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Home My WebLink About000189.tiff Lincoln National Administrative Services Corporation LINCOLN Lincoln National Life Insurance Company ri NATIONAL Lincoln National Health Plan EMPLOYEE BENEFITS December 18, 1990 Mr . Donald Warden Director of Finance Weld County 915 10th Street Greeley, CO 80631 Dear Mr . Warden: I have enclosed Lincoln National Health Plan' s Master Group Contract [for the HMO] for the contract year January 1 through December 31, 1991 . Please review the contract , and have the Commissioners execute the Contract by signing the Master Group Contract Application and/or by resolution . Please return the white and yellow copies of the Application to me by January 18, 1991, and retain the balance of the Contract for your records . Lincoln National Health Plan must received endorsed copies of the Application, or written concerns to the Master Group Contract , by January 18, 1991 . If neither of those items are received by that date, the contractual relationship between Weld County and Lincoln National Health Plan shall be determined strictly in accordance with the terms and provisions of the Master Group Contract as delivered to you. If I can be of assistance in facilitating the execution of the Master Group Contract , please do not hesitate to contact me . We at Lincoln National are looking forward to serving Weld County in the upcoming year . Best regards, (� Bru e A. Bode Employee Benefits Manager Enc. pc : Masoud Shirazi David Worden BAB/pa 2627 Redwing Rd. 1802 16th Street 4582 S. Ulster St. Pkwy. 5725 Mark Dabling Blvd. 720 N. Main St. Suite 120 Suite 3 Suite 1100 Suite 150 Suite 200 Fort Collins, CO 80526 Greeley, CO 80631 Denver, CO 80237 Cola. Springs. CO 8091^ ' • (303) 223-9898 (303) 351.6864 (303) 779-4700 (719) 548-8700 189 Affiliates of Lincoln National Corporation MASTER GROUP CONTRACT APPUCATiON ' • LINCOLN NATIONAL HEALTH PLAN OF COLORADO The entire contract consisting of the attached Master GroupContract(MGC),Evidenc.of Coverage(EOC),applicable Addenda,if any,and this Master Group Contract Application, has been entered into between Lincoln National Health Plan of Colorado,and(name below).In consideration of the Health Services Fee to be paid to Lincoln National Health Plan of Colorado,by Enrolling Unit on behalf of eligible Enrollees and Enrolled Family Dependents,Lincoln National Health Plan of Colorado agrees to arrange Medically Necessary Health Services as apedrad herein,in accordance with the terms,conditions,limitations and exclusions of this contract 1) NAME AND ADDRESS OF GROUP: 2) GROUP NUMBER(S): Weld County Lincoln National Group # 50158 915 10th Street HMO-Northern Colo. 50301, 50350 P.O. Box 758 HMO-Denver 74401, 74450 Greeley, CO 80632 3)GROUP RENEWAL DATE January 1 Monet Ow 4) ELIGIBILITY: In addition to the requirements herein,employee eligibility will be as follows: Employees must be scheduled to work a minimum of 32 hours per week to be eligible for benefits 5) NEWLY HIRED ELIGIBLE EMPLOYEES AND TERMINATED EMPLOYEES: In addition to the requirements herein,eligible employ- ees will have coverage provided and Health Services Fees due as follows: Newly hired eligible employees will have coverage effective the first of the month following employment through a full pay period (the 16th through the 15th) , if application is made within 31 days. Terminated employees will have coverage through the end of the month in which termination occurs, and for which premium has been paid. A full monthly premium will be charged. 6)GROUP OPEN ENROLLMENT PERIOD:Membership applications,subject to the terms of the attached contract,shall be accepted as follows: Nov. 16 through Dec. 15, for a January 1 effective date 7)OTHER ATTACHMENTS: none 8) COVERAGE: j;QQ Ma Contract Tvoe(Medical) Monthly Fee Fmolover Cnntrih O Design I 6729(7/90) 6755(7/90) Emp.Only $ 111.00 $ 105.00* ❑ Design VA 6752(7/90) 6756(7/90) Emp.& 1 Fam. Dap. $ 305.00 $ 105.00* ❑Design VIA 6753(7/90) 6757(7/90) Emp.&2 Fam.Dep. $ 305.00 $ 105.00* ❑Design IXA 6754(7/90) 6758(7/90) Emp.&3 or more Fam. Dep. $ 305.00 $ 105.00* ❑Design X 6730(7/90) 6759 (7/90) ir ❑ * Employer Contribution toward medical, dental & vision plans The foregoing rates shall remain effective subject to the terms and conditions of the attached contract and any attachment specified on this page through December 31, 1991 9)SUPPLEMENTAL ADDENDUM: =Prescription Drug Addendum Rx5 6625(10/89) ❑ ❑Prescription Drug Addendum Rx7 6649(10/89) ❑ ❑ Prescription Drug Addendum Rx10 6731(7/90) ❑ ❑Preventive Dental Addendum 6079(5/90) ❑Basic 6640 (12/88) Contract Tvo@(Dental) Monthly Fee Fmnlnvar Cnntrih ❑Comprehensive 6641 (12/88) Emp.Only $ $ O Comprehensive Orthodontic 6642 (12/89) Emp.& 1 Fain. Dep. $ $ ❑Medicare Supplement 6643( ) Emp.&2 Fam. Dep. $ $ ❑Durable Medical Equipment 6631 (12/88) Emp.&3 or more Fam. Dep. $ $ 10) Minimum Number of Enrollees 5 • 11) Executed in Colorado effective as of: January 1, 1991 � ROLLING UNIT `� �� , le, ' ri�.NOFCOLOgADOI� �a (Signal it M/ed R Pee) (Signmwe ci Authorized Representative) /G / l[Yaul Gordon Lacy Stephen T. O'Dell (Type or Print Above Name) (Type or Print Above Name) Chairman, County Commissioners General Manager (Tae) gam 6639(11/90) WMe:LNHP-Enrdurmnt Oeparlment Velosc LNHP-Regional Marketing Dep. Pink:Errpbyer { LINCOLN NATIONAL HEALTH PLAN OF COLORADO MASTER GROUP CONTRACT DESIGN IXA (Herein called the Contract) Lincoln National Health Plan of Colorado (herein called PLAN)hereby agrees with the Enrolling Unit to provide the Health Services set forth herein to Covered Persons,subject to the terms, conditions,exclusions and limitations of this Contract. This Contract is made in consideration of the Enrolling Unit's application and payment of the required Contract Charges as specified herein.A copy of the application is attached to and is made a part of this Contract. This Contract shall take effect on the date specified on the Application and will be continued in force by the timely payment of the required Contract Charges when due, subject to termination of this Contract as provided herein. All Coverage under this Contract shall begin and end at 12:01 a.m.Mountain Tune. This Contract is delivered in and governed by the laws of the State of Colorado. CONTENTS Section I Definitions of Terms Used in this Contract 2 Section II Enrollment and Effective Date of Individual Coverage 6 Section III Procedures for Reimbursement of Eligible Expenses 6 Section IV Coordination of Benefits and Subrogation 7 Section V Complaint and Grievance Processes 11 Section VI Termination of Individual Coverage 11 Section VII Contract Charges 14 Section VIII General Provisions 15 Section 1X Procedures for Obtaining Health Services 17 Section X Schedule of Benefits and Exclusions 19 6758 (07/90) '' Section I DEFINITIONS / "Acute Mental Disorder"means a condition determined by the Mental Health Provider to be psychological in nature,and which has an immediate onset and a short duration. "Addendum"means an attached description,if any,of Health Services covered only when such Addendum is signed by PLAN, and subject to payment of additional Health Services Fees. "Calendar Year"means the period from January 1 through December 31 of any year. "Chemical Dependency Services" means services and supplies covered under this Contract for the diagnosis and treatment of alcoholism and chemical or drug dependency as classified in the International Classification of Diseases of the U.S. Department of Health and Human Services. "Confinement" means an uninterrupted stay of more than eighteen (18) hours in a Hospital or Participating Skilled Nursing Facility. "Congenital Anomaly" means a defective development or formation of a part of the body which is determined by a Physician to have been present at the time of birth. "Contract"means the Master Group Contract,the application of the Enrolling Unit,Addenda, and amendments signed by PLAN which constitute the agreement regarding the benefits,exclusions and other conditions between PLAN and the Enrolling Unit. "Contract Charge"means the sum of the Health Services Fee for all Enrollees and Enrolled Family Dependents. "Contract Years"and"Contract Months"are determined from the effective date of this Contract. "Copayment Charge"means the charge,in addition to the Health Services Fee,which the Covered Person is required to pay for certain Health Services provided under this Contract The Covered Person is responsible for the payment of any Copayment Charge directly to the provider of the Health Services at the time of service.The total Copayment Charges paid by any Covered Person in any Contract Year may not exceed 200%of the total annual Health Services Fees paid to PLAN during the same period on behalf of the Covered Person through the Enrolling Unit. In those cases where the Enrollee has enrolled his or her Family Dependents with PLAN,the total Copayment Charges paid in any Contract Year by all Covered Persons in the family unit shall not exceed 200%of the total annual Health Services Fees paid to PLAN during the same period through the Enrolling Unit.The Enrollee is responsible for the recovery of excess Copayment Charges. (See Section III.) "Cosmetic Procedures" means those procedures which improve physical appearance, but which do not corect or , materially improve a physiological function, and are not Medically Necessary. "Coverage"means the entitlement by a Covered Person to Health Services provided under this Contract,subject to the terms,limitations,and exclusions of this Contract,and the following conditions: (a)Health Services must be provided when this Contract is in effect;(b)Health Services must be provided prior to the date that any of termination conditions two(2)th rough ten(10)of Section VI occur,and(c)Health Services must be provided only when the recipient is a Covered Person, and meets all eligibility requirements as described in Section II. "Covered Person"means either the Enrollee or an Enrolled Family Dependent,but applies only while Coverage of such person under this Contract is it effect. "Crisis Intervention" means Iort-term care for a condition which is determined by the Mental Health Provider to be psychological in nature,and which has a sudden onset and inhibits the normal daily functioning of the individual.Crisis Intervention services include evaluation and assistance to the individual in developing immediate coping skills. "Custodial Care"means any skilled or non-skilled Health Services,or personal comfort or convenience-related services which provide general maintenance,supportive,preventive and/or protective care.Custodial Care does not seek to cure, is provided in ar setting,and- ,y be provided between periods of acute or intercurrent health care needs.Custodial Care -2- is provided to an individual whose Health Service's requirements are stabilized and whose current medical condition is not expected to significantly and objectively improve or progress over a specified period of time.The absence of such improvement and progress will be based upon assessment b li predictable medical outcome or objectively documented through Y censed health professionals and Plan. Custodial Care may include the supervision or participation articip on periodic a Physicir .. licensed nurse, or registered therapist as necessary or desirable services. The mere participation of these profess: nals does not preclude the services as being custodial in nature and if the nature of the services can be safely and effecti'ely performed by a trained non-medical person,the services are custodial Further,Custodial Care and the nature of those services are not altered by the availability of the non-medical person. "Dental Surgery,Treatment or Care"means all services provided by or under the direction of a Dentist,including but not limited to any surgical procedure which involves the hard or soft tissues of the mouth. "Dentist"means any doctor of dental surgery, "D.D.S.", who is duly licensed and qualified to provide Dental Surgery, Treatment or Care under the law of jurisdiction in which treatment is received. "Designated Organ Transplant Facility"means a Hospital named as such by PLAN,which has entered into an agreement with or on behalf of PLAN to render Health Services for organ transplants which are not E which are covered under this Contract Experimental or Unproven and . "Durable Medical Equipment"means medical equipment which can withstand repeated use and is not disposable,is used to serve a medical purpose, is generally not useful to a person in the absence of a Sickness or Injury, and is appropriate for use in the home. "Eligible Expenses"are the fees established specific to the service area for Health Services covered under this Contract. "Eligible Person" means an employee of the Enrolling Unit or other specified in the application and this Contract,and who resides within person who meets unless he LN eligibility p approvesar-Pan-time employees(i.e.those employees who work or are e Service Area l PLAN approves other week)are not eligible unless prior approved in writing schedu led o s o less than 20 elide out outside the Service Area shall be covered only for Health Services rendered d bEligible Participating P who temporarily ice A ea.ex a of in the event of an Emergency, or upon prior written approval by PLAN. Providers in the Service Area except "Emergency"means a serious medical condition resulting from Injury,Sickness,or Mental Illness which arises suddenly and requires immediate care and treatment to avoid jeopardy to the life or health of a Covered Person. "Emergency Health Services"means those Health Services and supplies necessary for the treatment of an Emergency, which are generally provided no later than twenty-four(24)hours afterthe onset of an Emergency,subject to the conditions and Copayment Charges as described in this Contract. "Enrolled Family Dependent"means a Family Dependent who is enrolled for Coverage under this Contract. "Enrollee"means an Eligible Person who is enrolled for Coverage under this Contract. "Enrolling Unit"means the employer or other entity with whom this Contract is made. "Experimental or Unproven Procedures"means medical,surgical orpsychiatric procedures,treatments,devices and phar- macological regimes (including investigational drugs and drug therapies)as determined by the medical community at large, including but not limited to the Food and Drug Administration.PLAN reserves the right to change, time,the procedures considered to be Experimental or Unproven.Contact PLAN to determine if a particular treatment, device, or pharmacological regime is considered to be E from time to Experimental or Unproven. procedure, "Family Dependent"means a person who is(1)the Enrollee's legal spouse or(2)an unmarried dependent child(including a stepchild,legally adopted child,or a child for whom the Enrollee has coup-appointed guardianship and for whom the Enmller has legal or permanent parental responsibility and control)of either the Enrollee or the Enrollee's spouse,and (3)whc principal place of residence is with the Enrollee unless PLAN approves other arrangements. Enrolled Family Dependents who temporarily reside outside of the Service Area shall be covered only for Health Services rendered by Participating Providers in the Service Area,except in the event of an Emergency,oru n prior written bL The definition of"Family Dependent"is subject to the following conditions and limitations; [ten approval by PLAN. - 3 - • The term"Family Dependent"shall not include any unmarried dependent child 19 years of age or older, J . The term"Family Dependent'shall not include any unmarried dependent child 19 years of age or older but less than 23 years of age unless: a. The child is not regularly employed on a full-time basis; and b. The child is a Full-time Student and evidence satisfactory to PLAN is furnished upon request; and c. The child is primarily dependent upon the Enrollee for support and maintenance and evidence satisfactory to PLAN is furnished upon request; and 3. The Enrollee shall be responsible for any Health Services provided to the child at a time when the child did not satisfy these conditions.The Enrolling Unit agrees to assist PLAN in obtaining reimbursement from the Enrollee for such Health Services. "Full-time Student"means a person who is enrolled and attending full-time in a recognized course of study or training at: 1. an accredited high school or vocational school; 2. an accredited college or university; or 3. a licensed technical school,beautician school,automotive school,or similar training school. A person ceases to be a Full-time Student at the end of the Contract Month during which the person graduates or otherwise ceases to be enrolled and in attendance at the institution on a full-time basis.Aperson continues to be a Full- time Student during periods of vacation established by the institution,unless the person does not continue as a Full- time Student immediately following the period of vacation. "Health Services"means the health care services and supplies covered under this Contract,except to the extent that such health care services and supplies are limited or excluded under this Contract. "Health Services Fee" means the monthly fee required for each Enrollee and each Enrolled Family Dependent in accordance with the terms of this Contract. "Hospital"means an institution operated pursuant to law which is primarily engaged in providing Health Services on an inpatient basis for the care and treatment of injured or sick individuals through medical,diagnostic and surgical facilities, by,or under the supervision of,a staff of Physicians,and which has twenty-four(24)hour nursing services,and is accred- ited as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations.A Hospital is not primarily a place for rest or Custodial Care of the aged, and is not a nursing home,convalescent home or similar institution. "Initial Eligibility Period"means the period of time determined by PLAN and the Enrolling Unit during which Eligible Persons may enroll themselves and Family Dependents under this Contract "Injury"means bodily damage other than Sickness(excluding medical malpractice),including all related conditions and recurrent symptoms, not otherwise excluded under this Contract "Medical Director"means the Physician so named by PLAN as the Medical Director,or his or her designee. "Medically Necessary"services means those Health Services which are determined by PLAN to be necessary to meet the basic health needs of an individual. Determination of Medical Necessity is done on a case-by-case basis.The fact that a Physician has performed or prescribed a procedure or treatment does not mean that it is Medically Necessary.In addition, the service must(1)be consistent with the diagnosis of,and prescribed course of treatment for the patient's condition,(2) be required for reasons other than the convenience of the patient or his or her Physician, or not be required solely for custodial,comfort or maintenance reasons,and(3)be performed in the most cost efficient type of setting appropriate for the condition. -4- • "Medicare"means PartA and Part B of the insurance program established by The XVIII,United States Social Security Act, as later amended,42 U.S.C. Sections 1394,et seq. "Mental Health Provide?' means the organization, entity or individual who has entered into a service agreement with PLAN to arrange or provide the Mental Health Services and Chemical Dependency Services covered under this Contract. "Mental Health Services"means those services and supplies covered under this Contract for the diagnosis and treatment of Mental Illnesses which are classified in the International Classification of Diseases of the U.S. Department of Health and Human Services. "Mental Illness"means a physical or mental condition having an emotional or psychological origin or effect,including alcoholism and chemical or drug dependency. "Open Enrollment Period"means an annual period thirty-one(31)days in duration,subsequent to the Initial Eligibility Period,determined by PLAN and the Enrolling Unit,during which Eligible Persons may enroll themselves and Family Dependents under this Contract "Participating Alternate Facility"means a non-Hospital health care facility,or adjunct facility designated as such by a Hos- pital which (1) provides one or more of the following services on an outpatient basis: prescheduled surgical services, Emergency Health Services,urgent care services,or prescheduled rehabilitative,laboratory, or diagnostic services, and (2) has entered into a service agreement with PLAN to provide Health Services to Covered Persons. "Participating Home Health Agency"means a program which is(1)engaged in providing home health care services and is authorized pursuant to the law of jurisdiction in which treatment is received,and(2)has entered into a service agreement with PLAN to provide Health Services to Covered Persons. "Participating Hospital"means a Hospital which has entered into a service agreement with PLAN to provide Health Serv- ices to Covered Persons. "Participating Physician"means any Physician who has entered into a service agreement with PLAN to provide Health Services to Covered Persons. "Participating Primary Care Physician"means any Physician whose practice predominately includes pediatrics,internal medicine,obstetrics/gynecology,or family or general medicine,and who has entered into a Primary Care Physician serv- ice agreement with PLAN to provide Health Services to Covered Persons. "Participating Provider"means a Participating Hospital,Participating Physician,and any other Health Service provider who/which has entered into a service agreement with PLAN to provide Health Services to Covered Persons. "Participating Skilled Nursing Facility"means a Hospital or nursing home facility which is(1)licensed and operated in accordance with the law of jurisdiction in which treatment is received,(2)is Medicare approved,and(3)has entered into a service agreement with PLAN to provide Health Services to Covered Persons. "Physician"means any doctor of medicine,"M.D.",or doctor of osteopathy,"D.O",who is duly licensed and qualified under the law of jurisdiction in which treatment is received. "Reasonable and Customary Charges"means fees for covered Health Services and supplies which do not exceed the fees that the provider would charge any other payor for the same services. "Reconstructive Surgery"means any Medically Necessary surgery which is incidental to an injury,Sickness,or Congeni- tal Anomaly and whose purpose is to restore normal physiological functioning to the involved part of the body. "Semi-private Accommodations"means a room with two or more beds in a Hospital or Participating Skilled Nursing Facility. "Service Area" means the geographic area served by PLAN, as approved by regulatory agencies. Contact PLAN to determine the precise geographic area served by PLAN. "Sickness" means physical illness or disease, or pregnancy, but does not include Mental Illness. -5 - Section II ENROLLMENT AND ht-t•t_CTIVE DATE OF INDIVIDUAL COVERAGE A. Enrollment Eligible Persons may enroll themselves and their Family Dependents in PLAN during the Initial Eligibility Period or during an Open Enrollment Period specified by PLAN by submitting application on a form provided or approved by PLAN.In addition,new Eligible Persons may be enrolled in PLAN within 31 days of the date on which they first become Eligible Persons,and new Family Dependents may be enrolled in PLAN within 31 days of the date on which they first become Family Dependents,except that Family Dependents who are newborn children are covered at the moment of birth. Except during the time periods set forth in this paragraph, Eligible Persons and/or Family Dependents may not enroll in PLAN without the express written authorization of PLAN and evidence of insurability. The Enrolling Unit shall notify PLAN in writing within sixty (60) days of the effective date of enrollments, terminations or other changes;provided,however,that the Enrolling Unit shall notify PLAN in writing each month of any changes in the Coverage classification of any Enrollee. B. Effective Date of Coverage Coverage for an Eligible Person and his or her Family Dependents, if any, is effective on the date specified by Enrolling Unit and PLAN,provided that PLAN receives a properly completed individual enrollment application that was submitted to PLAN according to the enrollment provisions of Section WA of this Contract; and provided, however, that: 1. No Coverage shall be effective until this Contract takes effect; 2. No Family Dependent shall be covered under this Contract until the Eligible Person is covered. 3. If an Enrollee acquires a new Family Dependent by reason of adoption ormaniage,then Coverage forthat Family Dependent shall take effect on the date that the new Family Dependent is adopted or married, if PLAN and Enrolling Unit is notified by the Enrollee of the adoption or marriage within thirty-one(31)days of occurrence; and any necessary adjustments to Health Services Fees have been made. 4. If an Enrollee acquires a new Family Dependent who is a newborn child,then Coverage forthat Family Dependent shall take effect at the moment of birth and remain in effect for thirty-one(31)days beyond the date of birth.To continue Coverage forthat Family Dependent,the Enrollee shall notify PLAN and Enrolling Unit of the newborn child's birth and the name;and make any necessary changes in the Coverage classification and Health Services Fees. 5. Health Services for medical conditions arising prior to the effective date of Coverage and resulting in Confinement are covered as of the effective date only if the Covered Person notifies PLAN of Confinement within forty-eight(48)hours of the effective date,or as soon thereafter as is reasonably possible,and if Health Services are received in accordance with the terms,conditions,exclusions and limitations of this Contract. Section III PROCEDURES FOR REIMBURSEMENT OF ELIGIBLE EXPENSES Reimbursement of Eligible Expenses PLAN shall reimburse for Eligible Expenses incurred with non-participating providers only for MEDICALLY NECES- SARY EMERGENCY SERVICES OR SERVICES AUTHORIZED OR APPROVED BY PLAN in accordance with the terms of this Contract Participating Providers are responsible for submitting written proof of loss for Eligible Expenses directly to PLAN on the Covered Person's behalf. In the event a Covered Person is billed by a Participating Provider for Eligible Expenses,the Covered Person should contact PLAN. -6 - Written proof of loss for services rendered by non-participating providers, satisfactory to PLAN, shall be furnished at PLAN's office within ninety(90)days after the date of such loss.Failure to furnish proof within the time required shall invalidate or reduce Coverage unless it was not reasonably possible to have given proof within ninety(90)days or.in the absence of legal capacity of the Covered Person,later than one(1)year from the time in which proof is otherwise required. All Eligible Expenses shall be paid within sixty(60)days of receipt by PLAN of proof of loss.Where applicable,Eligible Expenses shall be aid to the Enrollee. Subject to written authorization from an Enrollee,all or a portion of any Eligible Expenses due ma) be paid directly to the provider of the Health Services. Copayment Reimbursement PLAN shall reimburse for amounts of Copayment Charges paid by any Enrollee in any Contract Year that exceed 200% of the total annual Health Services Fees paid to PLAN during the same period on behalf of the Enrollee through the Enrolling Unit In those cases where the Enrollee has enrolled his or her Family Dependents with PLAN, PLAN shall reimburse for amounts of Copayment Charges paid by all Covered Persons in the family unit in any Contract Year that exceed 200%of the total annual Health Services Fees paid to PLAN through the Enrolling Unit during the same period. Written notice that excess amounts of Copayment Charges have been paid by the Enrollee or by all Covered Persons in the same family unit must be sent to PLAN.Such notice must(1)include proof satisfactory to PLAN of the payment of Copayment Charges,and(2)be provided to PLAN not later than ninety(90)days after the end of the Contract Year.The amount of any excess Copayment Charges will be paid within sixty(60)days of receipt of written notice by PLAN that excess Copayment Charges have been paid by Covered Persons. Limitation of Actions No action at law or in equity shall be brought to recover on this Contract by a Covered Person prior to the expiration of ninety(90)days after proof of loss has been filed in accordance with the requirements of this Contract,nor shall such action be brought at all unless brought within three(3)years after the time written proof of loss is required by this Contract Section IV COORDINATION OF BENEFITS AND SUBROGATION Coordination of Benefits A. Applicability 1. This coordination of benefits("COB")provision applies to This Plan when an Enrollee or the Enrollee's Enrolled Family Dependents have health care coverage under more than one coverage plan"Coverage plan"and'This Plan"are defined below. 2. If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another coverage plan The benefits of This Plan: (a) Shall not be reduced when, under the order of benefit determination rules,This Plan determines its benefits before another coverage plan; but (b) May be reduced when,under the order of benefits determination rules,another coverage plan determines its benefits first.The above reduction is described in subsection D"Effect on the Benefits of This Plan." B. Definitions 1. "Coverage plan"is any of these which provides benefits or services for,or because of,medical or dental cart or treatment (a) Group insurance or group-type coverage, whether insured or uninsured.This includes prepayment, group practice or individual practice coverage.It also includes coverage other than school accident-type coverage. -7- (b) Coverage under a governmental plan,or covers_:required or provided by law.This does not include a state plan under Medicaid(Title XIX,Grants to States forMedicalAssistance Programs,of the United States Social Security act, as amended from time to time). Each contract or other arrangement for coverage under (a) or(b) is a separate coverage plan. Also, if an arrangem zt has two parts and COB rules apply only to one of the two,each of the parts is a separate cov- erage plan. 2. "This Plan"is the part of this group Contract that provides benefits for health care expenses. 3. "Primary Plan/Secondary Plan":The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another coverage plan covering the person. When This Plan is a Primary Plan,its benefits are determined before those of the other coverage plan and without considering the other coverage plan's benefits. When This Plan is a Secondary Plan, its benefits are determined after those of the other coverage plan and may be reduced because of the other coverage plan's benefits. When there are more than two coverage plans covering the person,This Plan may be a Primary Plan as to one or more other coverage plans, and may be a Secondary Plan as to a different coverage plan or plans. 4. "Allowable Expense"means a necessary, reasonable and customary item of expense for health care; when the item of expense is covered at least in part by one or more coverage plans covering the person for whom the claim is made. The difference between the cost of private accommodations in a Hospital and the cost of Semi-private Accom- modations in a Hospital is not considered an Allowable Expense under the above definition unless the patient's stay in a private Hospital room is Medically Necessary either in terms of generally accepted medical practice,or as specifically defined in the coverage plan. When a coverage plan provides benefits in the form of services,the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid. 5. "Claim Determination Period"means a Calendar Year. However, it does not include any part of a year during which a person has no Coverage under This Plan,or any part of a year before the date this COB provision or a similar provision takes effect. C. Order of Benefit Determination Rules 1. General.When there is a basis for a claim under This Plan and another coverage plan,This Plan is a Secondary Plan which has its benefits determined after those of the other coverage plan,unless; (a) The other coverage plan has rules coordinating its benefits with those of This Plan; and (b) Both those rules and This Plan's rules,in subsection 2 below,require that This Plan's benefits be determined before those of the other coverage plan. 2. Rules.This Plan determines its order of benefits using the first of the following rules which applies: (a) Non-Dependent/Dependent. The benefits of the coverage plan which covers the person as an employee, member or subscriber(that is,other than as a dependent)are determined before those of the coverage plan wt :h covers the person as a dependent. (b) Dependent Child/Parents not Separated or Divorced.Except as stated in Paragraph(2)(c)below,when This Plan and another coverage plan cover the same child as a dependent of different persons,called"parents": (i) The benefits of the coverage plan of the parent whose birthday falls earlier in a year are determined be- fore those of the coverage plan of the parent whose birthday falls later in that year.but - 8 - (ii) If both parents have the same birthday,the benefits of the coverage plan which covered one parer:longer are determined before those of the coverage plan which covered the other parent for a shorter period of time. Howeve: if the other coverage plan does not have the rule described in(i)immediately above,but instead has a rule -jased upon the gender of the parent,and if,as a result,the coverage plans do not agree on the order of benefits,the rule in the other coverage plan will determine the order of benefits. (c) Dependent Child/Separated or Divorced.If two or more coverage plans cover a person as a dependent child of divorced or separated parents,benefits for the child are determined in this order. 0) First, the coverage plan of the parent with custody of the child; (ii) Then, the coverage plan of the spouse of the parent with the custody of the child; and (iii)Finally,the coverage plan of the parent not having custody of the child. However,if the specific terms of a court decree state that one of the parents is responsible for the health care expense of the child,and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms,the benefits of that coverage plan are determined first.The coverage plan of the other parent shall be the Secondary Plan. This paragraph does not apply with respect to any Claim Determination Period or plan year during which any benefits are actually paid or provided before the entity has that actual knowledge. (d) Active/Inactive Employee.The benefits of a coverage plan which covers a person as an employee w no is neither laid off nor reared(or as that employee's dependent)are determined before those of a coverage plan which covers that person as a laid off or retired employee (or as that employee's dependent). If the other coverage plan does not have this rule, and if, as a result, the coverage plans do not agree on the order of benefits,this rule(d) is ignored. (e) Longer/Shorter Length of Coverage.If none of the above rules determines the order of benefits, le benefits of the coverage plan which covered an employee,member or subscriber longer are determined before those of the coverage plan which covered that person for the shorter term. (f) No-Fault Automobile Insurance.Your benefits unde this PLAN will be coordinated with minimum coverages required under the Colorado Autr. Accident Reparations Act(No-Fault). VHAT IF YOU FAIL TO PURCHASE THE REQUIRED NO-FAULT COVERAGE ON YOUR AUTO- MOBILE The benefits of this PLAN will not be available to you to the extent of minimum benefits required by the"No- Fault"Law for injuries suffered by you while operating or riding in a motor vehicle owned by you if said vehicle is in operation on the public highways of this State and such vehicle is not covered by No-Fault Auto- mobile Insurance as required by Law.This denial of benefits does not appl' to any other person injured in a motor vehicle accident if the injured person is a non-owner operator, passenger or a pedestrian and such other person is not covered by No-Fault Automobile Insurance. D. Effect on the Benefits of This Plan I. When This Subsection Applies.This subsection D applies when, in accordance with subsection C " -der of Benefit Determination Rules,"This Plan is a Secondary Plan as to one or more other coverage plans.In .:event the benefits of This Plan may be reduced under this subsection. Such other coverage plan or plans an referred to as"the other coverage plans" in subsection 2 immediately below. 2. Reduction in This Plan's Benefits.The benefits of This Plan will be reduced when the sum of: (a) The benefits that would be payable for the Allowable Expense under This Plan in the absence of this COB provision; and -9- (b) The benefits that would be payable for the Allowable Expenses under the other coverage plans,in the absence of provisions with a purpose like that of this COB provision,whether or not claim is made; exceeds those Allowable Expenses in a Claim Determination Period.In that case,the benefits of This Plan will be reduced so that they and the benefits payable under the other coverage plans do not total more than those Allowable Expenses. When the benefits of This Plan are reduced as described above,each benefit is reduced in proportion. It is then charged against any applicable benefit limit of This Plan. E. Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules.PLAN has the right to decide which facts it needs.It may get needed facts from or give them to any other organization or person.PLAN need not tell,or get the consent of,any person to do this. Each person claiming benefits under This Plan must give PLAN any facts it needs to pay the claim. F. Payments Made A payment made under another coverage plan may include an amount which should have been paid under This Plan. If it does,PLAN may pay that amount to the organization which made that payment That amount will then be treated as though it were a benefit paid under This Plan.PLAN will not have to pay that amount again.The term"payment made" includes providing benefits in the form of services,in which case"payment made"means reasonable cash value of the benefits provided in the form of services. G. Right of Recovery If the amount of the payment made by PLAN is more than it should have been paid under this COB provision,it may re- cover the excess from one or more of: 1. The persons it has paid or for whom it has paid; 2. Insurance companies; or 3. Other organizations. The"amount of the payments made"includes the reasonable cash value of any benefits provided in the form of services. Subrogation PLAN shall be subrogated to,and shall succeed to all rights of recovery of any Covered Person from a third party,includ- ing his or her employer,for the reasonable value of services provided under this Contract.PLAN may require assignment of the rights of recovery from the Covered Person,to the extent of the reasonable value of services and benefits provided by it plus reasonable costs of collection The Covered Person shall cooperate with PLAN in protecting the PLAN's legal rights under these subrogation provisions and acknowledges that PLAN's subrogation rights shall be considered as the first priority claim against any third party, to be paid before any other claims which may exist are paid,including claims for general damages by the Covered Person. The Covered Person shall do nothing to prejudice PLAN's lights under this provision,either before or after the need for services or benefits under this Contract. PLAN may, at its option, take necessary and appropriate action to preserve its rights under these subrogation provisions,including the right to bring suit in the name of the Covered Person.PLAN may collect, at its option, amounts from the proceeds of any settlement or judgment that may be recovered by the Covered Person or his or her legal representative, regardless of whether or not the Covered Person has been fully compensated. Any proceeds of settlement or judgment shall be held in trust by the Covered Person for the benefit of PLAN under these subrogation provisions,and PLAN shall be entitled to recover reasonable attorney fees from the Covered Person incurred in collecting proceeds held by the Covered Person. - 10- • • Section V COMPLAINT AND GRIEVANCE PROCESSES If a Covered Person has a complaint concerning the provision of Health Services or benefits under this Contract,a written or verbal complaint may be made by the affected Covered Person or by the affected Covered Person's legal guardian,to PLAN's Member Services Department. The PLAN's Member Services Department shall contact the complainant and attempt to resolve the verbal complaint through informal discussions,and shall notify the complainant of the resolution of the verbal complaint within thirty-one (31)days following its receipt If the Covered Person is not satisfied with the resolution of the verbal complaint,he or she may request, in writing,the PLAN's Member Services Department to present the complaint and all research infor- mation to the Member Relations Committee for further consideration. Written complaints and unresolved verbal complaints are researched and reviewed by the Member Relations Commit- tee.The Member Relations Committee shall review this information and notify the complainant of the resolution within sixty(60)days of the date the written complaint was first received.If the Covered Person is not satisfied with the resolution by the Member Relations Committee,the complainant has the right to successive levels of appeal through the PLAN's formal grievance process. Section VI TERMINATION OF INDIVIDUAL COVERAGE Termination Conditions Coverage of the Covered Person under this Contract,including Coverage for any Health Services rendered after the date of termination,for medical conditions arising prior to the date of termination,shall automatically terminate on the earliest of the following dates: 1. The date this Contract is terminated. 2. The last day of the last Contract Month that the required Health Services Fee has been paid. 3. In the case of a Covered Person who fails to pay a required Copayment Charge for Health Services rendered,the date specified by PLAN for termination of Coverage in written notice to the Enrolling Unit.Such notice shall be provided by PLAN at least thirty-one (31) days in advance of such termination. 4. The date specified by PLAN in written notice to the Enrollee that all Coverage under this Contract will terminate because the Enrollee knowingly provided PLAN with false,material information,including,but not limited to, information relating to another person's eligibility for Coverage or status as a Family Dependent;or false,material information relating to the Enrollee's health status or that of any Family Dependent 5. The date specified by PLAN in written notice to the Enrollee that all Coverage under this Contract wi'' 'erminate because the Enrollee permitted the use of the Enrollee's identification card by any unauthorized person,or used another person's card. 6. The date a Covered Person's residence is no longer in the PLAN Service Area.The Enrolling Unit or Enrollee shall be responsible for notifying PLAN of a Covered Person's move from the Service Area.Coverage under this Contract will terminate on the date of such move,even if such notice is not provided to PLAN. 7. The date the Enrolling Unit receives written notice from the Enrollee requesting termination of Coverage,or the date requested by the Enrollee in such notice, if later. 8. The date the Enrollee is retired or pensioned,unless a specific Coverage classification is specified for retired or pensioned individuals in the application attached to this Contract. 9. The date specified by PLAN,after thirty-one(31)days prior written notice to the Enrollee,that all Coverage under - 11 - this Contract will terminate due to the failure of the Enrollee to establish and maintain a satisfactory provider- patient relationship with any Participating Provider.Termination of Coverage under this condition shall not occur prior to the date that the Enrollee exercises his or her rights through the Complaint and Grievance Processes, should the Enrollee choose to do so. 10. The last day of the Contract Month in which the Covered Person ceases to be eligible as an Enrollee or Enrolled Family Dependent. Under certain circumstances, Covered Persons who cease to be eligible for Coverage under this Contract are entitled to continue Coverage under this Contract, as described below in "Continuation Coverage." Continuation Coverage A Covered Person whose Coverage ends under this Contract is entitled to elect continuation of Coverage in accordance with either Pan I (Federal continuation) or Part II (State continuation) of this subsection.The Covered Person should contact the Enrolling Unit to determine whether Part I or Part II is applicable. Part I: Continuation of Coverage Under Federal Law A. Qualifying Events The Covered Person's Coverage must have terminated due to one of the following Qualifying Events: 1. Termination of the Enrollee from employment with the Enrolling Unit,or reduction of hours,for any reason other than gross misconduct; 2. Death of the Enrollee; 3. Divorce or legal separation from the Enrollee; 4. Loss of eligibility by an Enrolled Family Dependent who is a child; 5. Entitlement of an Enrollee to Medicare benefits; 6. The Enrolling Unit filing for bankruptcy,underline XI,United States Code,on or after July 1,1986,but only for a retired Enrollee and his or her Enrolled Family Dependents. A Covered Person who is totally disabled may extend continuation coverage if: a. it has been determined that the Covered Person is totally disabled for Social Security purposes; and b. the Covered Person notifies the PLAN within 60 days of the date the detennination is made by the Social Security Administration. The Covered Person must elect continuation during the election period,and payment of the Health Service Fees is required.If the Covered Person elects continuation of Health Services,it must be the same Coverage that the Covered Person had at the time of the Qualifying Event. B. Notification Requirements and Election Period The Covered Person must notify the Enrolling Unit's designated plan administrator within sixty(60)days when divorce, legal separation,or loss of eligibility as an Enrolled Family Dependent would end Coverage. NOTE: PLAN is not the Enrolling Unit's designated plan administrator.The Covered Person should consult his or her Enrolling Unit. In the case of an Enrollee's reduction of hours,termination of employment,death,or entitlement to Medicare, the Enrolling Unit will notify its designated plan administrator. Within fourteen (14)days upon receiving such notification, the Enrolling Unit's designated plan administrator - 12 - will notify the eligible Covered Person(s)of the right to elect continuation, and of the Health Service Fee. quired. Continuation must be elected by the later of: 1. Sixty(60)days after the Covered Person's Coverage ends; or 2. Sixty(60)days after the Covered Person receives notice of the continuation right from the Enrolling Unit's designated plan administrator. A Covered Person whose Coverage was terminated due to a Qualifying Event must pay the initial Health Service Fees due within forty-five (45) days after electing continuation.All other Health Service Fees after the initial payment are due within the applicable grace period. C. Terminating Events Continuation under this Contract will end on the earliest of the following dates: 1. Eighteen(18)months from the date continuation began for a Covered Person whose Coverage ended because of Qualifying Event 1. 2. Twenty-nine(29)months from the date continuation began for Covered Persons whose coverage was extended due to total disability. 3. Thirty-six (36) months from the date continuation began for an Enrolled Family Dependent whose Coverage ended because of Qualifying Events 2,3,4 and 5. 4. The date Coverage terminates under the Contract for failure to make timely payment of the Health Services Fee. 5. The date coverage is obtained under any other group health plan.Except that,a Covered Person with a pre-existing condition which is limited or excluded under any other employer sponsored group health plan may continue coverage. 6. The date the Covered Person becomes entitled to Medicare,(except that this shall not apply in the event Covered Person's Coverage was terminated because of Qualifying Event 6). 7. The date the Contract ends. If a second qualifying event occurs, the following rules apply: 1. If a Covered Person is entitled to eighteen(18)months of continuation,and a second qualifying event occurs during that time, the Covered Person's Coverage may be extended up to a maximum of thirty-six (36)months from the date of Qualifying Event 1. 2. If a Covered Person is entitled to continuation due to Qualifying Event 6,and the retired Enrollee dies during the continuation period,the Enrolled Family Dependents shall be entitled to continue Coverage for thirty-six(36) months from the date of death. Terminating Events 2 - 6 shall apply during the extended continuation period. Part II: Continuation of Coverage Under State Law An Enrollee whose Coverage ends under this Contract may be entitled to elect continuation Coverage under state law, if the Enrolling Unit is not subject to the requirements of COBRA,or as an alternative to COBRA when both state law and COBRA apply. The Enrollee's C •erage must have ended due to termination of employment.The Enrollee shall not be entitled to con- tinuation Coverage under state law if: - 13 - a. Health Services Fees for Coverage up to the termination date have not been paid by or on behalf of the Enrollee; or b. the Enrollee has not been continuously covered under this Contract,or under any coverage plan providing similar coverage which this Contract replaced,for at least six(6)months immediately prior to termination from employ- ment;; or c. the Enrollee is covered by Medicare or Medicaid; or d. the entire Contract is discontinued. The Enrollee must elect continuation Coverage and pay Health Services Fees due within twenty(20)days from the date of termination from employment Continuation of Coverage under state law will end after a period of ninety(90)days after the date Coverage would have ended,or until the Enrollee is reemployed,whichever occurs first.At the end of the ninety(90)day continuation period under state law,the Enrollee or the Enrolled Family Dependents are entitled to conversion privileges as described below. Conversion A Covered Person who ceases to be eligible for PLAN Coverage for the reasons stated in termination conditions 8 or 10 above, or upon termination of continuation Coverage, and who continues to reside in the Service Area, may make application to PLAN for coverage under a conversion contract without furnishing evidence of insurability.Application and payment of the initial Health Services Fees must be made within thirty-one(31)days after termination of Coverage under this Contract.A conversion contract shall be issued in accordance with the terms and conditions in effect at the time of application. Out of Area Conversion PLAN may designate a carrier to provide conversion membership to any Covered Person who ceases to be eligible for PLAN Coverage for the reasons stated in termination conditions 6 or 10 above,and who no longerresides within the PLAN Service Area.Application to convert membership effective on the date of termination,without furnishing evidence of insurability,must be made to the PLAN designated carrier within thirty-one(31)days aftertennination of Coverage under this Contract.A conversion contract may be issued in accordance with the terms and conditions the designated carrier may have in effect at the time of application. Section VII CONTRACT CHARGES Computation of Contract Charges Each moncly Contract Charge shall be calculated on the basis of PLAN's record as to the number of Enrollees in each Coverage classification at the time of calculation,at the Health Services Fees then in effect.The initial Health Services Fees are shown in the Master Group Application,and/or any Addenda. Adjustments to Contract Charges Retroactive adjustments may be made for any additions or terminations of Enrollees and changes in Coverage classifi- cation not reflected in PLAN's records at the time the Contract Charge is calculated by PLAN. However,no retroactive credit shall be granted for any change occurring more than sixty(60)days prior to the date PLAN was notified of the change by the Enrolling Unit.. PLAN reserves the right to change the schedule of rates for Health Services Fees(1)on the due date after the first Contract Year or on any monthly due date thereafter, or(2_)on any date that the provisions of this Contract are amended.Written notice of any such change in rates shall be given by PLAN to the Enrolling Unit at least thirty-one(31)days prior to the effective cate of the change. - 14- • Payment of Contact Charge:. All Contract Charges are payable monthly in advance by the Enrolling Unit to PLAN at its offices or at an address specified by PLAN. The first Contract Charge is due and payable on the effective date of this Contract.Subsequent Contract Charges are due and payable no later than the first day of each Contract Month thereafter that this Contract is in effect. If a Covered Person's coverage is effective the 1st through the 15th of the month,the entire Health Service Fee is due for that month. If a Covered Person's coverage is effective the 16th through the end of the month,no Health Service Fee is due until the following month. Terminating Covered Person:If a Covered Person's coverage terminates the 1st through the 15th of the month no Health Service Fee is due for that month. If a Covered Person's coverage terminates the 16th through the end of the month the entire Health Service Fee is due for that month. Grace Period A grace period of ten(10)days will be granted for the payment of any Contract Charge,during which time this Contract shall continue in force. In no event shall any grace period extend beyond the date this Contract terminates. Contract Termination This Contract shall automatically terminate retroactive to the last paid date of Coverage at 12:01 a.m.on the day follow- ing the grace period if the Enrolling Unit fails to remit the required Contract Charge. Should such Contract Charge be received by the PLAN after the grace period outlined above,it will be totally within PLAN's discretion to reinstate the coverage or return the Contract Charge to the Enrolling Unit and terminate the group. PLAN or Enrolling Unit may terminate this Contract for other than non-payment of Contract charge by giving the other party written notice of termination thirty-one(31)days prior to the effective date of termination. Termination of this Contract shall be without prejudice to any written proof of loss furnished as provided in Section III for Eligible Expenses for Health Services rendered prior to the effective date of termination. Upon termination of this Contract, the Enrolling Unit shall be liable to PLAN for the payment of any and all Health Services Fees which are accrued and unpaid at the time of termination. Section VIII GENERAL PROVISIONS Entire Contract The Master Group Contract, the application of the Enrolling Unit, any individual Enrollee applications,Addenda and amendments shall constitute the entire Contract of Coverage between parties.All statements made by the Enrolling Unit or by an Enrollee shall,in the absence of fraud,be deemed representations and not warranties.No such statement shall void or reduce Coverage under this Contract or be used in defense of a legal action unless it is contained in a written application. Limitation of Actions No action in law or equity may be brought against PLAN,or any officer,director,or employee of PLAN,by any Covered Person with respect to any matter arising under this Contrast or the relationship between that Covered Person and PLAN without fu!! and complete compliance with the complaint procedure set forth in Section V of this Contract,nor shall such action be• aught at all unless brought within one(I)year from the date when the cause of action first arose.Written proofs of loss furnished under Section III of this Contract are subject to the provisions regarding limitation of actions set forth in that Section. - 15- Time Limit on Certain Defenses No statement, except a fraudulent statement,made by the Enrolling Unit shall be used to void this Contract after it has been in force for a period of two(2)years. Alterations No alteration of this Contract and no waiver of any of its provisions shall be valid unless evidenced by an Addendum or an amendment attached to this Contract which is signed by an executive officer of PLAN.No agent has authority to change this Contract or to waive any of its provisions. Minimum Number of Enrollees For initial coverage,the minimum number of Eligible Persons selecting Health Services must be the number specified on the Application.The Enrolling Unit must maintain at least the number specified on the Application,or at the PLAN's option this Contract may be terminated and conversion to an individual direct-pay plan will be allowed if the individual meets the conversion requirements outlined in this Contract and under applicable state law. Relationships Between Panics The relationships between PLAN and Participating Providers(except for the position of Medical Director),and between PLAN and Enrolling Units are contractual relationships between independent contractors. Participating Providers and Enrolling Units are not agents or employees of PLAN nor is PLAN or any employee of PLAN an agent or employee of Participating Providers or Enrolling Units. The relationship between a Participating Provider and any Covered Person is that of provider and patient.The Partici- pating Physician is solely responsible for the medical services provided to any Covered Person.The Participating Hospital is solely responsible for the Hospital services provided to any Covered Person. The relationship between any Enrolling Unit and any Covered Person is that of employer and employee,Family Depend- ent, or other Coverage classification as defined in this Contract. The Enrolling Unit is solely responsible for providing written notice to PLAN of the enrollment and Coverage changes, including termination of a Covered Person's Coverage through PLAN,and the timely payment of Contract Charges to PLAN. Records The Enrolling Unit shall furnish PLAN with all information,authorization,and supporting documentation which PLAN may reasonably require with regard to any matters pertaining to this Contract.All documents furnished to the Enrolling Unit by an individual in connection with the Coverage,and the Enrolling Unit's payroll and any other records pertinent to the Coverage under this Contract shall be open for inspection by PLAN at any reasonable time. Each Covered Person authorizes and directs any person or institution that has attended,examined or treated the Covered Person,to furnish PLAN at any reasonable time,upon its request,any and all information and records or copies of records relating to attendance,examination or treatment rendered to the Covered Person.PLAN agrees that such information and records will be considered confidential.PLAN shall have the right to submit any and all records concerning episodes of health care for Covered Persons to appropriate medical or other review bodies or individuals and/or Physicians. Examination of Covered Persons In the event of a question or dispute concerning the provision of Health Services or payment for such services under this Contract,PLAN may also reasonably require that a Covered Person be examined,at PLAN's expense,by a Participating Physician acceptable to PLAN. Clerical Error Clerical error shall not deprive any individual of Coverage under this Contract.Failure to report the termination of Cov- erage shall not continue such Coverage beyond the date it is scheduled to terminate according to the terms of this Contract. - 16- • Upon discovery of a clerical error,an appropriate adjustment in Health Services Fees shall be made. However,no such adjustment in Health Services Fees or Coverage shall be granted by PLAN to the Enrolling Unit for more than sixty(60) days of Coverage prior to the date PLAN was notified of such clerical error. Notice Notice given by PLAN to an authorized representative of the Enrolling Unit shall be deemed notice to all affected Enrollees and their Enrolled Family Dependents in the administration of this Contract, including termination of this Contract or the termination of individual Coverage. Covered Benefits In no event shall any Covered Person be responsible to pay for benefits received in accordance with this Contract except as otherwise provided in this Contract. Workers' Compensation Not Affected The Coverage provided under this Contract is not in lieu of and does not affect any requirements for coverage by Workers' Compensation Insurance. Conformity with Statutes Any provision of this Contract which,on its effective date,is in conflict with the statutes of the jurisdiction in which it is delivered is hereby amended to conform to the minimum requirements of such statutes. Non Discrimination In compliance with federal and state law, PLAN shall not discriminate on the basis of age, sex, color, race, disability, marital status, sexual preference,religious affiliation or public assistance status. Section IX PROCEDURES FOR OBTAINING HEALTH SERVICES A. HEALTH SERVICES RENDERED BY PARTICIPATING PROVIDERS Subject to the terms,conditions,exclusions,and limitations of this Contract,a Covered Person is entitled to Coverage described in Section X if such services(1)are authorized and determined to be Medically Necessary by PLAN and (2) are provided by or referred by the Participating Primary Care Physician. Each Covered Person shall select a Participating Primary Care Physician who shall be responsible for the coordination of all Health Services rendered to the Covered Person and for ensuring continuity of care.Covered Persons who have not selected a Participating Primary Care Physician within 31 days of enrollment may be assigned one by the PLAN. The Participating Primary Care Physician shall refer the Covered Person only to Participating Providers,except as provided in Section DC.B. All Health Services rendered to the Covered Person must be provided or referred by the Participating Primary Care Physician. Health Services obtained by the Covered Person without referral by the Participating Primary Care Physician are not covered.The fact that a Physician may prescribe,order, recommend, approve or provide a service or supply does not,in and of itself,make the service or supply a covered Health Service. Each Covered Person is responsible for verifying the participation status of the provider prior to receiving Health Services.These Health Services are subject to(1)payment by the Enrollee of the Health Services Fees required for Coverage under this Contract and (2) payment by the Covered Person of the Copayment Charge specified for any service. LIMITATION ON SELECTION OF PROVIDER In the case of a medical condition which significantly endangers either a Covered Person's health or the public health, - 17- / . the Covered Person may be required to receive all covered Health Services through a single PLAN Participating Physician or network of Participating Providers designated by PLAN. B. REFERRAL HEALTH SERVICES RENDERED BY NON-PARTICIPATING PROVIDERS In the event that specific Health Services cannot be provided by or through a Participating Provider,a Covered Person shall be entitled to Coverage for Eligible Expenses for Medically Necessary Health Services obtained through non- participating providers. All such Health Services, including but not limited to Miscellaneous Health Services identified in this Contract,must be authorized in writing in advance by PLAN, and are subject to all of the terms, conditions, exclusions, and limitations of this Contract. IT IS THE COVERED PERSON'S RESPONSIBILITY TO VERIFY THAT THE REQUIRED WRITTEN APPROVAL FROM PLAN HAS BEEN GRANTED, PRIOR TO RECEIVING SERVICES FROM NON- PARTICIPATING PROVIDER SHOULD THE COVERED PERSON RECEIVE CARE FROM A NON-PAR- TICIPATING PROVIDER, INCLUDING HOSPITALIZATION, WITHOUT THE REQUIRED APPROVAL BY PLAN, THE COVERED PERSON WILL BE RESPONSIBLE FOR ALL COSTS ASSOCIATED WITH THAT CARE. FAILURE OF PARTICIPATING PRIMARY CARE PHYSICIAN TO OBTAIN NECESSARY PRIOR APPROVAL FROM PLAN DOES NOT EXCUSE THE COVERED PERSON'S RESPONSIBILITY TO VERIFY APPROVAL FROM PLAN BEFORE RECEIVING SERVICES FROM OR THROUGH NON-PARTICIPATING PROVIDERS. C. EMERGENCY HEALTH SERVICES Covered Persons are directed to telephone their Participating Primary Care Physician whenever possible prior to receiving Emergency Health Services.PLAN will pay Eligible Expenses for Medically Necessary Emergency Health Services rendered to a Covered Person,subject to the terms,conditions,exclusions,and limitations of this Contract. Emergency Health Services rendered by Participating Providers are subject to a Copayment Charge for each incident. In order for Emergency Health Services rendered by non-participating providers to be covered under this Contract, the required Emergency Health Services must be(1)of such immediate nature that the Covered Person's life or health would be jeopardized if taken to a facility where the services of a Participating Physician would be available,or(2) provided under circumstances in which the Covered Person is unable,due to unconsciousness or the inability to be rational,to request treatment at a location where the services of a Participating Physician would be available.In this case, Coverage is subject to a Copayment Charge for each incident of Medically Necessary Emergency Health Services rendered by a non-participating provider. The above Copayment Charges for Emergency Health Services rendered by either Participating Providers or by non- participating providers are in addition to any other Copayment Charges which may apply to the Health Service.If, however, a Covered Person is confined, the above Copayment Charge is waived, but the Copayment Charges described in Section X.B.1. and X.E.2. shall apply. The Covered Person must notify PLAN within forty-eight(48)hours after Emergency Health Services are initially provided,or as soon thereafter as is reasonably possible.Full details of the Emergency Health Services received shall be made available by the Covered Person at the request of PLAN. Continuation of care thereafter shall require coordination by the Participating Primary Care Physician and the prior written authorization of PLAN. If the Covered Person is hospitalized,the PLAN may elect to transfer the Covered Person to a Participating Hospital as soon as it is medically appropriate in the opinion of the attending Physician.Emergency Health Services rendered by non-participating providers or in non-participating facilities are not covered if the Covered Person chooses to remain in a non-participating facility after PLAN has notified the Covered Person of the intent to transfer the Covered Person to a Participating Provider facility. ELIGIBLE EXPENSES FOR EMERGENCY HEALTH SERVICES Eligible Expenses for Emergency Health Services are the Reasonable and Customary Charges for the Health Services described in Section X of this Contract,provided during the course of the Emergency,and when Medically Necessary for stabilization and initiation of treatment until responsibility for medical care can be assumed by the Participating Primary Care Physician.The Health Services must be provided by or under the direction of a Physician and are subject to the exclusions and other provisions of this Contract. Health Services rendered on an Emergency basis are not - 18 - covered if,in the opinion of PLAN,the situation is later determined to be non-emergency.This determination shall be based on generally accepted medical criteria. D. SECOND OPINION POLICY Coverage of certain Health Services requires that the Covered Person obtain a consultation with a second Participating Physician prior to the scheduling of the Health Service.The Participating Physician shall notify the Covered Person that second opinions are implemented at the PLAN's discretion in accordance with PLAN policy.The Covered Person is then responsible for contacting PLAN to obtain a list of Participating Physicians who are authorized to render a second opinion and verify that the procedure or treatment referred for a second opinion is consistent with PLAN policy.The Enrollee will arrange a consultation with the second Participating Physician,not affiliated with the first Participating Physician.The consultation for the second opinion must occur within thirty-one (31)days of the first opinion, or as soon thereafter as is reasonably possible. In the event that the second opinion differs from the first opinion, the Covered Person may arrange for a third opinion. Coverage is provided for second and third opinions if arranged through PLAN as described above. Failure to comply with this procedure for obtaining a second opinion shall result in a total Copayment Charge of 40% of Eligible Expenses. E. COPAYMENT CHARGES In the event that two (2) or more Copayment Charges apply to a single Health Service, all applicable Copayment Charges shall apply,provided,however,that the total of all applicable Copayment Charges shall not exceed 40%of Eligible Expenses for the single Health Service. (PLAN Enrollees who wish to ascertain the total dollar amount of combined Copayment Charges may obtain such information from PLAN.) Section X SCHEDULE OF BENEFITS The amount paid by the Enrollee for Coverage under this Contract,exclusive of Copayment Charges or charges for non- covered services,is described in the Appendix. A. PHYSICIAN SERVICES (except for those identified in Sections X.C and X.D of this Contract),when provided or referred by the Participating Primary Care Physician, authorized by PLAN, and rendered through a P -ticipating Provider unless alternative arrangements have been authorized in advance by PLAN,or in the event of an ergency: 1. Services and supplies provided in a Physician's office,including diagnostic treatment and preventive medical care such as x-rays, electrocardiograms, electroencephalograms, and other clinical laboratory tests, well-baby care, physical examinations, voluntary family planning, application and removal of casts and dressings, immunizations, and Medically Necessary therapeutic injections. COPAYMENT CHARGE: $10.00 per visit during scheduled office hours or$25.00 after scheduled office hours except for Copayment Charges required for specific services and supplies set forth below. 2. Eye exams,excluding refraction,provided in the Physician's office. (No limitation applies to Covered Persons through the age of seventeen(17).) COPAYMENT CHARGE: $10.00 per visit Eye exams for refraction provided in a Participating Provider's office,limited to one(I)exam per Covered Person per Calendar Year. COPAYMENT CHARGE: $10.00 per visit 3. Physician surgical services and other medical care, including anesthesia, consultation with and treatment by - 19- specialists, and services by surgical assistants only when authorized in advance by PLAN,when provided in a Participating Physician's office. COPAYMENT CHARGE:$10.00 per visit,except for Copayment Charges for specific services and supplies set forth in this contract. 4. Allergy Testing and Treatment Ser ces.No Coverage is provided for RAST testing,except when skin testing is medically impossible. COPAYMENT CHARGE: $10.00 per visit 5. Dermatology Services. COPAYMENT CHARGE: $10.00 per visit B. HOSPITAL AND RELATED SERVICES,when provided or referred by the Participating Primary Care Physician, and authorized by PLAN: 1. Inpatient Services Some Health Services rendered while confined are subject to separate benefit limitations, restrictions and/or Copayment Charges, as described elsewhere in this Contract. a. Room and Board Unlimited Confinement,when Medically Necessary and approved by PLAN prior to admission in a Partici- pating Hospital on a Semi-Private Accommodations basis.The difference in cost between Semi-private and private room accommodations will not be considered an Eligible Expense unless private accommodations are Medically Necessary, or unless Semi-private Accommodations are not available. COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay- merits are limited to two(2)admissions per person per Calendar year,except copayments for transplant services. In addition to the Copayment Charges listed elsewhere in this Contract, the following shall apply when Health Services are rendered for organ transplants provided,however,that the total of all applicable Copayment Charges shall not exceed 40%of Eligible Expenses for the Health Service. 5%of Eligible Expenses for kidney and corneal transplants,and liver transplants in children with biliary atresia or children with other end stage liver rlicrasP,and other transplants as required by State Statutes when Health Services are rendered in a Designated Organ Transplant Facility. b. Other Inpatient Services and Supplies Services and supplies provided while confined in a Participating Hospital as described in Section X.B.l.a of this Contract Services and supplies include nursing cars,Medically Necessary meals and special diets,use of operating room and related facilities,use of intensive care unit and services, x-ray,laboratory and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, internal prosthetics, Medically Necessary special duty nursing,radiation therapy,inhalation therapy,and administration of blood and blood plasma,except that such services are subject to the terms,conditions,exclusions,and limitations of this Contract. COPAYMENT CHARGE: $100 per admission for non-surgical or surgical Health Services. Copay- ments are limited to two(2)admissions per person per Calendar year,except copayments for transplant services.In addition to the Copayment charges listed elsewhere in this Contract,the following shall apply when Health Services are rendered for organ transplants provided,however,that_ne total of all applicable Copayment Charges shall not exceed 40%of Eligible Expenses for the Health Service. 5%of Eligible Expenses for kidney and corneal transplants,and liver transplants in children with biliary atresia or children with other end stage liver disease,and other transplants as regulated by State Statutes when Health Services are rendered in a Designated Organ Transplant Facility. -20- 2. Outpatient Services and Supplies,at either Participating Hospital or Participating Alternate Facility and when provided or referred by the Participating Primary Care Physician and authorized by PLAN,except in the event of an Emergency. Emergency Health Services provided at or by nonparticipating facilities or providers are covered subject to the terms, conditions, exclusions and limitations of this Contract, and when PLAN later determines these Emergency Health Services to be Medically Necessary: a. Emergency Services 1) Services and supplies for stabilization or initiation of treatment of Emergency conditions,rendered on an outpatient basis in an emergency room of a Hospital. COPAYMENT CHARGE:$50.00 per visit except the the Copayment Charge described in Section X.B.1.a or X.E.2 will apply when the Emergency condition directly results in Confinement. 2) Services and supplies for stabilization or initiation of treatment of Emergency conditions, rendered on an outpatient basis in a physician's office or urgent care facility. COPAYMENT CHARGE: $25.00 per visit, except the Copayment Charge described in Section X.A.1 will apply when services are rendered by a Primary Care Physician during regularly scheduled office hours. b. Non-Emergency Services 1) Physician surgical services,supplies and other medical care,including anesthesia,consultation with and treatment by specialists,and services by surgical assistants only when authorized in advance by PLAN, for prescheduled outpatient surgery provided at a Participating Hospital or Participating Alternate Facility. COPAYMENT CHARGE: $50.00 per outpatient surgery 2) Prescheduled diagnostic and therapeutic services,including x-ray,radiation therapy and laboratory tests • and services,provided at a Participating Hospital or Participating Alternate Facility. COPAYMENT CHARGE: $10.00 per visit C. MATERNTI'Y, FAMILY PLANNING AND INFERTILITY SERVICES For the purposes of this subsection, maternity and obstetrical care shall mean pre- and post-partum care during pregnancy, childbirth, early termination of pregnancy,or any associated complications. 1. Services,equipment and supplies provided on an inpatient or outpatient basis for obstetrical care of the mother before and luring delivery and during the post-partum period, including Physician services, operations and special procedures such as Caesarean sections,Hospital services,including use of the delivery mom,x-ray and laboratory, injectable substances and anesthesia. Unless authorized in writing and in advance, obstetrical and neonatal care provided outside of the Service Area will not be covered if such care is rendered during the normal delivery period.The normal delivery period is the three to five week period prior to the expected delivery date. COPAYMENT CHAT :E: $10.00 per outpatient visit,and inpatient services-same as X.B.1. 2. Services and supplies provided on an inpatient or outpatient basis for family planning counseling and treatment, is ..ding infertility evaluation,birth control counseling and treatment,certain intrauterine devices,measurement L. contraceptive diaphragms,voluntary male or fer _le surgical sterilization,and up to two(2)elective abortions per lifetime if performed within ten(10)weeks of nception.(Donor semen for artificial insemination,in vitro fertilization,embryo transport procedures.surrogate parenting,and outpatient injectable substances and supplies related to infertility are not covered.) COPAYMENT CHARGE: $10.00 per outpatient visit, and inpatient services same as X.B.1. D. MENTAL HEALTH SERVICES AND CHEMICAL DEPENDENCY SERVICES -21 - is the following Health Services are covered only when provided or refereed by PLAN's Mental Health Provider. 1. Inpatient and outpatient Health Services for detoxification of chemical dependency,without limitation.Health Services otherwise covered under this Contract for the treatment of medical complications of chemical dependency are described in Sections X.A. and X.B. of this Contract 2. Inpatient Mental Health. Coverage,up to a maximum of forty-five(45)full days or ninety(90)partial days per Calendar Year, for inpatient Semi-private Accommodations,or private when Medically Necessary, for Mental Health Services when provided by the Mental Health Provider in a Participating Hospital or Participating Alternate Facility."Partial Days"means treatment for at least three(3)hours but not more than twelve(12)hours in a 24-hour period. COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.1.a plus $25.00 per day thereafter. 3. Inpatient Chemical Dependency. Coverage for Semi-private accommodations, or private when Medically Necessary, for a maximum of twenty-one(21)days per Calendar Year and two (2) Confinements per lifetime, for treatment of alcoholism or chemical dependency when authorized in writing in advance by the Mental Health Provider, and provided in an inpatient treatment facility designated by PLAN. Covered Person must complete prescribed and approved course of treatment of PLAN to be responsible for payment. COPAYMENT CHARGE:The first day's Copayment Charge is the same as specified in Section X.B.l.aplus $25.00 per day thereafter. 4. Outpatient Mental Health and Chemical Dependency Services are provided when furnished by the Mental Health Provider. COPAYMENT CHARGE: No charge per visit. The full Reasonable and Customary Charge for each appointment broken less than twenty-four(24)hours prior to the time of scheduled visit. E. MISCELLANEOUS HEALTH SERVICES THE FOLLOWING HEALTH SERVICES ARE COVERED PROVIDED THAT SUCH HEALTH SERVICES (EXCu'F EMERGENCY SURFACE AMBULANCE SERVICE) ARE (A) ORDERED, PROVIDED, OR AR- RANGED BY OR UNDER THE DIRECTION OF THE PARTICIPATING PRIMARY CARE PHYSICIAN AND (B) APPROVED IN WRITING IN ADVANCE BY PLAN AND(C) OBTAINED THROUGH A VENDOR OR PROVIDER SELECTED BY PLAN MANAGEMENT. 1. Home Health Agency and Private Duty Nursing Services Intermittent Health Services of a Participating Home Health Agency,and private duty nursing care,by,or under the supervision of. a registered nurse, in a Covered Person's home, required for care and treatment which otherwise would require Confinement in a Participating Hospital or Participating Skilled Nursing Facility. Covered Health Services include diagnostic and therapeutic nursing services and Physician home visits within the Service Area. COPAYMENT CHARGE: No charge per visit 2. Skilled Nursing Facility Up to sixty-two(62)days of Medically Necessary Confinement(Semi-Private Accommodations unless private accommodations are Medically Necessary)and medical services and supplies and equipment ordinarily provided in a Participating Skilled Nursing Facility for the care and treatment of an acute Injury or Sickness,and which otherwise would require Confinement in a Participating Hospital.Some Health Services rendered while confined are subject to separate benefit limitations,restrictions and/or Copayment Charges,as described elsewhere in this Contract. COPAYMENT CHARGE: No charge per confinement -22 - 3. Ambulance Services Medically Necessary ambulance transportation is covered if approved in advance by PLAN or when PLAN determines after the transportation is provided that the transportation was Medically Necessary. Ambulance transportation provided due to the absence of other medically appropriate forms of transportation is not covered. a. Emergency surface ambulance transportation by a licensed ambulance service to the nearest Hospital where Emergency care and treatment can be rendered. COPAYMENT CHARGE: $30.00 per trip b. Non-emergency surface ambulance transportation when referred by the Participating Primary Care Physician and approved in writing in advance by PLAN. COPAYMENT CHARGE: $30.00 per trip c. Air ambulance transportation only when medically appropriate surface ambulance transportation is not available. COPAYMENT CHARGE: $30.00 per trip 4. Rehabilitation Services Short term inpatient or outpatient,whichever is Medically Necessary,rehabilitative services (physical therapy, occupational therapy,and speech therapy)performed at a Participating Hospital or Participating Skilled Nursing Facility,or through Participaung Home Health Agency,or other Participating Provider.Rehabilitation services are limited to services which, in the judgment of the Participating Primary Care Physician and PLAN, are Medically Necessary and will result in significant improvement of a Covered Person's condition through short term therapy. (Short term means that significant improvement is anticipated within two (2)months of start of treatment.)All combined rehabilitation services are limited to a sixty-two(62)day period per Sickness episode, beginning with the first day of treatment. COPAYMENT CHARGE: $10.00 per outpatient visit, and No Charge per Confinement 5. Blood and Blood Products The administration of prescribed blood transfusions,including supplies and equipment used in the administration of blood,and blood products and derivatives if such products and derivatives are replaced in accordance with the blood bank's requirements.Coverage is provided for the drawing and storing of the Covered Person's blood for use by the Covered Person only for blood units used as replacement therapy for Medically Necessary treatment of conditions while the Covered Person is covered under this Contract. COPAYMENT CHARGE: No Charge 6. Temporomandibular Joint Syndrome Treatment of temporomandibular joint syndrome as a result of trauma: fracture of the jaw or laceration of the mouth,tongue,or gums is covered. Health Services and supplies provided for the treatment of temporomandi- bular joint syndrome are covered only when performed by a PLAN-designated Physician or oral surgeon. COPAYMENT CHARGE: 40% of Eligible Expenses 7. Hemodialysis Services and supplies,subject to approval by PLAN and a determination that the Covered Person meets PLAN medical criteria,when provided in a Participating Hospital or Participating Alternate Facility,for dialysis for end stage renal disease(ESRD), and services and supplies for renal conditions. COPAYMENT CHARGE: $10.00 per hemodialysis treatment -23- GENERAL EXCLUSIONS The following are not covered: 1. Dental Surgery, Treatment or Care (including such for overbite or underbite, maxillary and mandibulary osteotomies, and orthognathic conditions, whether or not related to temporomandibular joint dysfunction), or dental x-rays,supplies and appliances(including occlusal splints)and all associated expenses arising out of such Dental Surgery,Treatment or Care including hospitalizations.Hospital and Physician services and supplies and anesthesiology services referred by the Participating Primary Care Physician and approved in writing in advance by PLAN, for the correction of cleft lip or cleft palate which has been diagnosed as a Congenital Anomaly in newborn children,or as are necessary to safeguard the health of a Covered Person because of a specific non-dental physiological impairment are covered. Dental Services required due to trauma are limited to functional restoration of structures other than teeth.Treatment of trauma resulting in fracture of the jaw or laceration of the mouth,tongue, or gums is covered. 2. Health Services and associated expenses for temporomandibular joint syndrome,except as described in X.E.6. 3. Custodial Care, domiciliary care,respite care or rest cures. 4. Health Services and associated expenses for Cosmetic Procedures including,but not limited to,pharmaceutical regimes, nutritional procedures or treatments, plastic surgery, including reduction mammoplasty, and recon- structive mammoplasty,except when the original mastectomy was performed while the person was covered under this Contract. (Medically Necessary reconstructive surgery is not excluded.) 5. Health Services and associated expenses for Experimental or Unproven Procedures.treatments,devices or phar- macological regimes. • 6. Health Services and associated expenses for organ transplants,except for kidney,comeal and liver transplants in children with biliary atresia or children with other end stage liver disease. • 7. Health Services and associated expenses for in vitro fertilization, embryo transport, Gamete Intra-Fallopian • Transfer, surrogate parenting,donor semen,outpatient injectable substances and supplies related to infertility, elective abortions when performed beyond the tenth week of pregnancy,or elective abortions in excess of two (2) per lifetime, home childbirth, and non-Medically Necessary amniocentesis. 8. Health Services not authorized by PLAN or not Medically Necessary, or not provided or referred by the Participating Primary Care Physician,except in Emergency situations (described in Section IX.C.) 9. Hearing aids,cochlear implant devices and implant procedures,eye glasses,contact lenses and the fitting thereof, unless covered through an Addendum to this contract. 10. Personal comfort and convenience items or services obtained or rendered in or out of the Hospital or any facility, such as television,telephone,barber or beauty service,guest service and similar incidental services and supplies which are not Medically Necessary. 11. Mental Health Services, which are (a) rendered in connection with Mental Illnesses not classified in the International Classification of Diseases of the U.S.Department of Health and Human Services,or(b)for any of the following: learning, behavioral or developmental disabilities, mental retardation or autism, marriage counseling, counseling or therapy for weight reduction, behavioral training, personal growth, lifestyle or vocational counseling, biofeedback,pain control,hypnosis,sexual dysfunction or inadequacy,transsexualism, early infant stimulation,or psychotherapy credited toward earning a degree or required for educational purposes. 12. Services rendered by a provider with the same legal residence as a Covered Person,or who is a member of a Covered Person's family,including spouse,brother,sister,parent,or child. 13. Physical,psychiatric,or psychological examinations or testing,er vaccinations,immunizations,or treatments not otherwise covered under this Contract,when such services are for purposes of obtaining,maintaining or otherwise -24 - • relating to employment or insurance,marriage or adoption,or relating to judicial or administrative proceedings or orders,or which are conducted for purposes of medical research,or to obtain or maintain a license of any type. 14. Travel or transportation expenses (except ambulance service as specifically provided in this Contract) even though prescribed by a Physician. 15. Health Services and associated expenses for outpatient Hospital and Hospital emergency room or Participating Alternative Facility services obtained during normal Physician office hours (unless necessary because of an Emergency),except as specified in Section X.B.2.b,or when authorized in advance in writing by the Participating Primary Care Physician or PLAN. 16. Prosthetic devices,Durable Medical Equipment,and appliances,and personal comfort items,including air con- ditioners,even though prescribed by a Physician,unless covered through an Addendum to this Contract or when such devices,equipment or appliances are medically necessary for outpatient care in lieu of hospitalization or an integral part of a case management plan. 17. Health Services and associated expenses for surgical procedures and associated Health Services intended primarily for the treatment of morbid obesity, including gastric bypasses, gastric balloons, stomach stapling, wiring of the jaw,jejunal bypasses, and Health Services of a similar nature,unless Medically Necessary. 18. Health Services and associated expenses for sex transformation operations and for reversal of voluntary . sterilization. 19. Health Services otherwise covered under this Contract related to a specific condition or treatment when a Covered Person has terminated the specific scheduled service or treatment against the advice of a Physician, or has left a Hospital or inpatient facility against medical advice. 20. Health Services for military service connected disabilities for which the Covered Person is legally entitled to services and for which facilities are reasonably available to the Covered Person. 21. Health Services and associated expenses for megavitamin therapy,psychosurgery,radial keratotomy,nutritional based therapy for alcoholism or other chemical dependency, salabrasion, chemosurgery or other such skin abrasion procedures associated with the removal of scars,tattoos, actinic changes and/or which are performed as a treatment for acne,BAST testing,except with skin testing is medically impossible,acupuncture,services or treatment for sleep apnea,or chelation therapy,unless Medically Necessary for the treatment of metal poisoning. 22. Health Services provided by a chemical dependency treatment or rehabilitation program,except as described in Section X.D.,or unless covered through an Addendum to this Contract. 23. Prescription Medications for outpatient treatment, unless covered through an Addendum,to this Contract. 24. Health Services otherwise covered under this Contract,but rendered after the date individual Coverage under this Contract terminates, including Health Services for medical conditions arising prior to the date individual Coverage under this Contract terminates. 25. Medical supplies,oxygen,blood,blood derivatives and fees for blood replacement,and penile implant devices and procedures,except as described in Section X.E.5.,or unless covered through an Addendum to this Contract. 26. Outpatient nutritional and dietary services in the absence of a physiological disease condition. -25 - PRESCRIPTION MEDICATION ADDENDUM RX 5 In consideration of the Health Services Fees to be paid,the Master 8. Prescription Medications Group Contract and Evidence of Coverage is hereby amended by the attachment thereto of this Addendum. Prescription Medications which have been prescribed under the direction of the Participating Primary Care Section I of this Contract,entitled"Definitions"shall be modified Physician and obtained through a Participating Phar- by the following additions: macy. Prescription Medications shall, in all cases, be dispensed in generic equivalent form,or in accordance "Drug Formulary", if enacted, is a listing of Prescription with the PLAN Drug Formulary, if enacted, and as Medications approved for use by PLAN which may be amended from time to time,or upon PLAN approval. dispensed through Participating Pharmacies to a Covered Person. When designated by PLAN, a generic equivalent COPAYMENT CHARGE: $ 5.00 per Prescrip- shall be dispensed.This list shall be subject to periodic review tion Order or Refill, or the average retail price, and modification by PLAN. whichever is less.For a single Copayment Charge, a Covered Person may obtain one of the following: "Participating Pharmacy"means a pharmacy which has en- tered into a service agreement with PLAN to provide Pre- • the lesser of a consecutive thirty-four(34)day scription Drug services to Covered Persons. supply of medication,or 100 unit doses,unless limited by the manufacturer's packaging; "Participating Provider" means a Participating Hospital, Participating Pharmacy, Participating Physician, and any • up to a one(1)cycle supply of oral contracep- other Health Services provider who/which has entered into a tives; service agreement with PLAN to provide Health Services to Covered Persons. • a vial of insulin; "Prescription Medication" means a drug which has been A COVERED PERSON SHALL PAY TO A PAR- approved for use by the medical community at large,includ- TICIPATING PHARMACY 100% OF THE AD- ing but not limited to the Food and Drug Administration, DITIONAL COST OF ANY PRESCRIPTION which can, under federal or state law, be dispensed only MEDICATION WHICH,AT THE REQUEST OF pursuant to a Prescription Order. This definition includes THE COVERED PERSON OR PHYSICIAN, IS insulin, and compound dermatological or other formulas NOT DISPENSED ACCORDING TO THE CUR- which must be prepared by a pharmacist subject toaPrescrip- RENT PLAN DRUG FORMULARY, OR ITS tion Order. GENERIC EQUIVALENT,UNLESS APPROVED IN ADVANCE BY PLAN. "Prescription Order or Refill"means the authorization for a Prescription Medication issued by a Participating Physician The"Exclusions"subsection ofSection X shall be modified by the who is duly licensed to make such an authorization in the following addition: ordinary course of his or her professional practice. The following are excluded: The"Relationship Between Parties"subsection of Section VIII shall be modified by the following addition: 27. Contraceptive supplies or devices, (except diaphragms and birth control pills),drugs and supplies not requiring a Pre- "The Participating Pharmacy is solely responsible for the scription Order,(including but not limited to aspirin,antacid, pharmacy services provided to any Covered Person." oxygen,benzyl peroxide preparations,cosmetics,medicated soaps,syringes and bandages),food supplements,Antabuse, Section X.B.2.a of this Contract,entitled"Hospital Services"shall Methadone,and nicotine gum,Minoxidil hair preparations, be modified by the following addition: experimental drugs,(including those labeled"Caution-Lim- ited by Federal Law to Investigational Use'), newly devel- 3) Outpatient Prescription Medications provided by a Par- oped drugs and drug delivery systems, including patches, ticipating Hospital or Participating Alternate Facility in plasters, and tapes, and drugs determined by PLAN to be conjunction with Emergency services for the same con- ineffective,and Prescription Medications related to Health dition. Services which are not covered under this Contract. COPAYMENT CHARGE: $ 5.00 per Prescrip- tion Order or Refill Section X.E of this Contract, entitled "Miscellaneous Health Services",shall be modified by the following addition: 6625(10/89) Hello