Pediatric vision and dental benefits are only available to dependent children or health plan members under age 19.

(5) A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality. Prior approval is required. 12 month waiting period required. See your benefit booklet for more details.

(6) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug program.

(7) Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.

n or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.

(8) Under the soft mandatory generic provision, you are responsible for the payment differential when a generic drug is authorized by your provider and you purchase a brand name drug. Your payment is the price difference between the brand name drug and generic drug in addition to the brand name drug copayment or coinsurance amounts, which may apply.

# EHB West Virginia–Pediatric Vision (High Option)

# Vision Care Plan Benefit Summary

| IN-NETWORK BENEFIT | FREQUENCY |

| --- | --- |

| Eligible Participants | Members under 19 years of age^{(1)} |

| Eye Examination (including dilation, as professionally indicated) | Once every 12 months |

| Eyeglass lenses | Once every 12 months |

| Frames | Once every 12 months |

| Contact lenses (in lieu of eyeglass lenses) | Once every 12 months |

| | **MEMBER RESPONSIBILITY** |

| EYE EXAMINATION (including dilation as professionally indicated) | Covered In Full |

| FRAMES | |

| Pediatric Frame Selection | Covered In Full |

| STANDARD EYEGLASS LENSES^{(2)} (per pair) | |

| Single vision | Covered In Full |

| Bifocal | Covered In Full |

| Trifocal | Covered In Full |

| Lenticular | Covered In Full |

| OPTIONAL EYEGLASS LENSES/COATINGS/TREATMENTS (per pair) | **MEMBER RESPONSIBILITY** |

| Standard progressive lenses^{(3)} | Covered In Full |

| Select progressive lenses^{(3)} | Member pays $70 |

| Premium progressive lenses^{(3)} | Member pays $90 |

| Ultra progressive lenses^{(3)} | Member pays $195 |

| Polycarbonate lenses | Covered In Full |

| Blended segment lenses | Member pays $20 |

| Intermediate vision lenses | Member pays $30

r) | **MEMBER RESPONSIBILITY** |

| Standard progressive lenses^{(3)} | Covered In Full |

| Select progressive lenses^{(3)} | Member pays $70 |

| Premium progressive lenses^{(3)} | Member pays $90 |

| Ultra progressive lenses^{(3)} | Member pays $195 |

| Polycarbonate lenses | Covered In Full |

| Blended segment lenses | Member pays $20 |

| Intermediate vision lenses | Member pays $30 |

| Glass photochromic lenses | Member pays $20 |

| Plastic photosensitive lenses | Covered In Full |

| High-index (thinner and lighter) lenses | Member pays $55 |

| Polarized lenses | Member pays $75 |

| Fashion, sun or gradient tinted plastic lenses | Covered In Full |

| Ultraviolet Coating | Covered In Full |

| Scratch-resistant coating | Covered In Full |

| Scratch Protection Plan Single Vision | Member pays $20 |

| Scratch Protection Plan Multifocal | Member pays $40 |

| Standard ARC (anti-reflective coating) | Member pays $35 |

| Premium ARC (anti-reflective coating) | Member pays $48 |

| Ultra ARC (anti-reflective coating) | Member pays $60 |

| CONTACT LENSES (in lieu of eyeglass lenses—per pair or initial supply of disposable contact lenses from the Pediatric Contact Lens Selection) | |

| Contact lens evaluation and fitting | |

| Daily wear | Covered in full when the performing provider dispenses from the pediatric contact lens selection |

| Extended wear | Covered in full when the performing provider dispenses from the pediatric contact lens selection |

| | **Pediatric Contact Lens Selection^{(4)}** |

| Standard daily wear contact lenses | Covered In Full |

| Specialty contact lenses | Covered In Full |

| Disposable contact lenses | Covered In Full |

| Medically necessary contact lenses (prior approval required) | Covered In Full |

(1) Dependents will be terminated from the contract at the end of the month in which they turn 19 for individual contracts.

Note: Termination rules for employer groups are determined by client.

| Covered In Full |

| Specialty contact lenses | Covered In Full |

| Disposable contact lenses | Covered In Full |

| Medically necessary contact lenses (prior approval required) | Covered In Full |

(1) Dependents will be terminated from the contract at the end of the month in which they turn 19 for individual contracts.

Note: Termination rules for employer groups are determined by client.

(2) Includes glass, plastic or oversized lenses.

(3) Progressive multifocals can be worn by most people. Conventional bifocals will be supplied at no additional charge for anyone who is

unable to adapt to progressive lenses. However, the member's payment towards the progressive upgrade will not be refunded.

(4) Disposable contact lens wearers will receive four multi-packs of lenses. Planned replacement lens wearers will receive two multi-packs of lenses.

# EHB West Virginia– Adult Vision (High Option)

# Vision Care Plan Benefit Summary

| NETWORK BENEFIT (Independents & Vision Works) | FREQUENCY |

| --- | --- |

| ELIGIBLE PARTICIPANTS | Members 19 years of age or older |

| Eye Examination (including dilation, as professionally indicated) | Once every 12 months |

| POST REFRACTIVE SERVICES | |

| Frames | Discount on post refractive services received through a participating provider |

| Eyeglass Lenses | |

| Contact Lenses | |

# Schedule of Benefits

THIS PLAN MEETS THE MINIMUM ESSENTIAL HEALTH BENEFIT REQUIREMENTS FOR PEDIATRIC ORAL HEALTH AS REQUIRED UNDER THE FEDERAL AFFORDABLE CARE ACT.

THESE BENEFITS ARE ONLY AVAILABLE FOR CHILDREN THROUGH THE END OF THE CONTRACT YEAR THAT THEY TURN 19.

on post refractive services received through a participating provider |

| Eyeglass Lenses | |

| Contact Lenses | |

# Schedule of Benefits

THIS PLAN MEETS THE MINIMUM ESSENTIAL HEALTH BENEFIT REQUIREMENTS FOR PEDIATRIC ORAL HEALTH AS REQUIRED UNDER THE FEDERAL AFFORDABLE CARE ACT.

THESE BENEFITS ARE ONLY AVAILABLE FOR CHILDREN THROUGH THE END OF THE CONTRACT YEAR THAT THEY TURN 19.

This Policy will pay benefits for Covered Services shown below subject to the Schedule of Exclusions and Limitations and other Policy terms. Payment is based on the Maximum Allowable Charge (MAC) for the specific Covered Service. Participating Dentists accept contracted MACs as payment in full for services. Non-participating Dentists do not limit their charges and may bill You for the difference between their charge and the benefit paid by the Policy.

| Contract Year Deductible per Member: | $0 |

| --- | --- |

| Annual Maximum per Member: | Unlimited |

| Out of Pocket (OOP) Maximum per Member: | Combined with Medical |

| --- | --- | --- | --- | --- |

| Oral Evaluations (Exams) | None | 100% | 100% | N/A |

| Radiographs (All X-Rays) | None | 50% | 50% | N/A |

| Prophylaxis (Cleanings) | None | 100% | 100% | N/A |

| Fluoride Treatments | None | 50% | 50% | N/A |

| Palliative Treatment (Emergency) | None | 50% | 50% | N/A |

| Sealants | None | 50% | 50% | N/A |

| Space Maintainers | None | 50% | 50% | N/A |

| Amalgam Restorations (Metal fillings) | None | 50% | 50% | N/A |

| Resin-based Composite Restorations (White fillings) | None | 50% | 50% | N/A |

| Crowns | None | 50% | 50% | N/A |

| Crown Repair | None | 50% | 50% | N/A |

| Endodontic Therapy (Root canals, etc.) | None | 50% | 50% | N/A |

ers | None | 50% | 50% | N/A |

| Amalgam Restorations (Metal fillings) | None | 50% | 50% | N/A |

| Resin-based Composite Restorations (White fillings) | None | 50% | 50% | N/A |

| Crowns | None | 50% | 50% | N/A |

| Crown Repair | None | 50% | 50% | N/A |

| Endodontic Therapy (Root canals, etc.) | None | 50% | 50% | N/A |

| Other Endodontic Services | None | 50% | 50% | N/A |

| Surgical Periodontics | None | 50% | 50% | N/A |

| Non-Surgical Periodontics | None | 50% | 50% | N/A |

| Periodontal Maintenance | None | 50% | 50% | N/A |

| Prosthetics (Complete or Fixed Partial Dentures) | None | 50% | 50% | N/A |

| --- | --- | --- | --- | --- |

| Adjustments and Repairs of Prosthetics | None | 50% | 50% | N/A |

| Other Prosthetic Services | None | 50% | 50% | N/A |

| Implant Services | None | 50% | 50% | N/A |

| Simple Extractions | None | 50% | 50% | N/A |

| Surgical Extractions | None | 50% | 50% | N/A |

| Oral Surgery | None | 50% | 50% | N/A |

| General Anesthesia, Nitrous Oxide and/or IV Sedation | None | 50% | 50% | N/A |

| Consultations | None | 50% | 50% | N/A |

| Medically Necessary Orthodontics, with Our prior approval and a written plan of care Orthodontics | 12 Months | 50% | 50% | N/A |

### Medically Necessary Orthodontics Coverage:

In this section, "Medically Necessary" or "Medical Necessity" shall mean health care services that a physician or Dentist, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

care Orthodontics | 12 Months | 50% | 50% | N/A |

### Medically Necessary Orthodontics Coverage:

1. in accordance with the generally accepted standards of medical/dental practice;

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

3. not primarily for the convenience of the patient or physician/Dentist, 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.

As used subpart 1, above, "generally accepted standards of medical/dental practice" means:

- standards that are based on credible scientific evidence published in peer-reviewed, medical/dental literature generally recognized by the relevant professional community;

- recognized Medical/Dental and Specialty Society recommendations;

- the views of physicians/Dentists practicing in the relevant clinical area; and

- any other relevant factors.

A Medically Necessary orthodontic service is an orthodontic procedure that occurs as part of an approved orthodontic plan that is intended to treat a severe dentofacial abnormality.

### Coverage of Medically Necessary Orthodontics:

1. Orthodontic treatment must be Medically Necessary and be the only method capable of:

a) Preventing irreversible damage to the Member's teeth or their supporting structures and,

b) Restoring the Member's oral structure to health and function.

2. Members must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.

ry Orthodontics:

1. Orthodontic treatment must be Medically Necessary and be the only method capable of:

a) Preventing irreversible damage to the Member's teeth or their supporting structures and,

b) Restoring the Member's oral structure to health and function.

2. Members must have a fully erupted set of permanent teeth to be eligible for comprehensive, Medically Necessary orthodontic services.

3. All Medically Necessary orthodontic services require prior approval and a written plan of care.

## IV. Eligibility

# A. APPLYING FOR COVERAGE

When you apply for coverage, you will be asked to select one of the following types of coverage:

- Employee only.

- Employee and child.

- Employee and spouse.

- Employee and children.

- Family.

An Application must be completed in all instances. In reviewing an Application, we may request more information. Coverage will not begin until your Application has been approved and you have been provided with an Effective Date.

# B. ELIGIBLE EMPLOYEES AND PREMIUM COST SHARING

See your Plan Administrator for specific employee eligibility and any employee premium cost sharing requirements.

# C. ELIGIBLE DEPENDENTS

An eligible Dependent is an individual identified by the Certificate Holder through the appropriate enrollment process or on an application form accepted by the Plan who is:

a. Spouse of the opposite sex:

The Certificate Holder's spouse under a legally valid existing marriage between persons of the opposite sex.

Please check with your Group Administrator to see if the following (b and c) are applicable:

b. Spouse of the same sex:

The Certificate Holder's spouse under a legally valid existing marriage between persons of the same sex when entered into within a state that sanctions such marriages by law and that is valid pursuant to such law at the time of the marriage.

c. Domestic Partner:

opposite sex.

Please check with your Group Administrator to see if the following (b and c) are applicable:

b. Spouse of the same sex:

c. Domestic Partner:

A Domestic Partner shall be considered for eligibility as long as a domestic partnership (a voluntary relationship between two (2) Domestic Partners) exists with you. In addition, the children of the Domestic Partner shall be considered for eligibility as if they were your children as long as the domestic partnership exists.

d. Dependent Children:

- The Certificate Holder or spouse's children and stepchildren.

- Adopted children or children placed for adoption with the Certificate Holder or Certificate Holder's spouse.

- Any Dependent children which by court order must be provided health care coverage by the Certificate Holder or the Certificate Holder's spouse.

- Children for whom either the Certificate Holder or the Certificate Holder's Spouse is the legal guardian. We will require court or government approval of guardianship.

- Children placed for foster care with the Certificate Holder or Certificate Holder's spouse.

# 1. Dependent Age Limits and Disabled Children

The age limits for all Eligible Dependent children are specified in Section III. Coverage for Eligible Dependents will continue past the age limit for Eligible Dependents who cannot work to support themselves due to a physical or mental disability. The disability must have started before the age limit was attained and must be medically certified by a Physician. Following the Eligible Dependent reaching the age limit, we may annually require further proof of the continuance of such incapacity and dependency.

# 2. Adopted Children

e age limit for Eligible Dependents who cannot work to support themselves due to a physical or mental disability. The disability must have started before the age limit was attained and must be medically certified by a Physician. Following the Eligible Dependent reaching the age limit, we may annually require further proof of the continuance of such incapacity and dependency.

# 2. Adopted Children

Any child under the age of 18 who is adopted by you, including a child who is legally placed with you for adoption, will be eligible for Dependent insurance upon the date of placement with you. A child will be considered placed for adoption when the natural parents (or legal guardian) legally consent to the adoption process under applicable state law and you come legally obligated to support that child, totally or partially, prior to that child's adoption. You may be required to provide documentation evidencing the consent. See the Special Enrolment Procedures.

If a child placed for adoption is not adopted, all health coverage ceases when the placement ends.

# 3. Qualified Medical Child Support Order

If a Qualified Medical Child Support Order is issued for your child, that child will be eligible for coverage as required by the order and the child will not be considered a Late Entrant for Dependent insurance. A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction or state agency that satisfies all of the following:

- the order specifies your name and last known address, and the child's name and last known address;

- the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined;

- the order states the period to which it applies; and

- the order specifies each plan that it applies to.

iction or state agency that satisfies all of the following:

- the order specifies your name and last known address, and the child's name and last known address;

- the order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be determined;

- the order states the period to which it applies; and

- the order specifies each plan that it applies to.

The Qualified Medical Child Support Order may not require the health insurance policy to provide coverage for any type or form of benefit or option not otherwise provided under the Group Health Plan.

# 4. Custodial Parent Rights

If a child has health coverage through an insurer of a noncustodial parent, the custodial parent may be provided information as may be necessary for the child to obtain benefits. The custodial parent, or the Provider with the approval of the custodial parent, may submit Claims for Services without the noncustodial parent's approval and payment for such Claims may be sent directly to the custodial parent, the Provider or the state Medicaid agency.

The payment to the custodial parent, the Provider or the state Medicaid agency fully satisfies our obligation to the noncustodial parent under this Group Health Plan with respect to the covered child's Claims.

# D. ENROLLMENT UPON INITIAL ELIGIBILITY

1. Time for Applying. An Eligible Employee has until the first of the month beginning after the date of becoming an Eligible Employee to enroll by submitting an Application for participation on such form(s) as may be prescribed from time to time by the Group Health Plan and by providing the Group Health Plan with such other information as may be requested.

2. Required Information. Participation by the Eligible Employee and, if applicable, his Eligible Dependent(s) shall be contingent upon receipt by the Group Health Plan of a completed Application form and any other information requested by the Group Health Plan or us and, if applicable, payment of any required employee contribution.

Health Plan with such other information as may be requested.

3. Effective Date. If an Eligible Employee enrolls in the Group Health Plan pursuant to this section, the Eligible Employee and, if applicable, his or her Eligible Dependent(s) shall become Covered Person(s) effective the first day of the month after he or she first becomes an Eligible Employee (the Covered Person's "Enrollment Date"). If the Eligible Employee and, if applicable, his or her Eligible Dependent(s), fail to enroll in the Group Health Plan by the first day of the month after becoming eligible, the Eligible Employee and, if applicable, his or her Eligible Dependents must wait for the Group Health Plan's next open enrollment period to enroll in the Group Health Plan unless they are eligible to enroll under a Special Enrollment procedure or a Qualified Medical Child Support Order described elsewhere within this Section IV.

4. Initial and Annual Enrollment and Effective Dates for Coverage Offered Through an Exchange. If your coverage under the Group Health Plan is a QHP offered through an Exchange, the Exchange is responsible for establishing an enrollment process that includes:

- Determining employer eligibility to purchase coverage for Qualified Employees;

- Providing the timeframe for a qualified employers to select the level of coverage or QHP that will be available to Qualified Employees;

- Providing the timeframe for a Qualified Employee to complete an application for coverage;

- Determining and verifying employee eligibility to enroll in a QHP;

- Processing the enrollment of Qualified Employees into QHPs; and

- Establishing effective dates for employee coverage.

meframe for a qualified employers to select the level of coverage or QHP that will be available to Qualified Employees;

- Providing the timeframe for a Qualified Employee to complete an application for coverage;

- Determining and verifying employee eligibility to enroll in a QHP;

- Processing the enrollment of Qualified Employees into QHPs; and

- Establishing effective dates for employee coverage.

A qualified employer may purchase coverage during the initial open enrollment period beginning on October 1, 2013 for coverage effective as of January 1, 2014.

After the initial open enrollment period, Qualified Employees generally may enroll in or change QHP coverage only during subsequent open enrollment periods that occur after the employer's annual election period unless otherwise specified in this Section IV.

# E. ELIGIBILITY CHANGES AND SPECIAL ENROLLMENT PROCEDURES

For Highmark WV to administer consistent coverage for you and your Dependents, you must inform the Group immediately of any changes in eligibility (births, adoptions, deaths, marriages, divorces, etc.) that may affect your coverage.

# 1. Dependent Additions and Special Enrollment Available for New Dependents

Special Enrollment is available if you marry or acquire a child through birth, adoption or placement for adoption. You must notify your Plan Administrator and submit an Application to us within 30 days of the event to add a newly acquired Eligible Dependent. If we receive the Application within 30 days of the event, the Effective Date of the Eligible Dependent's coverage will be:

- The date of birth or placement for adoption.

- The first of the next month after marriage.

If we do not receive the Application within 30 days of the event, acceptance of the Application may be denied.

# 2. Special Enrollment Rights for Loss of Other Coverage

a. Loss of other group coverage. Special Enrollment is available for individuals, provided:

Eligible Dependent's coverage will be:

- The date of birth or placement for adoption.

- The first of the next month after marriage.

If we do not receive the Application within 30 days of the event, acceptance of the Application may be denied.

# 2. Special Enrollment Rights for Loss of Other Coverage

a. Loss of other group coverage. Special Enrollment is available for individuals, provided:

1. They remain eligible under the Group Health Plan terms;

2. They originally declined this coverage because of the other coverage;

(i) If the other coverage was COBRA, it has since exhausted; or

(ii) If the other coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated; and

3. The employee requests such enrollment not later than 30 days after the date of exhaustion of the other coverage.

b. Loss of Medicaid or CHIP Coverage. Special Enrollment is also available to an individual if the individual:

(i) is no longer eligible for coverage under title XIX of the Social Security Act (Medicaid) or a state children's health plan under title XXI of the Social Security Act (CHIP), provided the individual requests coverage under the Group Health Plan within 60 days after the date of termination from this coverage; or

Coverage. Special Enrollment is also available to an individual if the individual:

(ii) becomes eligible for assistance for Group Health Plan coverage under title XIX of the Social Security Act (Medicaid) or state children's health plan under title XXI of the Social Security Act, provided the individual requests coverage under the Group Health Plan within 60 days of the date the individual is determined to be eligible for assistance.

Coverage for both of the above situations shall be effective on the first day of the month following the date of enrollment.

3. Additional Special Enrollment Rights if you have coverage through an Exchange

You may be permitted a Special Enrollment period of 30 days through an Exchange from the date of occurrence of any of the following triggering events:

- A Qualified Employee or dependent (including a spouse) of an enrollee loses other minimum essential coverage;

- A Qualified Employee gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption;

- A Qualified Employee's enrollment or non-enrollment in a QHP is unintentional, inadvertent, erroneous or is the result of an error, misrepresentation, or inaction of the Exchange or its agents;

- An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled violated a material provision of its contract with the enrollee;

- A Qualified Employee or enrollee gains access to new QHPs as a result of a permanent move;

- An Indian may enroll in a QHP or change from one QHP to another one time per month; or

- A Qualified Employee demonstrates to the Exchange that the individual meets "other exceptional circumstances" as the Exchange or HHS may provide, inclu

violated a material provision of its contract with the enrollee;

- A Qualified Employee or enrollee gains access to new QHPs as a result of a permanent move;

- An Indian may enroll in a QHP or change from one QHP to another one time per month; or

- A Qualified Employee demonstrates to the Exchange that the individual meets "other exceptional circumstances" as the Exchange or HHS may provide, including those that would impede his or her ability to enroll on a timely basis, through no fault of his or her own (e.g., a natural disaster).

4. Changes in Eligibility

You must immediately notify your Group of any changes in eligibility (e.g., divorce) or when a Covered Person under your Certificate becomes eligible for Medicare or becomes covered under another health insurance policy. When you or a Dependent becomes ineligible, you and your Dependents may be eligible for continuation coverage described in this Section IV. COBRA continuation coverage allows individuals 60 days to notify their Group of such ineligibility from the date they become ineligible. It is important to notify the Group as soon as possible to avoid loss of guaranteed availability rights for other coverage.

5. Nondiscrimination

Subject to all limitations within this Contract, individuals may not be excluded from coverage under the terms of the Contract, or charged more for benefits, based on specified factors related to

health status, medical condition (both physical and mental), Claims experience, receipt of health care, medical history, genetic information, evidence of insurability, or disability.

Highmark WV does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation.

# F. OPEN ENROLLMENT

benefits, based on specified factors related to

health status, medical condition (both physical and mental), Claims experience, receipt of health care, medical history, genetic information, evidence of insurability, or disability.

Highmark WV does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation.

# F. OPEN ENROLLMENT

During the Group Health Plan's open enrollment period, an Eligible Employee may elect to participate in the Group Health Plan, singly or with his Eligible Dependents, or to add, modify, or eliminate coverage under the Group Health Plan. Any changes elected during the Group Health Plan's open enrollment period shall be effective as of the first day of the Benefit Period immediately following the close of the open enrollment period.

# G. EFFECTIVE DATE

Coverage starts on the Effective Date:

- In accordance with the provisions of the Group Contract and this Certificate;

- Upon acceptance by us of your Application; and

- Only when premiums are fully paid.

No benefits will be provided for Charges Incurred prior to your Effective Date. Coverage will not be delayed or denied due to confinement in a Hospital or other health care institution on your Effective Date.

# H. IDENTIFICATION CARDS (ID CARDS)

You will receive an ID Card. It contains information you will need when filing a claim or making an inquiry. Your ID Card is the property of Highmark WV. The ID Card must be returned to Highmark WV if your coverage ends for any reason. Further use of the ID Card is not permitted and may subject you to legal action.

# I. MEDICARE ELIGIBILITY

Upon becoming eligible for Medicare, coverage may be continued in any of several ways. Your Plan Administrator can tell you if any of the following options are available to you.

# 1. Active Employees

If you are still actively employed, you may be allowed to continue your coverage through your Group on the same basis as prior to your becoming Medicare-eligible.

# 2. Retirees

EDICARE ELIGIBILITY

Upon becoming eligible for Medicare, coverage may be continued in any of several ways. Your Plan Administrator can tell you if any of the following options are available to you.

# 1. Active Employees

If you are still actively employed, you may be allowed to continue your coverage through your Group on the same basis as prior to your becoming Medicare-eligible.

# 2. Retirees

If you have retired and coverage is provided to you under your former employer's Group Contract, you may be allowed to participate on the same basis as above. You may be required to pay part of the premium in accordance with your Group Contract. The Group must collect from you your portion of the premium.

If your former Group does not provide retiree benefits, coverage may be available with Highmark WV. To be considered for coverage, you must apply for and enroll in Medicare Part A and Part B.

Highmark WV is not permitted to offer a Direct Pay (non-group) policy to a Medicare-eligible person. You may obtain a Medicare Supplemental or Medicare Advantage policy, however if you are a Medicare eligible resident of West Virginia, you are not eligible for Traditional Medicare Supplemental coverage if you are presently enrolled in a Group Medicare Advantage product.

# J. NON-MEDICARE RETIREES

If you have retired and coverage is not continued under your former employer's Group Contract and you are not eligible for Medicare, you may be eligible for coverage under our individual conversion product. Coverage under the conversion coverage contract may be different. You must apply in writing no later than 30 days after your coverage stops.

You must pay for conversion coverage from the date you stop being a Member under this Contract. If you pay from that date, your coverage under the conversion contract will start on the date the coverage under this Contract stops. Further information is provided in this Section IV.

# K. HOW AND WHEN YOUR BENEFITS MAY CHANGE

ou must apply in writing no later than 30 days after your coverage stops.

# K. HOW AND WHEN YOUR BENEFITS MAY CHANGE

The benefits provided by this Certificate may be changed or revised at any time by amendment to the Group Contract, and if applicable, by approval of the West Virginia Offices of the Insurance Commissioner. If the benefits are changed or revised, the Plan Administrator will be given notice prior to the changes becoming effective. It is the Plan Administrator's responsibility to notify you of these changes and when they become effective. If you are receiving Covered Services at the time your new benefits become effective, we will only pay for such Services to the extent they continue to be Covered Services under the new benefits.

# L. HOW AND WHEN YOUR COVERAGE STOPS

- When a Covered Person stops being an Eligible Dependent, coverage stops as specified in this Certificate or Group Contract.

- When a Covered Person stops being an eligible Certificate Holder, all coverage stops according to the terms of the Group Contract.

- Termination of the Group Contract by the Plan Administrator automatically ends all of your coverage. It is the responsibility of the Plan Administrator to tell you of such termination.

- If Highmark WV terminates the Contract, you and the Plan Administrator will be notified 60 days in advance of the coverage termination date. You may be eligible for conversion coverage as indicated in this Section IV.

- We have the right to void coverage of any Covered Person who engages in fraud or an intentional misrepresentation of a material fact.

- When a Group or Covered Person fails to make a required premium payment, coverage stops at the end of the month of the last fully paid premium payment.

of the coverage termination date. You may be eligible for conversion coverage as indicated in this Section IV.

- We have the right to void coverage of any Covered Person who engages in fraud or an intentional misrepresentation of a material fact.

- When a Group or Covered Person fails to make a required premium payment, coverage stops at the end of the month of the last fully paid premium payment.

For enrollees in a QHP through an Exchange, coverage may terminate when:

- The enrollee is no longer eligible for coverage in a QHP through the Exchange;

- The enrollee changes from one QHP to another during the annual enrollment period;

- The QHP terminates or is no longer certified;

- Non-payment on premiums; or

- The employer chooses to withdraw from participation in the Exchange.

When coverage stops, you will be provided a Certificate of Creditable Coverage free of charge. You may also request a Certificate of Creditable Coverage Certificate by contacting Member Services.

To protect your rights for other coverage after termination of your eligibility for this Group Health Plan, be sure to avoid lapses in Creditable Coverage of more than 63 days.

M. CONTINUATION COVERAGE – COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended)

Your Group Administrator can tell you if your Group Health Plan is subject to the following COBRA regulations and, if so, how these benefits are administered. Your employer is required to provide you with notice of your COBRA rights if your Group Health Plan is subject to COBRA.

han 63 days.

M. CONTINUATION COVERAGE – COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended)

A federal law (Public Law 99-272, Title X) known as COBRA was enacted requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage under the Group Health Plan would otherwise end. This Section is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of the law. Both you and your covered spouse, if applicable, should take the time to read this Section and the notice provided by your employer carefully and refer to them in the event that any action is required on your part.

EMPLOYEE: If you are an employee covered by this Group Health Plan, you may have the right to choose this continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).

EMPLOYEE’S SPOUSE: If you are the covered spouse of an Eligible Employee, you may have the right to choose continuation coverage for yourself if you lose Group Health Plan coverage for any of the following four (4) reasons:

1. The death of the employee;

2. The termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment;

3. Divorce or legal separation from the employee; or

4. The employee becomes entitled to Medicare.

to choose continuation coverage for yourself if you lose Group Health Plan coverage for any of the following four (4) reasons:

1. The death of the employee;

2. The termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment;

3. Divorce or legal separation from the employee; or

4. The employee becomes entitled to Medicare.

EMPLOYEE’S CHILD: In the case of a covered Eligible Dependent child of an employee (including a child of a covered employee born or adopted during the period of COBRA continuation), he / she has the right to continuation coverage if Group Health Plan coverage is lost for any of the following five (5) reasons:

1. Death of the employee;

2. The termination of the employee’s employment (for reasons other than gross misconduct) or reduction in employee’s hours of employment;

3. Parent’s divorce or legal separation;

4. Employee becomes entitled to Medicare; or

5. The Dependent ceases to be an Eligible “Dependent child” under the terms of the Group Health Plan.

You also have a right to elect continuation coverage if you are covered under the Group Health Plan as a retiree or spouse or child of a retiree, and lose coverage within one year before or after the employer’s commencement of proceedings under Title 11 (bankruptcy), United States Code.

The Eligible Employee or family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a child losing Dependent status within 60 days of the date of the qualifying event which would cause a loss of coverage. The notice must be in writing, and should be sent to the Plan Administrator. When the employer is notified that one of these events has happened, you will in turn be notified that you and your Eligible Dependents have the right to choose continuation coverage. Under the law, you and your Eligible Dependents have 60 days from the later of the date you would lose coverage or from the date of the notice to elect continuation coverage

should be sent to the Plan Administrator. When the employer is notified that one of these events has happened, you will in turn be notified that you and your Eligible Dependents have the right to choose continuation coverage. Under the law, you and your Eligible Dependents have 60 days from the later of the date you would lose coverage or from the date of the notice to elect continuation coverage. If and when you and your Eligible Dependents make this election, coverage will become effective on the day after coverage would otherwise be terminated.

If you do not choose continuation coverage, your coverage under the Group Health Plan will end in accordance with the provisions outlined in this Certificate.

If you choose continuation coverage, the Plan Administrator is required to give you coverage, which, as of the time coverage is being provided, is identical to the coverage provided under the Group Health Plan to similarly situated employees or Eligible Dependents. If coverage for similarly situated employees and Eligible Dependents is modified after you elect continuation coverage, your coverage will be modified accordingly.

The required continuation coverage for employee and Eligible Dependents is up to 18 months for employee's termination or reduction in hours of employment. An extension from 18 months up to 29 months is available under certain circumstances to disabled employees (*) who have been determined by the Social Security Administration (SSA) to have a disability onset date either before the COBRA event or within the first 60 days of COBRA continuation coverage. The required continuation coverage is up to 36 months for Eligible Dependents in the following situations: when the employee is entitled to Medicare; divorce or legal separation; death of employee; and cessation of Dependent child status.

However, the law also provides that your continuation coverage may be terminated for any of the following reasons:

first 60 days of COBRA continuation coverage. The required continuation coverage is up to 36 months for Eligible Dependents in the following situations: when the employee is entitled to Medicare; divorce or legal separation; death of employee; and cessation of Dependent child status.

However, the law also provides that your continuation coverage may be terminated for any of the following reasons:

1. The employer no longer provides Group Health Plan coverage to any of its employees;

2. You do not pay the premium for your continuation coverage in a timely manner;

3. You first become covered, after electing COBRA continuation coverage, under any other group health plan (as an employee or otherwise) which does not contain any exclusion or limitation which would apply to the COBRA covered individual; or

4. You first become entitled to Medicare, after electing COBRA continuation coverage.

You do not have to show that you are insurable to choose continuation coverage. However, you will have to pay all of the cost, the Group rate premium plus a 2% administrative fee, for your continuation coverage. At the end of the 18-month, 29-month, or 36-month continuation coverage period, you must be allowed to enroll in an individual conversion health plan provided under the current group health plan, if the plan provides a conversion privilege. In addition, under the Health Insurance Portability & Accountability Act (HIPAA, 1996), in certain circumstances, such as when you exhaust COBRA coverage, you may have the right to buy individual health coverage.

If you have any questions about COBRA, please contact your Plan Administrator. In addition, if you have changed your marital status or you, your spouse, or any eligible covered Dependent have changed address; please notify your Plan Administrator in writing. If any covered child is at a different address, please notify your Plan Administrator in writing so that a separate notice may be sent.

age.

(*) Note: A qualified beneficiary who is determined under Title II or XVI of the Social Security Act to have been disabled as of the date of the COBRA event or within 60 days of COBRA coverage, may be eligible to continue coverage for an additional 11 months (29 months total). You must notify the employer within 60 days of the determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. You must provide a copy of the SSA determination of disability. The employer can charge up to 150% of the applicable premium during the 11-month extension. The disabled individual must notify the employer within 30 days of any final determination that he or she is no longer disabled. If the coverage is extended to a total of 29 months, extended coverage will cease upon a final determination that the qualified beneficiary is no longer disabled.

# N. CONTINUATION COVERAGE - MINI-COBRA

West Virginia law requires that insurers offer Group coverage, at the same benefit levels and Group rates for a period of up to 18 months, in the event a Covered Person loses Group coverage due to termination for reasons other than misconduct that would disqualify you for unemployment benefits. This law applies to former Covered Persons of certain small employers with 2-19 employees who are not entitled to coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

oup rates for a period of up to 18 months, in the event a Covered Person loses Group coverage due to termination for reasons other than misconduct that would disqualify you for unemployment benefits. This law applies to former Covered Persons of certain small employers with 2-19 employees who are not entitled to coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

A Covered Person must give written notice to Highmark WV within 20 days after the termination of employment of his or her intent to apply for continuation coverage. The notice must, at a minimum, identify the Covered Person, the Employer and, to the extent that information is known, the names and addresses of all other eligible dependents, and the benefit plan number. You may obtain a copy of this notice for your completion by contacting Member Services.

Highmark will then send each eligible adult Covered Person an election and premium notice within 15 days after receipt of the completed notice of intent. The election and premium notice, along with the initial premium payment, must be submitted to Highmark WV within 30 days.

This continuation coverage may be terminated for any of the following reasons:

1. After 18 months of continuation coverage;

2. If you do not pay the premium for your continuation coverage in a timely manner;

3. If you become covered under any other group health plan;

4. If you become entitled to Medicare; or

5. Your former employer terminates coverage for all employees and does not replace it with similar coverage under another group health plan.

# O. MILITARY SERVICE

ons:

1. After 18 months of continuation coverage;

2. If you do not pay the premium for your continuation coverage in a timely manner;

3. If you become covered under any other group health plan;

4. If you become entitled to Medicare; or

5. Your former employer terminates coverage for all employees and does not replace it with similar coverage under another group health plan.

# O. MILITARY SERVICE

If you are called up for active military service, commissioned corps of the Public Health Service and certain non-military emergency responders, you may be entitled to military coverage under the Uniformed Services Employment and Reemployment Rights Act (USERRA). USERRA may also entitle you reenrollment upon returning from active military service without any Waiting Periods, any Pre-Existing Condition exclusions, or a significant break in coverage.

# P. INPATIENT BENEFITS INCURRED BEFORE TERMINATION AND EXCEEDING THE TERM OF CONTRACT

If you are an Inpatient of a Hospital or Skilled Nursing Facility on the day your coverage stops, the benefits listed under the Inpatient Services Section, subsections Bed, Board and General Nursing Services and Ancillary Services only, will continue until the earliest of the following:

1. We pay your maximum benefits;

2. You leave the Hospital or Skilled Nursing Facility;

3. The end of the Benefit Period in which your coverage stopped; or

4. You have other group health care coverage for the condition that requires your Inpatient Hospital or Skilled Nursing Facility care.

No other benefits will be provided once your coverage stops.

# Q. CONVERSION PRIVILEGE

t of the following:

1. We pay your maximum benefits;

2. You leave the Hospital or Skilled Nursing Facility;

3. The end of the Benefit Period in which your coverage stopped; or

4. You have other group health care coverage for the condition that requires your Inpatient Hospital or Skilled Nursing Facility care.

No other benefits will be provided once your coverage stops.

# Q. CONVERSION PRIVILEGE

If either you or a Dependent stop being a Covered Person, you and your Dependents may be eligible for conversion to a non-group policy offered by Highmark WV if there was continual coverage under this Group Health Plan for three months immediately prior to the termination. You are eligible for conversion coverage if the Group coverage is terminated (including discontinuance of the group policy in its entirety), with the exception of the following reasons:

1. You fail to pay any required contribution for your group health care coverage;

2. You obtain other group health insurance coverage within 31 days of termination of coverage under the Group Contract;

3. You become covered under Medicare; or

4. You have similar coverage under any group or non-group health benefits plan, or are provided similar benefits pursuant to, or in accordance with, the requirements of any state or federal law.

The conversion coverage and rates may be different than the coverage provided under this Contract. However, we will not require evidence of insurability for eligibility under the conversion coverage and there will not be any Preexisting Condition Exclusions on the conversion coverage. You must apply in writing and make the first premium payment to us for such coverage no later than 31 days after your coverage under this Contract ends.

# R. GUARANTEED RENEWABILITY OF COVERAGE

der this Contract. However, we will not require evidence of insurability for eligibility under the conversion coverage and there will not be any Preexisting Condition Exclusions on the conversion coverage. You must apply in writing and make the first premium payment to us for such coverage no later than 31 days after your coverage under this Contract ends.

# R. GUARANTEED RENEWABILITY OF COVERAGE

Your coverage will renew or continue in force except in situations involving nonpayment of premiums, fraud, violation of participation or contribution rules, termination of the plan, enrollee's movement outside the service area or discontinuance of a product or all coverage.

# V. Health Care Benefits

This Section describes the Covered Services available to you. Please refer to Section III for specific payment details, benefit maximums and limitations.

For assistance in obtaining more specific benefit information on what procedures or tests are covered, call Member Services. Certain Services may also require Prior Authorization. For additional information, see Section VIII, visit Highmark WV's website at www.highmarkbcbswv.com or contact Member Services.

# A. MEDICAL NECESSITY REQUIREMENT AND MEMBER LIABILITY

All Services must be Medically Necessary unless otherwise specified. Medical Necessity is determined by qualified Highmark WV personnel. Generally, Network Providers are prohibited from billing you for Services determined by Highmark WV to not be Medically Necessary. However, you could be responsible for such Charges in certain circumstances. In order to charge you, among other things, the Network Provider must provide you with advance notice, in writing, that the Service or Supply may not be Medically Necessary along with estimated Charges. You must also agree in writing to proceed with such Services and Supplies and to assume the cost thereof

ally Necessary. However, you could be responsible for such Charges in certain circumstances. In order to charge you, among other things, the Network Provider must provide you with advance notice, in writing, that the Service or Supply may not be Medically Necessary along with estimated Charges. You must also agree in writing to proceed with such Services and Supplies and to assume the cost thereof. In addition to the preceding requirements, Highmark WV requires some Network Providers to specifically request a determination in advance that a Service or Supply is not Medically Necessary. For more information, refer to Section VIII. Non-Network Providers may bill you for Services deemed by us as not Medically Necessary.

# B. PRIOR AUTHORIZATION

Certain Services require Prior Authorization. For more information, go to Section VIII, call Member Services or visit Highmark WV's website at www.highmarkbcbswv.com. The authorization list is located under the Provider drop-down tab.

# C. ALLERGY TESTS AND TREATMENT

Allergy tests that are performed and related to a specific diagnosis are Covered Services. Desensitization Treatments are also Covered Services.

# D. AMBULANCE SERVICES

See also, Emergency Care Services Section.

# 1. General

Ambulance Services are covered when clinical condition is such that the use of any other method of transportation would endanger the patient's medical condition. Payment will not be made for ambulance Service when an ambulance was used simply for convenience or because other means of transportation was not available.

Trips must be to the closest facility that can give Covered Services appropriate for your condition. Transportation will also be covered when provided by a professional ambulance Service for other than local ground transportation. Special Treatment must be required and the transportation must be to the nearest Hospital qualified to provide the special Treatment.

Reimbursement may be made for Services that meet the following conditions:

at can give Covered Services appropriate for your condition. Transportation will also be covered when provided by a professional ambulance Service for other than local ground transportation. Special Treatment must be required and the transportation must be to the nearest Hospital qualified to provide the special Treatment.

Reimbursement may be made for Services that meet the following conditions:

- Emergency situations, e.g., as a result of an accident, injury or acute illness, or

- The need to be restrained, or

- Unconsciousness or shock, or

- Oxygen or other emergency Treatment is required on the way to the destination, or

- Fracture that had not been set or the possibility of a fracture, or

- Sustained an acute stroke or myocardial infarction, or

- Severe hemorrhage, or

- Confinement to a bed before and after the ambulance trip, or

- Could be moved only by stretcher.

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, and, in non-emergency situations, be capable of transporting Members with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle.

# 2. Air Ambulance Services.

Air ambulance transportation is covered if the aircraft meets air ambulance criteria and when the Service is medically appropriate. The Covered Person's medical condition must require immediate and rapid ambulance transportation that cannot be provided by land ambulance and either:

- The point of great distances or other obstacles are involved in getting the patient to the nearest Hospital with appropriate facilities capable of providing the required level and type of care to treat the Member's condition; or

- Pick-up is inaccessible by land vehicle.

Air ambulance Services are not covered for transport to a facility that is not an acute care Hospital, such as a nursing facility, physician's office or a Member's home.

# E. AUTISM SPECTRUM DISORDER

he patient to the nearest Hospital with appropriate facilities capable of providing the required level and type of care to treat the Member's condition; or

- Pick-up is inaccessible by land vehicle.

Air ambulance Services are not covered for transport to a facility that is not an acute care Hospital, such as a nursing facility, physician's office or a Member's home.

# E. AUTISM SPECTRUM DISORDER

Treatments include those that are ordered or prescribed by a licensed physician or licensed psychologist in accordance with a Treatment Plan developed from a comprehensive evaluation by a Certified Behavior Analyst for an individual diagnosed with Autism Spectrum Disorder. See Section VIII for information regarding Treatment Plans. Treatment may include, but not be limited to, Applied Behavioral Analysis provided or supervised by a Certified Behavioral Analyst.

Progress reports are required semi-annually from the Certified Behavior Analyst. In order for Treatment to continue, we may require documented Objective Evidence or a clinically supportable statement of expectation that:

(1) The individual's condition is improving in response to Treatment, and

(2) A maximum improvement is yet to be attained, and

(3) There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

# F. BONE MARROW PROCEDURES

Benefits are provided for the following types of bone marrow transplants.

- Allogeneic.

- Autologous.

- Syngeneic.

- Peripheral stem cell transplants.

Covered Services will include the following.

- Bone marrow donation and storage.

- Pre-transplant chemotherapy and/or radiation Treatment.

- Bone marrow or peripheral stem cell transplant.

- Post-transplant Outpatient care directly related to the transplant.

vided for the following types of bone marrow transplants.

- Allogeneic.

- Autologous.

- Syngeneic.

- Peripheral stem cell transplants.

Covered Services will include the following.

- Bone marrow donation and storage.

- Pre-transplant chemotherapy and/or radiation Treatment.

- Bone marrow or peripheral stem cell transplant.

- Post-transplant Outpatient care directly related to the transplant.

- Expenses for transportation to and from the site of the transplant operation. Benefits will also be provided for meals and lodging for the covered recipient and one additional adult. If the patient is a minor, expenses for transportation, meals, and lodging will be provided for the patient and two accompanying adults (Contact Medical Management to receive further details regarding travel and lodging), and

- Retransplantation.

# G. CLINICAL TRIALS COVERAGE

Coverage is provided for approved clinical trials if the individual's referring provider has concluded that the member's participation in the trial would be appropriate or the individual provides medical and scientific information establishing that participation in the trial would be appropriate. Coverage includes routine patient costs for items and services furnished in connection with participation in the trial. Highmark WV will not discriminate against any individual participating in such trials.

An approved clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is one of the following:

1. A federally funded or approved trial;

2. A clinical trial conducted under an FDA investigational new drug application; or

3. A drug trial that is exempt from the requirement of an FDA investigational new drug application.

# H. COST EFFECTIVE NON-COVERED SERVICES

ion to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is one of the following:

1. A federally funded or approved trial;

2. A clinical trial conducted under an FDA investigational new drug application; or

3. A drug trial that is exempt from the requirement of an FDA investigational new drug application.

# H. COST EFFECTIVE NON-COVERED SERVICES

We may approve benefits that are not expressly Covered in this Policy in limited circumstances if we determine that any such Services present a more appropriate means of Treatment is appropriate. Coverage for these Services must be approved in advance and in writing by Highmark WV.

# I. DENTAL SERVICES FOR AN ACCIDENTAL INJURY

Dental Services will be covered only when due to an accidental injury to the jaws, sound natural teeth, mouth or face. Such Services must be Incurred within one year from the date of the accident. Injury as a result of chewing or biting shall not be considered an accidental injury.

# J. DIAGNOSTIC SERVICES

Diagnostic Services include:

- Radiology, ultrasound and nuclear medicine,

- Laboratory and pathology Services,

- EKG, EEG, and other electronic diagnostic medical procedures,

- Other forms of medical imaging.

# K. EMERGENCY SERVICES

Coverage shall be provided for Emergency Medical Services to the extent necessary to screen and Stabilize an Emergency Medical Condition. Emergency Services are those provided to evaluate and treat an Emergency Medical Condition, a condition manifesting itself by the sudden, and unexpected onset of acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman the health of the unborn child, serious impairments to bodily functions or serious dysfunction of any bodily part or organ based on a Prudent Layperson standard

of acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman the health of the unborn child, serious impairments to bodily functions or serious dysfunction of any bodily part or organ based on a Prudent Layperson standard. Emergency Medical Conditions include, but are not limited to, heart attacks, strokes, loss of consciousness or respiration, convulsions and other acute conditions, which we determine to be a Medical Emergency only if:

• Severe symptoms occur suddenly and unexpectedly;

• Immediate care is secured; and

• The illness or condition, as finally diagnosed or as indicated by its symptoms, is one, which would normally require immediate Medical Care.

**Prior Authorization is not required for Treatment of Emergency Medical Conditions.**

If a Member seeks Treatment at a Hospital emergency room and receives Services that are not Medically Necessary, this Policy will not reimburse the cost of such Services, other than a Medical Screening Exam to determine if an Emergency Medical Condition exists or, if based on retrospective review, a Prudent Layperson would have believed an Emergency Medical Condition exists (in any case, less any applicable Coinsurances and Deductibles).

Note. Emergency Care received in a Physician's office will be paid as any other Office Visit.

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.

ion satisfies the criteria above.

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.

# L. HABILITATIVE SERVICES

Medically Necessary Services that help a person gain, keep or improve skills for daily living.

• 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.

• Physical Therapy. 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.

• Spinal Manipulation. The Treatment by means of manual manipulation of the spine.

• Speech Therapy. The treatment for the correction of a speech impairment.

• Cardiac Rehabilitation. The physiological and psychological rehabilitation of patients with cardiac conditions through regulated exercise programs.

# M. HOME HEALTH CARE SERVICES

The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency:

• Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife.

• Physical therapy, occupational therapy or speech therapy.

• Medical and surgical supplies.

• Prescription Drugs.

• Oxygen and its administration.

• Medical social Services.

• Home health aide visits when you are also receiving Skilled Care or Therapy Services.

• Laboratory tests.

• Home infusion therapy.

We do not pay Home Health Care benefits for any Services or Supplies not specifically listed above. Non-covered examples include, but are not limited to:

cal and surgical supplies.

• Prescription Drugs.

• Oxygen and its administration.

• Medical social Services.

• Home health aide visits when you are also receiving Skilled Care or Therapy Services.

• Laboratory tests.

• Home infusion therapy.

We do not pay Home Health Care benefits for any Services or Supplies not specifically listed above. Non-covered examples include, but are not limited to:

- Dietician Services.

- Homemaker Services.

- Food or home delivered meals.

- Custodial Care.

- Maintenance therapy.

- Routine prenatal care.

- Mental Illness, Drug Abuse, or Alcoholism services.

- Private duty nursing.

- Personal comfort items.

# N. HOME, OFFICE AND OTHER OUTPATIENT VISIT

Medical Care rendered to a Member who is an Outpatient for a condition not related to Surgery, pregnancy or Mental Illness, except as specifically provided, including Medical care Visits, Telemedicine Services and consultations for the examination, diagnosis and treatment of an injury or illness.

# O. HOSPICE SERVICES

Hospice care consists of health care benefits provided to a terminally ill Covered Person. Benefits will begin when the prognosis of life expectancy is estimated to be six months or less.

A Treatment Plan must be developed and submitted to us for our approval by the Covered Person's Physician and the Hospice Provider.

A licensed Hospice organization or a Hospice program sponsored by a Hospital or Home Health Care Agency and approved by us must provide all Covered Services. The Covered Services listed in the Home Health Care Services Section are also considered Hospice Services. In addition, your coverage includes:

- Acute Inpatient hospice care.

- Respite care.

- Dietary guidance.

- Durable medical equipment.

- Home Health aide visits.

Approved Prescription Drugs will be limited to a two-week Supply per Prescription Order or Refill. These Prescription Drugs must be required for palliative or supportive care.

h Care Services Section are also considered Hospice Services. In addition, your coverage includes:

- Acute Inpatient hospice care.

- Respite care.

- Dietary guidance.

- Durable medical equipment.

- Home Health aide visits.

Approved Prescription Drugs will be limited to a two-week Supply per Prescription Order or Refill. These Prescription Drugs must be required for palliative or supportive care.

In addition to the excluded Services listed in the Home Health Care Services Section, no Hospice Services will be provided for:

- Physician Visits.

- Volunteer Services.

- Spiritual counseling.

- Bereavement counseling for family members.

- Chemotherapy or radiation therapy if other than palliative.

# P. HOSPITAL-BASED CLINICS

A non-emergency Outpatient Visit in a Hospital-based clinic setting may apply to your Outpatient facility benefit and not to your Office Visit benefits.

# Q. INJECTABLE DRUGS

Certain injectable drugs may require Authorization. Contact Medical Management for additional information. Their phone number is located on the back of your ID Card.

# R. INPATIENT SERVICES

# 1. Bed, Board and General Nursing Services

- A semiprivate room.

- A private room (a room with one bed). We will pay only the Hospital's average semiprivate room rate.

- A bed in a special care unit approved by us. The unit must have facilities, equipment, and supportive services for the intensive care of critically ill patients.

# 2. Ancillary Services, including:

- Operating, delivery, treatment rooms, and equipment.

- Prescription Drugs.

- Whole blood, blood derivatives, blood plasma and blood components, including administration and blood processing.

- Anesthesia, anesthesia Supplies and Services given by an employee of Hospital or Facility Other Provider.

- Oxygen and other gasses.

- Medical and surgical dressing, Supplies, casts, and splints.

- Diagnostic Services.

- Therapy Services.

rooms, and equipment.

- Prescription Drugs.

- Whole blood, blood derivatives, blood plasma and blood components, including administration and blood processing.

- Anesthesia, anesthesia Supplies and Services given by an employee of Hospital or Facility Other Provider.

- Oxygen and other gasses.

- Medical and surgical dressing, Supplies, casts, and splints.

- Diagnostic Services.

- Therapy Services.

3. Medical Care Visits. The personal examination given to you by your Physician or Professional Other Provider. Consultations are not a part of this benefit. Benefits are provided for one Visit for each day you are an Inpatient.

4. Intensive Medical Care. Constant attendance and Treatment when your condition requires it.

5. Concurrent Care. Care for a medical condition by a Physician who is not your surgeon while you are in the Hospital for Surgery. Concurrent Care is also care by two or more Physicians during one Hospital stay for two or more unrelated conditions.

6. Diagnostic Surgical Procedures. Surgical procedures to diagnose your condition while you are in the Hospital.

7. Inpatient Consultation. A personal bedside examination by another Physician or Professional Other Provider, performing within the scope of their license, when requested by your Physician. The Physician or Professional Other Provider rendering the consulting Service must be board-eligible, if applicable, and possess the knowledge, training, and skill needed to provide this Service. Consultation Services are not covered if the consultant subsequently takes charge of the patient. At that point, we will consider him the treating Physician. We will not provide coverage for both the treating Physician and initial treating Physician for Services rendered during the same time period. Staff consultations required by Hospital rules are not covered.

# 8. Newborns

rovide this Service. Consultation Services are not covered if the consultant subsequently takes charge of the patient. At that point, we will consider him the treating Physician. We will not provide coverage for both the treating Physician and initial treating Physician for Services rendered during the same time period. Staff consultations required by Hospital rules are not covered.

# 8. Newborns

- Inpatient Newborn Care. Routine care of a newborn, including circumcision while the mother remains an Inpatient for the maternity admission (if covered by your Policy), or if the newborn is added to your Policy within the time limit specified in Section IV. Coverage must be in effect for the newborn care to be a Covered Service. Each new Dependent must be added to your Policy within 31 days of acquiring the new Dependent, regardless of the type of coverage in effect at the time you acquire the

new Dependent. Refer to the Section III for information on how to apply for the necessary coverage.

- Newborn Hearing Impairment Testing. In West Virginia, health care Providers present at or immediately after childbirth are required to perform a test for hearing loss on the infant unless the infant's parents refuse. If delivery takes place in a non-covered facility including home birth, a West Virginia health care Provider shall inform the parents of the need to obtain this Service within the first month of life. The newborn testing shall be a covered benefit.

- Detection and Control of Diseases in Newborns. West Virginia law requires the Hospital or Birthing Center in which the infant is born, the parents or legal guardians, the Physician attending the newborn child, or any person attending the newborn child not under the care of a Physician, to ensure that the newborn be tested for diseases specified by the State Public Health Commissioner and set forth in West Virginia code §16-22-3.

# S. MATERNITY SERVICES

nia law requires the Hospital or Birthing Center in which the infant is born, the parents or legal guardians, the Physician attending the newborn child, or any person attending the newborn child not under the care of a Physician, to ensure that the newborn be tested for diseases specified by the State Public Health Commissioner and set forth in West Virginia code §16-22-3.

# S. MATERNITY SERVICES

Hospital, medical and surgical Services for a normal pregnancy and complications of pregnancy, miscarriage, and non-elective abortions are Covered Services. Coverage for non-elective abortion is limited to those necessary to avert the death of the member or to terminate pregnancies caused by rape or incest. These are Covered Services for the Policyholder and all Eligible Dependents. These are not Covered Services if the Policyholder or Eligible Dependent has become pregnant to serve in the capacity of a Surrogate Mother or of Surrogate Parent.

We will not restrict maternity benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a Provider obtain Authorization from us for prescribing lengths of stay in excess of the above periods. Precertification is required only when the Inpatient stay exceeds 48 hours and 96 hours respectively.

# T. MEDICAL SUPPLIES AND EQUIPMENT

or the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a Provider obtain Authorization from us for prescribing lengths of stay in excess of the above periods. Precertification is required only when the Inpatient stay exceeds 48 hours and 96 hours respectively.

# T. MEDICAL SUPPLIES AND EQUIPMENT

1. Medical and Surgical Supplies. These Supplies include syringes, needles, oxygen, surgical dressings, splints, and other similar items that serve only a medical purpose. Covered Services do not include items usually stocked in the home for general use such as elastic bandages or thermometers.

2. Durable Medical Equipment. Durable medical equipment must be prescribed by a Physician or Professional Other Provider acting within the scope of their license. It must serve only a medical purpose and must be able to withstand repeated use. You may rent or purchase the equipment; however, we will not pay more in total rental costs than the customary purchase price, as determined by us.

3. Orthotic Devices. Rigid or semi-rigid supportive devices that limit or stop the motion of a weak or diseased body part.

4. Prosthetic Appliances. The purchase, fitting, adjustments, repairs and replacements of prosthetic devices that are artificial substitutes and necessary supplies that:

- replace all or part of a missing body organ and its adjoining tissues.

- replace all or part of the function of a permanently useless or malfunctioning body organ.

Excluded are:

- Dental appliances.

- Replacement of cataract lenses unless needed because of a lens prescription change.

- Elastic bandages.

- Garter belts or similar devices.

- Orthopedic shoes that are not attached to braces.

# U. MENTAL HEALTH CARE AND SUBSTANCE ABUSE (DRUG AND ALCOHOL) COVERAGE

- replace all or part of the function of a permanently useless or malfunctioning body organ.

Excluded are:

- Dental appliances.

- Replacement of cataract lenses unless needed because of a lens prescription change.

- Elastic bandages.

- Garter belts or similar devices.

- Orthopedic shoes that are not attached to braces.

# U. MENTAL HEALTH CARE AND SUBSTANCE ABUSE (DRUG AND ALCOHOL) COVERAGE

For purposes of Mental Health Parity, "Serious Mental Illness" means an illness included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, as periodically revised, under the diagnostic categories or subclassifications of: (A) Schizophrenia and other psychotic disorders; (B) bipolar disorders; (C) depressive disorders; (D) substance-related disorders with the exception of caffeine-related disorders and nicotine-related disorders; (E) anxiety disorders; and (F) anorexia and bulimia.

# 1. Mental Health Care

Covered Services for the Treatment of Mental Health Care include:

- Individual psychotherapy.

- Group psychotherapy.

- Family counseling; counseling with family members to assist with diagnosis and treatment. This coverage will provide payment for Covered Services only for those family members who are considered Covered Persons under this Policy. Charges will be applied to the Covered Person who is receiving family counseling Services, not necessarily the patient.

- Electroshock Therapy or convulsive drug Therapy and related anesthesia only if given in a Hospital or Psychiatric Hospital.

- Psychological testing.

- Intensive Outpatient Services (IOP).

- Partial Hospital (PH).

- Psychiatric Inpatient hospitalization.

# 2. Drug Abuse and Alcoholism (Substance Abuse) Services

Covered Services for Drug Abuse and Alcoholism rehabilitation include:

the patient.

- Electroshock Therapy or convulsive drug Therapy and related anesthesia only if given in a Hospital or Psychiatric Hospital.

- Psychological testing.

- Intensive Outpatient Services (IOP).

- Partial Hospital (PH).

- Psychiatric Inpatient hospitalization.

# 2. Drug Abuse and Alcoholism (Substance Abuse) Services

Covered Services for Drug Abuse and Alcoholism rehabilitation include:

- Individual psychotherapy.

- Group psychotherapy.

- Family counseling; counseling with family members to assist with diagnosis and treatment. This coverage will provide payment for Covered Services only for those family members who are considered Covered Persons under this Contract. Charges will be applied to the Covered Person who is receiving family counseling Services, not necessarily the patient.

- Covered Services also include Inpatient detoxification Services.

Services beyond the evaluation or to diagnose conditions related to mental deficiency, retardation, an autistic disease of childhood, learning disabilities or mental retardation are not covered.

We do not pay benefits for Mental Illness that cannot be treated. We will, pay benefits to determine if the disorder or illness can be treated. Your Physician must certify that there is a reasonable likelihood that your treatment will be of substantial benefit and substantial improvement is likely.

# V. ORGAN TRANSPLANT SERVICES

The following human organ transplants are Covered Services:

- Heart.

- Heart / lung.

- Lung (single or double).

- Liver.

- Pancreas.

Note: Kidney transplants are covered under Surgical Services, Special Surgery.

Benefits will be provided for:

is a reasonable likelihood that your treatment will be of substantial benefit and substantial improvement is likely.

# V. ORGAN TRANSPLANT SERVICES

The following human organ transplants are Covered Services:

- Heart.

- Heart / lung.

- Lung (single or double).

- Liver.

- Pancreas.

Note: Kidney transplants are covered under Surgical Services, Special Surgery.

Benefits will be provided for:

- Expenses of the recipient directly related to the transplant procedure. This includes pre-operative care and post-operative care, and immunosuppressant drugs.

- Expenses for the acquisition, transportation, and storage costs directly related to the donation of a human organ to be used in a covered organ transplant procedure.

- Retransplantation.

- Expenses for transportation to and from the site of the transplant Surgery. Benefits will also be provided for meals, and lodging, for the covered recipient and one additional adult. If the patient is a minor, expenses for transportation, meals and lodging are provided for the patient and two accompanying adults. Contact Medical Management to receive further details regarding travel and lodging.

The Group Health Plan providing coverage for the recipient in a transplant operation shall also provide for the reimbursement of any medical expenses of a live donor to the extent benefits remain and are available under the recipient's Group Health Plan, after benefits for the recipient's own expenses have been paid. Such benefits may be limited to those expenses directly relating to the organ donation.

# W. PEDIATRIC DENTAL

Benefits are provided for Covered Persons under age nineteen (19) for the following when rendered by a Participating Dentist:

- Oral Evaluations:

nt benefits remain and are available under the recipient's Group Health Plan, after benefits for the recipient's own expenses have been paid. Such benefits may be limited to those expenses directly relating to the organ donation.

# W. PEDIATRIC DENTAL

Benefits are provided for Covered Persons under age nineteen (19) for the following when rendered by a Participating Dentist:

- Oral Evaluations:

o Comprehensive, periodic and limited problem focused - one (1) of these services per six (6) months. Once paid, comprehensive evaluations are not eligible to the same office unless there is a significant change in health condition or the patient is absent from the office for three (3) or more year(s).

o Consultations - one (1) of these services per Dentist per patient per twelve (12) months for a consultant other than a Pedodontist or Orthodontist.

o Detailed problem focused - one (1) per Dentist per patient per twelve (12) months per eligible diagnosis.

- Radiographs - Full mouth x-rays - one (1) every five (5) year(s). Bitewing x-rays - one (1) set(s) per twelve (12) months.

- Prophylaxis - one (1) per six (6) months. One (1) additional for Covered Persons under the care of a medical professional during pregnancy.

- Fluoride treatments:

o Topical fluoride treatment - one (1) per twelve (12) months under age fourteen (14).

o Fluoride varnish - one per twelve (12) months under age fourteen (14).

- Palliative treatment (Emergency)

- Sealants - one (1) per tooth per lifetime under age sixteen (16) on permanent first and second molars.

- Space maintainers - one (1) per five (5) year period for Covered Persons under age fourteen (14) when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars, or deciduous molars and permanent first molars that have not, or will not, develop.

- Preventive resin restorations - one (1) per tooth per lifetime under age sixteen (16) on permanent first and second molars.

- Amalgam Restorations (metal fillings)

d for Covered Persons under age fourteen (14) when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars, or deciduous molars and permanent first molars that have not, or will not, develop.

- Preventive resin restorations - one (1) per tooth per lifetime under age sixteen (16) on permanent first and second molars.

- Amalgam Restorations (metal fillings).

- Crowns - one (1) per tooth per lifetime for Covered Persons under age fifteen (15).

• Periodontal Services:

○ Periodontal maintenance following active periodontal therapy - two (2) per twelve (12) months in addition to routine prophylaxis.

○ Surgical periodontal procedures - one (1) per thirty-six (36) months per area of the mouth.

• Replacement of restorative services only when they are not, and cannot be made, serviceable:

○ Basic restorations - not within twenty-four (24) months of previous placement.

○ Single crowns - not within five (5) years of previous placement.

○ Buildups and post and cores - not within five (5) years of previous placement.

○ 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.

○ Pulpal therapy - one (1) per eligible tooth per lifetime. Eligible teeth limited to those with no secondary permanent tooth to replace the primary tooth.

○ Root canal retreatment - one (1) per tooth per lifetime.

○ 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.

○ General anesthesia and IV sedation - limited to thirty (30) minutes per session when Dentally Necessary and Appropriate and related to a Covered Service.

○ Orthodontics

retreatment - one (1) per tooth per lifetime.

○ 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.

○ General anesthesia and IV sedation - limited to thirty (30) minutes per session when Dentally Necessary and Appropriate and related to a Covered Service.

○ 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 Covered Person's oral structure to health and function.

# Limitations

• Orthodontic treatment limitations:

• All pediatric orthodontic treatment is subject to Precertification and must be part of an approved written plan of care.

• To be eligible for pediatric orthodontic treatment, a Covered Person must:

○ have been enrolled under this Agreement for twelve (12) consecutive months ("waiting period"), and must continue to be enrolled during the duration of treatment; and

○ have a fully erupted set of permanent teeth.

• 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 Covered Person to the less costly treatment. However, if the Covered Person and the Provider choose the more expensive treatment, the Covered Person is responsible for the additional charges beyond those allowed under this ABP.

# X. PEDIATRIC VISION

Benefits are provided for Covered Persons under age nineteen (19) every twelve (12) consecutive months for the following when rendered by a Participating Vision Provider:

less costly treatment. However, if the Covered Person and the Provider choose the more expensive treatment, the Covered Person is responsible for the additional charges beyond those allowed under this ABP.

# X. PEDIATRIC VISION

Benefits are provided for Covered Persons under age nineteen (19) every twelve (12) consecutive months for the following when rendered by a Participating Vision Provider:

• one (1) comprehensive eye examination (including dilation as professionally indicated);

• one (1) pair of single vision, bifocal, trifocal or lenticular lenses (including glass, plastic or oversized lenses); and

• one (1) pair of frames from a selection designated by Highmark WV.

# Y. PRESCRIPTION DRUG CLAIMS

If your Policy includes a Prescription Drug benefit offered by Highmark WV, you may be able to fill a prescription through a Network of Participating Pharmacies, Non-Participating Pharmacies, or a Mail Order Pharmacy Service. Please refer to Section X for details of your Prescription Drug Benefits.

# Z. PREVENTIVE CARE SERVICES

Note: In addition to the Covered Services listed below, there are other routine screening, immunization and Diagnostic Services covered as afforded by the Patient Protection and Affordability Care Act (PPACA). For additional information, go to www.healthcare.gov or contact Member Services. Their phone number is on the back of your ID Card.

# 1. Routine Gynecological Services

- Pap smears (including related Office Visits) - annually or more often if recommended by a Physician.

- Human Papilloma Virus (HPV) Testing - one every 3 years age 30 and older.

- Mammograms according to the following schedule:

Age 35 through 39 years of age - one baseline mammogram

Age 40 and over - one per Benefit Period

Note: As required by law, female enrollees have direct access to a women's health care Provider of their choice.

# 2. Well-Woman Care Services

recommended by a Physician.

- Human Papilloma Virus (HPV) Testing - one every 3 years age 30 and older.

- Mammograms according to the following schedule:

Age 35 through 39 years of age - one baseline mammogram

Age 40 and over - one per Benefit Period

Note: As required by law, female enrollees have direct access to a women's health care Provider of their choice.

# 2. Well-Woman Care Services

Benefits are provided for female Members for items and services in accordance with a predefined schedule based on age and sex, including, but not limited to, an initial physical examination to confirm pregnancy, screening for gestational diabetes, coverage for contraceptive methods and counseling and breastfeeding support and counseling.

3. Prostate screening exam and prostate specific antigen (PSA) test for males over age 50 - one per benefit period.

4. Colorectal Cancer Screening for individuals age 50 and older or a person under age 50 with high risk factors (e.g. family history).

- Exam - one per Benefit Period.

- Fecal Occult Test - one per Benefit Period.

- Flexible Sigmoidoscopy - one every 5 years.

- Colonoscopy - one every 10 years.

- Double Contrast Barium Enema - one every 5 years.

Note: Benefits for Colorectal Cancer Screening are also provided for symptomatic persons under age 50. Coverage for this benefit is provided under Physician and/or Outpatient Hospital/Facility Services level as set forth in Section III rather than at the Preventive Care level.

5. Annual Kidney disease screening and laboratory testing; including any combination of blood pressure testing, urine albumin or urine protein testing, and serum creatinine testing.

6. Other preventive Services as indicated in Section III.

# AA. PRIVATE DUTY NURSING SERVICES

/or Outpatient Hospital/Facility Services level as set forth in Section III rather than at the Preventive Care level.

5. Annual Kidney disease screening and laboratory testing; including any combination of blood pressure testing, urine albumin or urine protein testing, and serum creatinine testing.

6. Other preventive Services as indicated in Section III.

# AA. PRIVATE DUTY NURSING SERVICES

Skilled Care rendered by a registered, licensed vocational or licensed practical nurse when ordered by a Physician. Care that is primarily non-medical or Custodial Care is not covered. Such Services must be certified initially and every 30 days by your Physician for Medical Necessity. Inpatient Services are Services that we decide are of such a nature or degree of complexity that the Provider's regular nursing staff cannot give them.

# BB. REHABILITATION SERVICES

Diagnostic tests, assessment, monitoring or Treatments which are designed to remediate a patient's condition or to restore the patient to his or her optimal physical, medical, psychological, social, emotional, vocational and economic status.

- 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. In order to be considered a Covered Service, this therapy must be expected to improve the level of functioning within a reasonable period of time.

- Physical Therapy. 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.

- Spinal Manipulation. The Treatment by means of manual manipulation of the spine.

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

Physical Therapy. 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.

- Spinal Manipulation. The Treatment by means of manual manipulation of the spine.

- Speech Therapy. The treatment for the correction of a speech impairment. In order to be considered a Covered Service, this therapy must be expected to improve the level of functioning within a reasonable period of time.

- Cardiac Rehabilitation. The physiological and psychological rehabilitation of patients with cardiac conditions through regulated exercise programs.

Rehabilitative services includes care rendered by the following:

- A Hospital duly licensed by the state of West Virginia that meets the requirements for rehabilitation;

- Hospitals as described in the Medicare Provider Reimbursement Manual, Part 1;

- A distinct part rehabilitation unit in a Hospital duly licensed by the state of West Virginia; or

- A Hospital duly licensed by the state of West Virginia that meets the requirements for cardiac rehabilitation; or

- Similar facilities located outside of the state.

Rehabilitation Services do not include Services for mental health, chemical dependency, Vocational Rehabilitation, long-term maintenance or custodial Services.

Your Physician must certify that there is reasonable likelihood that Rehabilitation Services will correct or restore you to your optimal physical, medical, psychological, social, emotional, vocational and economic status.

## CC. SKILLED NURSING FACILITY SERVICES

Benefits for the same Services available to an Inpatient of a Hospital are also covered for an Inpatient of a Skilled Nursing Facility. Such Services must be Skilled Care and authorized and provided pursuant to your Physician's Plan of Treatment. Your Physician must certify initially and every two weeks that you are receiving Skilled Care and not merely Custodial Care.

No benefits are payable:

- Once a patient can no longer significantly improve from Treatment for the current condition as determined by us.

- For Custodial Care.

- Solely for the treatment of Mental Illness, Drug Abuse, Alcoholism, or pulmonary tuberculosis.

## DD. SPECIAL SERVICES

1. Pre-Admission Testing. Outpatient tests and studies required for your scheduled Hospital admission as an Inpatient, which would have been covered as an Inpatient.

2. Mastectomy Benefits.

- Reconstruction of breast on which the mastectomy was performed;

- Reconstructive surgery of the other breast to present symmetrical appearance;

- Prostheses and coverage for physical complications at all stages of the mastectomy procedure, including lymphedemas in a manner determined in consultation with the attending physician and the patient.

- Minimum stay of 24 hours of Inpatient care following a total mastectomy or partial with lymph node dissection for treatment of breast cancer.

- Minimum stay of 48 hours of Inpatient care for a radical or modified mastectomy.

3. Diabetic Services. Services provided or performed for the Treatment of both insulin dependent and non-insulin dependent diabetes includes:

ing physician and the patient.

- Minimum stay of 24 hours of Inpatient care following a total mastectomy or partial with lymph node dissection for treatment of breast cancer.

- Minimum stay of 48 hours of Inpatient care for a radical or modified mastectomy.

3. Diabetic Services. Services provided or performed for the Treatment of both insulin dependent and non-insulin dependent diabetes includes:

- Blood glucose monitors and monitor supplies; (paid under your durable medical equipment (DME) benefits)

- Insulin infusion devices; (paid under your DME benefits)

- Insulin, syringes (paid under your Prescription Drug benefits), and insulin injection aids or devices;

- Pharmacological agents for controlling blood sugar (paid under your Prescription Drug benefits);

- Urine ketone testing strips;

- Urine micro albumin test;

- Blood pressure monitoring device;

- Podiatric appliances and therapeutic footwear;

- Foot Orthotics; and

- Orthopedic appliances including canes, crutches and walkers, and other items as may be medically necessary.

You may directly access any Network Provider for one annual diabetic retinal exam.

Diabetes self-management education to ensure the proper self-management and Treatment, including diet education, is a Covered Service. However, this education is limited to:

- Visits upon diagnosis of diabetes;

- Visits necessitated by a significant change in the patient's symptoms or conditions resulting in a change in the patient's self-management; and

- When a new medicine or therapeutic process relating to Treatment or management of the patient's condition has been identified as Medically Necessary.

Education services may be provided by:

- A licensed pharmacist when providing instruction on the proper use of equipment covered by this Policy or supplies and medication prescribed by a licensed Physician;

- A diabetes educator certified by a national diabetes educator certification program;

- A registered dietitian registered by a nationally recognized professional association of dieticians.

Education services may be provided by:

- A licensed pharmacist when providing instruction on the proper use of equipment covered by this Policy or supplies and medication prescribed by a licensed Physician;

- A diabetes educator certified by a national diabetes educator certification program;

- A registered dietitian registered by a nationally recognized professional association of dieticians.

National diabetes education certification or any professional association of dietitians must be certified to the Insurance Commissioner by the West Virginia Health Department.

# 4. Dental Anesthesia Services

General anesthesia for dental procedures and associated outpatient hospital or ambulatory facility charges provided by appropriately licensed health care individuals in conjunction with dental care is covered if the Member is:

- Seven years of age or younger or is developmentally disabled and is an individual for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual or other medically compromising condition of the enrollee or insured and for whom a superior result can be expected from dental care provided under general anesthesia; or

- A child who is twelve years of age or younger with documented phobias, or with documented mental illness, and with dental needs of such magnitude that treatment should not be delayed or deferred and for whom lack of treatment can be expected to result in infection, loss of teeth or other increased oral or dental morbidity and for whom a successful result cannot be expected from dental care provided under local anesthesia because of such condition and for whom a superior result can be expected from dental care provided under general anesthesia.

Prior authorization is required for general anesthesia and associated outpatient hospital or ambulatory facility charges for dental care and must be provided by:

l morbidity and for whom a successful result cannot be expected from dental care provided under local anesthesia because of such condition and for whom a superior result can be expected from dental care provided under general anesthesia.

Prior authorization is required for general anesthesia and associated outpatient hospital or ambulatory facility charges for dental care and must be provided by:

- A fully accredited specialist in pediatric dentistry;

- A fully accredited specialist in oral and maxillofacial surgery; and

- A dentist to whom hospital privileges have been granted.

This section applies only to general anesthesia, not the dental care for which the general anesthesia is provided nor does it apply to dental care rendered for temporal mandibular joint disorders.

# EE. SPECIALIST VIRTUAL VISITS

Benefits are provided for a Specialist Virtual Visit subsequent to the Member's initial Visit with his or her treating specialist for the same condition. The Specialist Virtual Visit is to provide specialist follow-up services to Members who do not have readily available access to such specialty services. Covered Services do not include services related to mental illness.

There may be an additional charge, dependent where this Covered Services is performed (Originating Site)

# FF. SURGICAL SERVICES

1. Surgery. This must be done by a Physician or Professional Other Provider performing within the scope of their license. Benefits include Medical Care Visits before and after Surgery.

# 2. Special Surgery

- Sterilization.

- Removal of impacted teeth. Partial and Full-bony impacted teeth are covered under your medical benefits; all soft tissue impactions would be covered under your Dental benefits, if applicable.

- Mandibular staple implant, due to trauma and/or accidental injury.

- Maxillary or mandibular frenectomy.

- Kidney transplants

e Visits before and after Surgery.

# 2. Special Surgery

- Sterilization.

- Removal of impacted teeth. Partial and Full-bony impacted teeth are covered under your medical benefits; all soft tissue impactions would be covered under your Dental benefits, if applicable.

- Mandibular staple implant, due to trauma and/or accidental injury.

- Maxillary or mandibular frenectomy.

- Kidney transplants

3. Multiple Surgical Procedures. When more than one surgical procedure is performed through the same body opening during one operation, you are covered for the most complex procedure. When more than one surgical procedure is performed through more than one body opening during one operation, you are covered for the most complex procedure and for one-half of the benefit for additional procedures.

4. Assistant at Surgery. A Physician's help to your surgeon in performing covered Surgery when no qualified house staff member, intern, or resident exists.

5. Anesthesia. Administration of anesthesia, done in connection with a Covered Service, by a Physician or certified registered nurse anesthetist who is not the surgeon or the assistant at Surgery. This benefit includes care before and after the administration. The Services of a standby anesthesiologist are covered during coronary angioplasty Surgery.

6. Second Surgical Opinion. A second Physician's opinion and related Diagnostic Services to help determine the need for elective covered Surgery Services recommended by your first Physician is a Covered Service. The second opinion must be provided by someone other than the first Physician who recommended the Surgery. This benefit is not payable while you are an Inpatient of a Hospital. We cover a third opinion if the first two opinions conflict. The Surgery is a Covered Service even if the Physicians' opinions conflict.

# GG. TEMPOROMANDIBULAR DISORDERS (TMD) / CRANIOMANDIBULAR DISORDERS (CMD)

d Service. The second opinion must be provided by someone other than the first Physician who recommended the Surgery. This benefit is not payable while you are an Inpatient of a Hospital. We cover a third opinion if the first two opinions conflict. The Surgery is a Covered Service even if the Physicians' opinions conflict.

# GG. TEMPOROMANDIBULAR DISORDERS (TMD) / CRANIOMANDIBULAR DISORDERS (CMD)

- Benefits will be provided for the following procedures for the Treatment of TMD or CMD:

- Health history.

- Clinical examination.

- Diagnostic imaging procedures.

- Conventional diagnostic and therapeutic injections.

- Limited orthotics; splints or appliances are limited to one every three years. All adjustments to the appliance performed during the first six months of installation are considered part of the total appliance fee.

- Physical medicine and physiotherapy; which shall include:

- Ultrasound

- Diathermy

- High Voltage Galvanic Stimulation

- Transcutaneous Nerve Stimulation

- Surgery, including arthrotomy and diagnostic arthroscopy.

### HH. THERAPY SERVICES

Services or supplies used to promote the recovery from an illness or injury include:

1. Radiation Therapy. The Treatment of disease by X-ray, gamma ray, accelerated particles, mesons, neutrons, radium, or radioactive isotopes.

2. Chemotherapy. The Treatment of malignant disease by chemical or biological antineoplastic agents.

4. Dialysis Treatments. The Treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body through hemodialysis or peritoneal dialysis. Dialysis Treatment includes home dialysis.

5. Respiratory Therapy. Introduction of dry or moist gasses into the lungs for Treatment purposes.

6. Hyperbaric and Pulmonary Therapy. The administration of oxygen in a pressurized chamber. Under pressurization, oxygen levels are increased.

### II. WELL CHILD CARE AND IMMUNIZATION SERVICES

1. Well Baby Care Services.

emodialysis or peritoneal dialysis. Dialysis Treatment includes home dialysis.

5. Respiratory Therapy. Introduction of dry or moist gasses into the lungs for Treatment purposes.

6. Hyperbaric and Pulmonary Therapy. The administration of oxygen in a pressurized chamber. Under pressurization, oxygen levels are increased.

### II. WELL CHILD CARE AND IMMUNIZATION SERVICES

1. Well Baby Care Services.

Routine Office Visits, lab tests and immunizations for ages one month to six years are Covered Services. Allowable Office Visits, lab tests and immunizations will follow the schedule recommended by the American Academy of Pediatrics (AAP). You may access this information at www.aap.org or contact Member Services.

2. Well Child Care Service.

Routine immunizations and related Office Visits for children ages six years through seventeen years are Covered Services. Allowable Office Visits and immunizations will follow the schedule recommended by the AAP. You may access this information at www.aap.org or contact Member Services.

## VI. Exclusions / What Is Not Covered

We do not provide benefits for the following Services, Supplies, or Charges and as a result, you may be responsible for the related Charges.

1. Not prescribed by or performed by or under the direction of a Physician or Professional Other Provider.

2. Not performed within the scope of the Provider's license.

3. Received from other than a Provider.

4. Experimental or Investigational.

5. Not Medically Necessary. (See Sections V for information on your liability for not Medically Necessary Services.)

6. Services outside generally accepted medical standards and practices.

7. To the extent governmental units or their agencies provide benefits, unless the injury, ailment, condition, disease, disorder, or illness is related to military service, except that benefits are provided for Covered Services received from a Veterans Administration Hospital.

8. Injuries, conditions, diseases, disorder, or illnesses that occur as a result of any act of war.

dards and practices.

8. Injuries, conditions, diseases, disorder, or illnesses that occur as a result of any act of war.

9. Where you have no legal obligation to pay in the absence of this or like coverage.

10. Received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust or similar person or group.

11. Received from a member of your Immediate Family.

12. Incurred before your Effective Date.

13. Incurred after you stop being a Covered Person, except as specified in Section VIII.

14. The following physical examinations or

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