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Home My WebLink About990450.tiff A Group Health Care Program Group Master Contract Blue Cross an S Blue Shield An Independent Licensee of the Blue Cross and Blue Shield Association 990450 THE BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT TABLE OF CONTENTS Page No. SECTION I. APPLICATION-ACCEPTANCE 1 SECTION II. GENERAL AGREEMENTS 1 Contract Effective Date 1 Anniversary Date 1 Annual Renewal Date 1 Employee 1 Employer 1 Remitting Agent 1 Remittance 1 Membership Certificate Terms 1 Group Administrator 2 Assignment 2 Contract Provision Changes 2 Reserve Funds 2 Notices 2 Governing Laws 2 Attorneys' Fees and Expenses 3 Warranties and Representations 3 Enforcement of the Contract 3 Interpretation of the Contract 3 BlueCard Program. 3 Termination of Contract 3 SECTION III. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 4 Changes 4 Payment 4 Service Date 4 Termination for Non-Payment 4 Retroactive Refund of Membership Premium 4 Cashing of Check Not Acceptance 5 SECTION IV. MEMBERSHIP/APPLICATION 5 Eligibility 5 Receipt of Applications 5 Notification of Cessation of Membership 5 i 990325 BLUE CROSS AND BLUE SHIELD OF COLORADO GROUP MASTER CONTRACT NO. 99-00772000 For Weld County Government Employer C07720 Group Number SECTION I. APPLICATION ACCEPTANCE The Application for Group Health Coverage ("Application") executed by the Employer has been accepted by Blue Cross and Blue Shield of Colorado (sometimes referred to as "we," "us," and "our"). P Such Application and its contents are incorporated in this Group Master Contract ("Contract"). In the event of any inconsistency between the terms of the Application and the terms of the Contract, the terms of the Contract will control. SECTION 11, GENERAL AGREEMENTS The purpose of this Contract is to provide under the circumstances specified herein health and hospitalization benefits to certain of the Employer's Employees and their Dependents. Such persons, when covered hereunder, are referred to as "Members." 1. Contract Effective Date. The effective date of the Contract shall be 12:01 A.M. on the first day of January, 1999, at Denver, Colorado; the Contract shall continue to remain in effect through December 31, 1999. 2. Anniversary Date. The Anniversary Date is the effective date for (i) enrollment or coverage changes to the Employee's Membership or (ii) to group enrollment and benefit eligibility implemented by the Employer. 3. Annual Renewal Date. The date a group is due for rate modification through application of the appropriate renewal rating formulas. 4. Employee. An Employee as defined in the Application as eligible for enrollment; the Employee is the Subscriber, and Identification Cards for the Employee and his or her covered Dependents are issued in the name of the Employee as the Subscriber. 5. Employer. The Employer or organization with whom Blue Cross and Blue Shield of Colorado has contracted, and by reason of the Contract the Employees and their Dependents become eligible for the coverage and benefits described in the Contract. 6. Remitting Agent. The Employer agrees to (i) act as remitting agent for the enrolled Members, (ii)make payroll deductions for that part of premium not otherwise provided for, and (iii)remit all premiums to us not later than the due date for each remitting period. 7. Remittance. The Employer shall pay to us monthly, in advance, required premiums on behalf of all enrolled Employees and Dependents who meet the eligibility requirements specified in the Application. 8. Membership Certificate Terms. The definitions and other terms of the Membership Certificate are incorporated herein by reference. 1 990325 BCBS922000C 9. Group Administrator. The Employer will designate a person as the principal contact for all matters pertaining to Blue Cross and Blue Shield of Colorado group coverage. That person will assist Employees in the administration and payment of claims. It is understood that Blue Cross and Blue Shield of Colorado is not the "administrator" within the meaning of the Employee Retirement Income Security Act (ERISA). 10. Assignment. None of the rights, benefits, duties, or obligations of the Employer may be assigned without the prior written consent of a duly authorized officer of Blue Cross and Blue Shield of Colorado. Any attempted assignment will be void. 11. Contract Provision Changes. a. This Contract constitutes the entire agreement between the parties hereto and supersedes all other contracts, either oral or in writing, between the parties with respect to the subject matter hereof. No course of action,usage or custom or internal policy of Blue Cross and Blue Shield of Colorado may amend or become a part of this Contract. Except as provided in paragraphs b. and c. immediately below, no change or modification to this Contract shall be valid unless the same is in writing and signed by the parties hereto. b. During the initial annual term or any renewal annual term of the Contract, the provisions of this Contract may be amended at any time by an endorsement signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado. When the endorsement has been so signed, the endorsement shall be deemed a part of the Contract, effective as of the date specified by the endorsement. c. Any amendment resulting from state or federal law, or regulation, or ruling or approval by the Commissioner of Insurance of the State of Colorado may be made at any time by endorsement to the Contract signed only by a duly authorized officer of Blue Cross and Blue Shield of Colorado and shall become effective as of the effective date of such law,regulation, ruling, or approval. 12. Reserve Funds. Neither any Member nor the Employer shall be entitled to share in any reserve or other funds that may be accumulated or otherwise owned by Blue Cross and Blue Shield of Colorado, unless and until a right to share in such funds is granted in writing by the Board of Directors of Blue Cross and Blue Shield of Colorado. 13. Notices. All notices to Blue Cross and Blue Shield of Colorado shall be sent by United States mail or personal delivery to Blue Cross and Blue Shield of Colorado, 700 Broadway, Denver, CO 80273. All notices to Employees or the Employer shall be sent by United States mail to the last address appearing in the records of Blue Cross and Blue Shield of Colorado or by personal delivery to the office of the Employer. The Employer shall notify Members in the event that this Contract is terminated within ten (10) days of the date that the Employer has notice that this Contract is to be or has been terminated, whichever occurs first. If the Employer has engaged the services of a broker/consultant, then delivery of all notices to the named broker/consultant meets the requirements of this Contract. Notice shall be effective upon mailing. Notice mailed to the Employer or broker/consultant shall be deemed effective notice to each Employee. However, the Employer agrees to post each notice promptly in a place reasonably calculated to facilitate the Employees' reading of the notice. 14. Governing Laws. This Contract is made and delivered in the State of Colorado, and will be interpreted and enforced so as to remain in compliance with Colorado statutes and regulations. Nothing contained herein shall be interpreted to mean that Blue Cross and Blue Shield of Colorado is doing business in any other state or jurisdiction. Any legal action against us must be brought in the City and County of Denver, Colorado. Should any provision of this Contract in any way contravene the laws of Colorado or the United States of America, such provision shall not be deemed a part of the Contract. However, the Contract shall be otherwise enforceable. r "CBe22"Ca�• 2 15. Attorneys' Fees and Expenses. a. Should it become necessary for either party to this Contract to seek the assistance of an attorney for the purpose of litigating or arbitrating any action against the other party arising from any part of the Contract, the prevailing party shall be entitled to recover from the losing party its reasonable attorneys' fees. In addition, the prevailing party shall be entitled to recover from the losing party all other reasonably incurred costs and expenses. b. The Employer shall indemnify and hold harmless Blue Cross and Blue Shield of Colorado from its costs including losses, claims, settlements,judgments, or fees, including attorneys' fees and other litigation costs, and our internal costs if such costs were incurred by us by our participation in lawsuits or arbitration proceedings related to the obligations undertaken or acts performed by us under this Contract. However, except for costs incurred by us in participating in lawsuits or arbitration proceedings brought by persons who are ineligible for coverage hereunder, the Employer's obligation to indemnify us shall apply only to costs incurred after this Contract has been cancelled or terminated. 16. Warranties and Representations. The Employer acknowledges that no warranties or representations other than those contained in this Contract have been made or given by Blue Cross and Blue Shield of Colorado or its representatives or, if so given, have not been relied upon by the Employer. 17. Enforcement of the Contract. Failure of Blue Cross and Blue Shield of Colorado or the Employer to enforce any of the provisions of this Contract shall not constitute a waiver of rights for that or subsequent breaches. 18. Interpretation of the Contract. This Contract shall not be interpreted against any party for the reason of having prepared its language and provisions. Rather, it shall be construed so as to effect the purposes of the parties in a manner consistent with the terms of this Contract and sound principles of contract interpretation. 19. BlueCard Program. The calculation of subscriber liability for covered services for claims incurred outside the geographic area Blue Cross and Blue Shield of Colorado serves and processed through the BlueCard Program typically will be at the lower of the provider's billed charges or the negotiated rate Blue Cross and Blue Shield of Colorado pays the on-site Blue Cross and/or Blue Shield Plan. The negotiated rate paid by Blue Cross and Blue Shield of Colorado to the on-site Blue Cross and/or Blue Shield Plan for health care services provided through the BlueCard Program may represent either (i) the actual price paid on the claim, or (ii) an estimated price that reflects adjusted aggregate payments expected to result from settlements or other non-claims transactions with all of the on-site Plan's health care providers or one or more particular providers, or(iii) a discount from billed charges representing the on-site Plan's expected average savings for all of its providers or for a specified group of providers. Plans using either the estimated price or average savings factor methods may prospectively adjust the estimated or average price to correct for over-or underestimation of past prices. In addition, statutes require Blue Cross and/or Blue Shield Plans in a small number of states to use a basis for calculating member/subscriber liability for covered services that does not reflect the entire savings realized or expected to be realized on a particular claim. Thus, when your covered employees/subscribers receive covered services in these states, their subscriber liability for covered services will be calculated using these states' statutory methods. 20. Termination of Contract. a. Blue Cross and Blue Shield of Colorado may terminate the Contract at ally time during its term for (i) Employer's failure to make timely payment of amounts due hereunder, (ii) failure of the group to meet eligibility requirements, (iii) failure of the group to maintain enrollment percentage requirements, as provided in the Application, or (iv) misrepresentation of material facts or any other breach of the Contract. BCBS922G SOC 3 990325 b. Blue Cross and Blue Shield of Colorado, at its sole option, may reinstate this Contract after it has been terminated. We may impose such conditions on the Contract's reinstatement as we deem appropriate, including, without limitation, acceptable health statements. It is understood, however, that there is no right to reinstatement, and any reinstatement will be in the sole discretion of Blue Cross and Blue Shield of Colorado. SECTION Ill. PREMIUMS CHANGES, PAYMENT, SERVICE DATE, TERMINATION FOR NON-PAYMENT, RETROACTIVE REFUND OF MEMBERSHIP PREMIUM, CASHING OF CHECK NOT ACCEPTANCE 1. Changes. From January 1, 1999 through December 31, 1999, premiums are guaranteed. Blue Cross and Blue Shield of Colorado reserves the right to review monthly premium whenever a group, section, or classification of Employees is added to or deleted from enrollment under the Contract. The Employer shall notify Blue Cross and Blue Shield of Colorado no later than 30 days prior to the effective date of such addition or deletion, and any change in monthly premium which may be required as the result of an increased or decreased total group enrollment will become effective on the same date as such addition to or deletion from total enrollment under the Contract. This provision shall apply regardless of the Employer's normal rate review date or any other advance rate notification agreement which may be in effect between Blue Cross and Blue Shield of Colorado and the Employer. 2. Payment. Initial premium shall become payable on or before the effective date of the Contract. Subsequent premiums shall be payable on or before the established Service Date of each month thereafter. Claims processing and payment will be suspended if premium is not timely paid. In no event shall coverage under the Contract become effective until we accept the Application and payment of the initial premium is received by Blue Cross and Blue Shield of Colorado. 3. Service Date.The Service Date is the 1st or 16th day of the month as established for the group for billing purposes (the "due date"). 4. Termination for Non-Payment. The Contract shall terminate by its own terms if premium is not paid on or before 30 days after the Service Date, and no notice of cancellation other than this provision shall be required. However, we may by sending notice thereof terminate this Contract before 30 days after the Service Date if premium is not paid on or before the Service Date. When the Contract is terminated or cancelled, the effective date of such cancellation or termination shall be the date to which membership premium was last paid. All claims shall be refused when dates of service are beyond the last "paid-to-date" of coverage according to the records of Blue Cross and Blue Shield of Colorado. 5. Retroactive Refund of Membership Premium. a. A retroactive refund of membership premium paid beyond the date of termination will be granted if written notification is received by Blue Cross and Blue Shield of Colorado at least one month before the termination date and benefit payments have not been made on behalf of a Member's claim for services rendered subsequent to the termination date. b. If notification is received less than one month before the termination date, no refund of membership premium will be made. Failure to comply with this provision shall negate any claim by, or on behalf of, the Employer or the Member for a retroactive refund of membership premium. 6. Cashing of Check Not Acceptance. It is understood that negotiation and deposit of checks sent to us shall not be deemed to be acceptance by us of such payment, nor shall such ""tea 4 negotiation and deposit of the check prevent us from later returning such payment by issuance of a check for the amount of the check to us. SECTION IV. MEMBERSHIP/APPLICATION 1. Eligibility. All Employees, who have a regular work week as indicted on the application and addendum, paid for such employment by the employer, and listed as an Employee on the Employer's State unemployment insurance tax returns, and the Dependents of the Employees, are eligible to enroll for membership under the Contract. We may inspect such records, public and private, as are necessary to verify employment. 2. Receipt of Applications. Applications for Employees' coverage must be received by us within 30 days of the Contract Effective Date or within 30 days of eligibility for coverage, whichever is later. If the application is not received within this time period, the Employee is subject to current underwriting, state or federal law for provisions for late enrolles. 3. Notification of Cessation of Membership. Employer shall advise us when Employer has notice that a Member is no longer employed by Employer or otherwise does not satisfy membership requirements. Employer shall so notify us, at the latest, by the first Service Date after a Member ceases to be employed by Employer or otherwise ceases to meet membership requirements. Employer agrees that no person will be kept on Employer's payroll or otherwise be represented as an Employee of the Employer for the purpose of obtaining or maintaining coverage hereunder. The Employer agrees to observe the terms thereof, and hold us harmless for all costs incurred,including attorneys'fees,in the defense of any claim or suit brought at any time by a person ineligible for coverage. Weld County Goverment BLUE CROSS AND BLUE SHIELD (Group Name) OF COLORADO By By � ti Dale K. Aall C. David Kikumoto Printed or Typed Name Printed or Typed Name (Title) Chair (Title) Chief Executive Officer (Date) February 10, 1999 (Date) January 25, 1999 990325 BCBSs22GCOC 5 ENDORSEMENT NO.: 1 TO GROUP MASTER CONTRACT NO.: 99-00772000 The Contract identified above is hereby amended by this endorsement which is issued to form part of the Contract with the Employer. Effective January 1, 1999, this Contract is amended to incorporate Membership Certificate No. 95297 (Rev. 6-97) for Custom Plus coverage, and any amendment(s) as listed below: Amendment No. Title 96674 (11-97) Amendment for Custom Plus Coverage WEDLDEV.AMC Dependent to age 25 PCS3TIER.AMC Prescription Drug Program BLUE CROSS AND BLUE SHIELD OF COLORADO By C1 <e,k4IV (Title) Chief Executive Officer Date January 26, 1999 FORM NO. 94987 BCBS44M.END 990325 Summary of Benefits for Custom Plus Benefit Highlights Your deductible $200 single; $400 family Your payment allowance After you have met your deductible, we pay 80% of the next $5,000 single, $10,000 family for most covered services. After yearly maximum amount is reached, we pay 100% of our maximum benefit allowance. Maximum benefit allowance is the amount we pay for a particular medical or surgical service. Participating physicians accept this allowance as payment in full. Physician selection Unrestricted Claim forms None with participatingproviders Lifetime maximum $1,000,000 per member What You Pay After Your Services Deductible Explanation Hospitalization 20% Includes semiprivate room or medically necessary private room; operating, treatment, and recovery room; drugs; lab and X-rays; anesthesia; oxygen; blood transfusions (3-pint deductible each admission) Surgical care 20% Maternity care 20% Newborn well-baby care— 20% inpatient Emergency care 20% Ambulance service 20% We pay up to a specified dollar amount. Physicians'office visits 20% Lab and X-ray outpatient 20% Allergy testing and treatment 20% Prescription drugs— Copay per prescription of$15 Copay per prescription of$15 generic outpatient generic formulary, $25 brand formulary, $25 brand formulary, $40 formulary, $40 non-formulary non-formulary through a participating through a participating pharmacy (34 day supply). Copay per pharmacy (34 day supply). prescription of$30 generic formulary, Copay per prescription of$30 $50 brand formulary, $80 non- generic formulary, $50 brand formulary through the Prescription formulary, $80 non-formulary Mail Service (60 or 90 day supply). through the Prescription Mail Service (60 or 90 day supply). 990325 WELDCTY.CP.snc wpD What You Pay After Your Services Deductible Explanation Mental Illness* or alcoholism inpatient 50% Up to a maximum of 45 days or 90 partial days per benefit year outpatient 50% Up to 30 visits per benefit year for Mental Illness, and up to $500 per benefit year for alcohol abuse care Drug abuse care inpatient 50% Up to 30 days per benefit year or 60 days per lifetime outpatient 50% Up to $250 per benefit year Hospice care inpatient 20% Up to 30 days with prior benefit authorization outpatient 20% Up to 91 days per benefit period at no less than $91 per day for hospice care services Home health care 20% Up to 60 visits per year Occupational, physical, and 20% speech therapy *Mental Illness does not include treatment for schizophrenia,schizoa££ective disorder,bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. These conditions are covered as any other physical illness. This is a general benefit summary for this health plan. A complete listing and description of benefits,limitations,and exclusions are found in and are governed by the Membership Certificate and the Master Contract. WELDCTY.CP SRC.WPD ■ Amendment for Custom Plus Coverage This amendment is effective on your group's anniversary date, or your effective date of membership, whichever is later. On the Welcome page, the next to the last paragraph is deleted in its entirety and the following language is substituted therefor: Remember that visiting health care providers that participate with Blue Cross and Blue Shield of Colorado can also save you money. Participating health care providers have agreed to accept our Payment as Payment in full. They will file claim forms for you. We make Payment directly to them, saving you the trouble. Your doctor may well be a participating provider. All participating providers are listed for you in a handy directory. If we do not have a Participating Provider for a Covered Service or supply, and that service or supply is received from a Nonparticipating Provider, we will arrange to make sure that you pay no more than what you would have paid for such Covered Service if it had been received from a Participating Pro- vider. Call our Customer Service department at (800) 331-6170 or (303) 831-2900 to arrange for such service or supply from a Nonparticipating Provider. We shall not deny or restrict Participating Provider Covered Services solely because you obtain treatment from a Nonparticipating Provider. The section entitled Introduction is amended to add a new subheading entitled "Network Access Plan" as follows: Network Access Plan Blue Cross and Blue Shield of Colorado strives to provide an extensive pro- vider network that adequately addresses Members' health care needs. The Network Access Plan describes Blue Cross and Blue Shield of Colorado's provider network standards for ensuring network sufficiency in service, access, and availability, as well as assessment procedures to ensure that the network continues to meet Member needs. To request a copy of this document, call (800) 331-6170. This document is available for your in- person review at 700 Broadway in Denver, Colorado, in the Customer Service Department, fourth floor. The section entitled Definitions is amended to add new definitions entitled "Biologically Based Mental Illness"and "Mental Illness"as follows: Biologically Based Mental Illness— schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. Biologically Based Mental Illness conditions are considered medical conditions, not Mental Illness, and are covered as any other physical illness. Mental Illness— nonbiologically based conditions that have a psychiatric diagnosis or that require specific psychotherapeutic treatment, regardless of the underlying condition (e.g., depression secondary to diabetes or 990'!95 FORM NO.96674 U 1-97) 1 B4)866111.JIM NI.' primary depression). Anorexia Nervosa and Bulimia Nervosa, eating disorders, are classified as manifest mental disorders. In the section entitled Membership Eligibility, Enrollment, Changes, and Termination, the subheading entitled "What We Will Pay for After Your Coverage Ends —Extension of Benefits" is deleted in its entirety and the following language is substituted therefor: What We Will Pay for After Your Coverage Ends — Extension of Benefits When your coverage is terminated for any reason other than nonpayment of premium, fraud or abuse, we shall provide for continued care for the Member being treated at an inpatient Facility until the Member is discharged, subject to the terms of this Certificate. The section entitled Cost Containment Features is deleted in its entirety and the following section is substituted therefor: 4 Cost Containment Features This section describes steps you must take prior to receiving certain services or supplies so that we can determine if benefits are payable under the terms of this Certificate. This section also describes additional features such as personal benefits management and second surgical opinions. Concurrent Hospital Review We may review your medical care while you are in the Hospital to help ensure that you are receiving appropriate and Medically Necessary Hospital services. If you are admitted to the Hospital for a Medical Emergency, it is in your best interest for a family member, the Hospital, or your Physician to notify Blue Cross and Blue Shield of Colorado so that we can assist with management of your Hospital benefits and planning for covered medical services after discharge. Your attending Physician, the Hospital Utilization Review Committee, or Blue Cross and Blue Shield of Colorado may determine that further hospitalization is not Medically Necessary. The Hospital will give you timely notice of such a determination. If you or your Physician disagrees with this determination, you, your Physician, or the Hospital will notify us and we will review the determination. We will notify both you and the Hospital of our decision. If you elect to remain in the Hospital after you have been notified that further Hospital care is not Medically Necessary, we will not allow benefits for the rest of your stay. We will send written notification of our decision to you, your attending Physician, and the Hospital. You will be responsible for all charges incurred after the recommended day of discharge. FORM NO-96674[11-97, 2 Bcp666m.amc.wpd You or your representative may appeal our Concurrent Hospital Review decision by following the medical procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Personal Benefits Management Our personal benefits management program identifies cost-effective alternative services which may be provided to Members on a voluntary basis. Whenever it is appropriate, we investigate and recommend alternative care settings such as your own home or an outpatient office. Extensions or exceptions to regular contract benefits are authorized only when a Covered Service can be replaced with a less-costly, noncovered service. Personal benefits management is considered on a case-by-case basis. Our case managers, all experienced registered nurses, identify patients who might ultimately benefit from an alternative care setting or extension of the benefit period. If your case seems appropriate for the program, the nurse consultant will discuss your care with your health care Providers. With help from Blue Cross and Blue Shield of Colorado, you, your family, and your doctor will decide the most cost-effective and appropriate means of providing your care. All personal benefits management ceases upon termination of your coverage. Commonly managed cases include high-risk mothers and infants, Members with traumatic head and spinal cord injuries, end-stage cancer, and AIDS. You or your representative may appeal our personal benefits management decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Pre-admission Certification Pre-admission certification is a program designed to help control medical costs by encouraging the use of outpatient services whenever possible. Inpatient admissions for medical care and for selected surgical procedures must be pre-certified by us prior to admission to the Hospital to ensure that you receive care in the most medically appropriate and cost-effective setting. To obtain pre-admission certification for services from a Nonparticipating Provider, you must ask your Physician to complete a pre-admission certi- fication form and submit it to us for review. Forms are available upon request from our Customer Service office. If your Physician is a Partici- pating Provider, the Provider is responsible for obtaining the pre- admission certification. We will review your case and send you a written confirmation of our decision within two working days of receipt of the form. If the inpatient admission is approved, all benefits normally available under your coverage will be provided. If we do not approve the inpatient admission, Hospital room expenses for your inpatient stay will not be Paid. If your Physician is 990325 FORM NO.96674(11-97) 3 6goHf6n�.dm( pd nonparticipating and you fail to obtain pre-admission certification, all expenses may be denied. Pre-admission certification is required for all elective (nonemergency) medical care provided in an inpatient setting and for the surgical procedures listed below. Pre-admission certification is not required for accidents, maternity care, medical emergencies, mental illness, alcoholism, or drug abuse care. Pre-admission certification is required prior to a Hospital admission for the following surgical procedures. Antral puncture and inferior turbinate fracture —repair of punctured sinus and/or broken bone in the nasal cavity Blepharoplasty—reconstruction of the eyelid* Breast biopsy— sample of breast tissue Bronchoscopy— examination of the lung passages with a bronchoscope Cystoscopy— direct visual examination of the urinary tract with a cystoscope Fracture, closed reduction -- setting of broken bones without a surgical incision Gastrointestinal endoscopy—inspection of the stomach and/or the intestinal tract with an endoscope Gynecological procedures - Examination under anesthesia - Cryotherapy— therapeutic use of cold - Dilation and curettage (D&C) —removal of growths or other material from the wall of the uterus - Hysterosalpingogram—X-ray of the uterus and fallopian tubes - Removal of intrauterine device (IUD) - Hymenotomy—surgical incision of the hymen - Hysteroscopy— inspection of the uterus with a special instrument - Laparoscopy— examination of the interior of the abdomen with a special instrument - Culdoscopy—visual exam of the female pelvic area with a special instrument Hammertoe — deformed toe Mammoplasty—reconstruction of the breast* Manipulation of joints Meatotomy— incision of the urinary pathway to enlarge it Muscle and cervical node biopsy— tissue sample in neck region Myringotomy— surgery of the ear drum Otoplasty—reconstruction of the ear lobe* Otoscopy— exam of ear Rectal polypectomy— surgical removal of rectal polyps Removal of benign lesions, cysts, and neuromas Removal of fingernail or toenail Resection of hand or foot bane Small skin graft Sterilization procedures, male or female Tenotomy— cutting of a tendon },:45 FORM NO 96674(11-99) 4 Bcp866m-amawpd Therapeutic abortion Urethral dilation —widening of the urinary tract *Surgery for cosmetic reasons is not covered. You or your representative may appeal our pre-admission certification decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Prior Benefit Authorization Prior benefit authorization is a determination by us, prior to your receipt of certain specified services, that such services meet all of the eligible-for- coverage criteria listed under Experimental/Investigational (see Section 2: Definitions) and are in compliance with the provisions of this Certificate. When a service requires our prior benefit authorization according to the terms of this Certificate, your Physician must submit to us a written request for prior authorization. Telephone requests cannot be accepted, and oral authorizations will not be honored. To facilitate the timely discharge of patients to home health care or hospice care, we will give prior benefit authorization over the telephone for a minimal number of days of service. The prior benefit authorization forms must be submitted immediately after the telephone approval. We will give you and the Provider of service written confirmation of benefits before the date on which services are performed. Our approval letters are valid for 180 days and apply only to the procedure specified. Any subsequent procedures must also be submitted in writing by the Provider and approved by us prior to the date of the service. If the approved procedure is not done within that time period, then your Physician must submit another prior benefit authorization request for us to review. A new written approval letter must then be issued. To receive benefits for the following services, they must be authorized in advance of the date of services. If your Provider is nonparticipating and you fail to obtain our prior benefit authorization, benefits may be denied. 1. Bone marrow transplants and peripheral stem cell transplants. 2. Cosmetic and restorative/reconstructive surgery. 3. Dental-related services for cleft palate or cleft lip. 4. Growth hormone therapy. 5. Home health care. 6. Hospice care. 7. Implantable hearing devices such as an electromagnetic bone conductor or cochlear implant, including any necessary training required to use the device. 990325 5 FORM NO.96674(1197) licp6(ilm umc w pd 8. Maxillofacial surgery (surgery on bones of face,jaw, cheeks). 9. Orthognathic surgery (upper and lower jaw augmentation). 10. Pre-term delivery prevention programs such as home uterine monitoring and drug intervention. 11. Surgery for obesity. 12. X-ray and surgical procedures for the diagnosis and treatment of impotence. 13. Speech therapy. You or your representative may appeal our prior benefit authorization decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Second Surgical Opinion The second surgical opinion program enables you to obtain another professional opinion prior to having surgery that is not a Medical Emergency. Such a second opinion may lead to the use of alternative medical treatment rather than surgery. You may request a second surgical opinion. We may also request that you obtain a second surgical opinion to determine if the surgery is Medically Necessary. You or your representative may appeal our benefit determination by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Retrospective Claim Review Retrospective review of claims consists of reviewing services after they have been provided to determine that services were provided as prior authorized, to evaluate claim charges, and to evaluate appropriateness of services billed. Medical records may be requested by Blue Cross and Blue Shield of Colorado and reviewed by Blue Cross and Blue Shield of Colorado medical consultants to assist in Payment decisions. The section entitled What We Will Pay For—Benefits is amended as follows: The heading entitled "Payment Allowances Under This Coverage" is deleted in its entirety and the following language is substituted therefor: Payment Allowances Under This Coverage After you meet the required Deductible, we will Pay the following allowances for Covered Services in each Member's Benefit Year: 1. Under an Individual Membership, we will Pay 80 percent of the first $5,000 of eligible charges and 100 percent of any remaining eligible charges. The payment allowance excludes care or supplies received for Mental Illness, alcoholism, or drug abuse. t FORM NO.96674(11-97) 6 Bcp866m.amc wpd 2. Under a Family Membership, we will Pay 80 percent of the first $5,000 of eligible charges for each family Member up to $10,000 per family and 100 percent of any remaining eligible charges. The payment allowance excludes care or supplies received for Mental Illness, alcoholism, or drug abuse. NOTE: No more than $5,000 per individual family Member can be applied toward the $10,000 family maximum. 3. For inpatient Mental Illness or alcoholism, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for up to 45 full days of inpatient care and supplies, or 90 partial days, or any combination of full and partial days equivalent to 45 full days, counting two partial days as one full day. 4. For inpatient drug abuse, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for 30 full days per Member's Benefit Year of inpatient care and supplies, or 60 full days per lifetime. 5. For outpatient Mental Illness, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum of 30 visits per Member's Benefit Year. 6. For outpatient alcoholism, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum Payment of$500. 7. For outpatient drug abuse, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum Payment of$250. If we do not have a Participating Provider for a Covered Service or supply, and that service or supply is received from a Nonparticipating Provider, we will arrange to make sure that you do not pay any more than what would have been paid for such Covered Service if it had been received from a Participating Provider. Call our Customer Service department at (800) 331-6170 or (303) 831-2900 to arrange for such service or supply from a Nonparticipating Provider. Under the heading entitled "Your Payment Responsibilities to Participating and Nonparticipating Providers,"the subheading entitled Nonparticipating is deleted in its entirety and the following language is substituted therefor: Nonparticipating— If you choose a Nonparticipating Provider, we will Pay you directly for Covered Services unless you assign your benefits to the Provider. You will be responsible to the Provider of services for all charges, regardless of our Maximum Benefit Allowance or the amount of our Payment to you or the Provider. 990325 FORM NO.96674(I1-97) 7 RryB6iimamc wyd Under the subsection entitled "Medical Emergencies," the subheading entitled Hospital Benefits, Inpatient: is amended to delete the second paragraph. The subsection entitled "Mental Illness, Alcoholism, or Drug Abuse Care" is amended as follows: The definition of Mental Illness conditions is deleted in its entirety and the following language is substituted therefor: Mental Illness conditions— are those that have a psychiatric diagnosis or that require specific psychotherapeutic treatment, regardless of the under- lying condition (e.g., depression secondary to diabetes or primary depres- sion). Anorexia Nervosa and Bulimia Nervosa, eating disorders, are classified as manifest mental disorders. Biologically Based Mental Illness conditions are considered medical conditions, not Mental Illness, and are covered as any other physical illness. Under "Benefits," Outpatient: is deleted in its entirety and the following language is substituted therefor: Outpatient: If you receive outpatient treatment for Mental Illness, alcoholism, or drug abuse from a Physician, Other Professional Provider, Hospital, Alcoholism Treatment Center, or Other Facility, benefits will be subject to the Deductible and Paid at 50 percent of the Maximum Benefit Allowance for each Member as described below. Maximum payments in each Member's Benefit Year of: • 30 visits for Mental Illness; • $500 for alcoholism; and • $250 for drug abuse. Under "Limitations and Exclusions,"item Nos. 5 and 6 are deleted in their entirety and the following language is substituted therefor: 5. Diagnosis-- Benefits for Mental Illness are provided only for the diagnoses of manifest mental disorders. These disorders are described in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. 6. Diagnostic Services— Laboratory and X-ray services performed on an outpatient basis for the diagnosis and treatment of Mental Illness, alcoholism, or drug abuse are Paid at 50 percent of covered charges. The section entitled What We Will Not Pay For— General Limitations and Exclusions is amended as follows: The subheading entitled "Nonparticipating Facility Provider" is deleted in its entirety. FORM NO.96674❑1-97) 8 Bcp866rn ame wpd The section entitled General Provisions is amended as follows: The subheading entitled "Advance Benefit Confirmation" is deleted in its entirety and the following language is substituted therefor: Advance Benefit Confirmation If you wish to know what benefits will be Paid before receiving a service or sending a claim to us, we may require you to submit a written request for such information. In some cases, we may require a written statement from your Physician identifying the circumstances of your case and the specific services that will be provided. The subheading entitled "Availability of Provider Services" is deleted in its entirety. The section entitled How To File Claims and Appeals is amended as follows: The subheadings entitled "How to File Claims"and "Separate Claim Forms Required"are deleted in their entirety and the following language is substituted therefor: How to File Claims 1. When a Participating Facility or a Participating Professional Provider bills us for Covered Services, we will Pay them the appropriate benefit directly. Payment is subject to any applicable Deductible or Coinsurance requirements. If you assign your benefits to a Provider, payment will be Paid to the Provider. NOTE: Blue Cross Plans have a system which processes claims for inpatient Hospital admissions when you receive services in Participating Hospitals outside Colorado. 2. If a Nonparticipating Provider does not bill us directly, you must file your own claim. To obtain claim forms, contact our Customer Service Center. You must complete the claim form and attach the itemized bill from the Provider. Balance due statements, cash register receipts, and cancelled checks are not acceptable. All information on the claim form and itemized bill must be readable. If information is missing on your claim form or is not readable, it will be returned to you. The information contained on the itemized bills will be used to determine benefits, so it must support information reported on the submitted claim form. The claim form contains detailed instructions on how to complete the form and what information is necessary. Separate Claim Forms Required 1. A separate claim form is required for each Nonparticipating Provider for which you are requesting reimbursement. If you assign your benefits to the Provider, we may require that a copy of the executed assignment of benefits agreement be submitted with each claim form. FORM NO.96674(II 97) 9 990325 2. A separate claim form is required for each Member when charges for more than one family Member are being submitted. The section entitled Automobile No-Fault Insurance Provisions is amended as follows: The subheading entitled "What Happens if You Do Not Have a Complying Policy"is deleted in its entirety and the following language is substituted therefor: What Happens if You Do Not Have a Complying Policy We will Pay benefits for injuries received by the Member, while he/she is riding in or operating a motor vehicle which he or she owns if it is not covered by an automobile No-Fault complying policy as required by law. We will also Pay benefits under the terms of the Certificate for injuries sustained by a Member who is a nonowner operator, passenger, or pedestrian involved in a motor vehicle accident if that Member is not covered by a complying policy. In that event, we may exercise our rights under Section 11: Third-Party Liability —Subrogation. This amendment is part of and to be read in conjunction with your Certificate. C. David Kikumoto Chief Executive Officer Blue Cross and Blue Shield of Colorado zcsc. sx. : FORM NO 96674 U 1-991 10 Bcp88Gm.xmcwpd DEPENDENTS NOTICE OF AMENDMENT TO YOUR BLUE CROSS AND BLUE SHIELD OF COLORADO MEMBERSHIP CERTIFICATE OR EMPLOYEE BOOKLET ISSUED FOR YOU AND YOUR ELIGIBLE DEPENDENTS WHILE ENROLLED IN GROUP COVERAGE Your Blue Cross and Blue Shield of Colorado Membership Certificate or Employee Booklet is hereby amended in accordance with the group Master Contract between Blue Cross and Blue Shield of Colorado and your Employer. Effective on your group's Annual Renewal Date, or your Effective Date of Membership, whichever is later: In the section entitled DEFINITIONS, the definition of Dependent is deleted and the following language is substituted therefor: Dependent. Under a Subscriber's Membership, a Subscriber's Dependents may include: • A legal spouse. • An unmarried child under 19 years of age, and an unmarried child under 25 years of age who is financially dependent upon the parent. At the end of the month of the limiting age, as appropriate, the child is automatically removed from the coverage as a Dependent. • An unmarried child of any age who is medically certified as disabled and dependent upon the parent. We must receive notice of the disability condition. NOTE: A child includes, natural-born children of the Subscriber or the Subscriber' spouse, adopted children, a child placed for adoption, or a child required to be covered because of a court order pursuant to state law. A child does not include grandchildren or other children unless legal guardianship has been established pursuant to state law. We may request proof that a child qualifies as an eligible Dependent. This Amendment is part of and to be read in conjunction with your Certificate or Booklet. Insert this Amendment inside your Certificate or Booklet. \‘4()i Ceit4IP O C. David Kikumoto Chief Executive Officer Blue Cross and Blue Shield of Colorado WELDDEVAMC 990325 PRESCRIPTION DRUG PROGRAM NOTICE OF AMENDMENT TO YOUR BLUE CROSS AND BLUE SHIELD OF COLORADO MEMBERSHIP CERTIFICATE OR EMPLOYEE BOOKLET ISSUED FOR YOU AND YOUR ELIGIBLE DEPENDENTS WHILE ENROLLED IN GROUP HEALTH COVERAGE Your Blue Cross and Blue Shield of Colorado Membership Certificate or Employee Booklet is hereby amended in accordance with the group Master Contract between Blue Cross and Blue Shield of Colorado and your Employer. Effective on your group's Anniversary Date or your Effective Date of Membership, whichever is later: The section entitled WHAT WE WILL PAY FOR-BENEFITS, is amended to include the Prescription Drug Program, which is subject to the provisions of the Certificate. Any references to "an independent pharmacy" under the Prescription Drug and Medicines subsection, are deleted and replaced by the following language: PRESCRIPTION DRUG PROGRAM Definitions Prescription drugs and medicines—those that require a Physician's written prescription for purchase and are given for the treatment or diagnosis of a covered medical condition.All drugs and medicines must be approved by the Food and Drug Administration, and must not be identified as Experimental/Investigational. Copayment— the predetermined fixed-dollar amount which a Member must pay to receive a specific benefit. Covered Drug — is any drug or medicine which may be lawfully dispensed by a licensed pharmacist on the prescription of a Physician. Insulin is also considered to be a covered prescription medicine. Drug formulary — a list of drugs that is approved for use by Blue Cross and Blue Shield of Colorado and will be dispensed through Network Pharmacies to members. This list shall be subject to periodic review and changes by Blue Cross and Blue Shield of Colorado. Mail Order Service — a Mail Order Service to provide maintenance medication. Non-Participating Pharmacy —a pharmacy which does not participate in this program. Participating Pharmacy — a pharmacy which has signed an agreement to provide pre-paid prescription drugs in accordance with this prescription drug program section. For a listing of Participating Pharmacies, refer to the Pharmacy Roster, which may be found in the enrollment materials and any subsequent notices, or call our Customer Service Department. Prescription Mail Service — a Participating Pharmacy which provides a Mail Order Service for maintenance medication. PCS3TIER.AMC 1 990325 Benefits Full benefit is received when purchasing prescription drugs which are on the Blue Cross and Blue Shield of Colorado drug formulary, prescribed by an authorized provider, and purchased from an Participating Pharmacy. Prescription drugs which are not included in the Blue Cross and Blue Shield of Colorado Drug Formulary are a benefit, but are subject to an additional copay amount. The only injectable drugs which are a benefit without requiring prior authorization from Blue Cross and Blue Shield of Colorado are insulin, glucagon, sumatriptan (lmitrex) and anaphylactic kits. All other injectable drugs require prior authorization. Insulin needles, syringes, and supplies (example lancets and test strips) are a benefit of the plan and must be dispensed in the days supply corresponding to the amount of insulin to be dispensed and will be included under the same copayment as the insulin. When prescriptions are filled by a network pharmacy or thorough the mail services program: a. Members must pay the copayment for each prescription drug or related refill directly to the network pharmacy when picking up an order or when ordering by mail. b. If the retail price of a filled prescription drug is less than the copay amount, the member will pay the actual retail price. When prescriptions are filled by a pharmacy that has not contracted with Blue Cross and Blue Shield of Colorado: a. The member must pay the pharmacy the full charge for the drug. b. If a member obtain a prescription drug from a non-network pharmacy in an emergency situation, the member will be reimbursed 100 percent of the charge for the drug, minus the copayment amount. To be paid, please the procedure outlined in the Certificate under Section 8: How To File Claims and Appeals. Drug Dispensed by Mail Service The Member may enroll in and use Prescription Mail Service if he/she takes maintenance medications. A maintenance medication is taken regularly to treat a chronic health condition such as blood pressure, ulcers, or diabetes. To use the Prescription Mail Service program, follow the directions on the order form. Order forms are available from our Customer Service Department. Limitations and Exclusions 1. Copayments — refer to your most current identification card or ask your pharmacy for the applicable copay amount. The copayment is based on whether the drug is listed on the Blue Cross and Blue Shield of Colorado formulary. Generic formulary drugs are avialable at the lowest copayment, brand formulary drugs at the intermediate copayment and non-formulary drugs at the highest copayment. For each prescription purchased through the mail order program, the copay amount will be twice the amount for generic, formulary or nonformulary drugs as indicated on your identification card or provided by your network pharmacy for a 90-day supply. If you order up to a 34-day supply, the cost will be one copay amount. 2. Quantity of prescription — benefits under this program are limited to specific amounts. The amount of medication supplied by a network pharmacy must not exceed a 34-day supply. A mail order purchase must not exceed a 90-day supply. Benefits for oral contraceptives are limited to the supply for one menstrual cycle. A separate copay must be made for each cycle's supply, unless purchased from the PCS Managed Mail service program, which is limited to three cycles. 2 PCS3TIRR.AMC 3. Therapeutic devices and appliances — such as support garments and other nonmedical items, regardless of their intended use, are not covered. 4. Refills—we will not cover any refill in excess of the number specified by the primary care medical group or other authorized provider, or any refill dispensed after one year from the physician's order. 5. Government programs — drugs for which the cost is recoverable under local, state (excluding Medicaid), or federal programs, including Workers' Compensation, are not covered. 6. Prescription drugs — any drug which, as required under the federal Food, Drug and Cosmetic Act, does not bear the legend: "Caution: Federal law prohibits dispensing without a prescription" is not covered, even if it is ordered by a physician, unless specifically included as a benefit by Blue Cross and Blue Shield of Colorado. 7. Delivery charge —any charge by the pharmacy for delivery services is not covered. 8. Experimental drugs — drugs which are experimental or investigational in nature, or used for such indication and/or dosage regimen, as defined in Section 2:Definitions of your Certificate, are not covered. 9. Noncovered service —drugs ordered for cosmetic purposes or related to a noncovered service are not covered. 10. Drug intolerance—drugs with a high rate of intolerance may be filled with a one-week supply initially. If the member's response is favorable, the remainder of the order will be filled without another copay. 11. Generic drugs — benefit is limited to the cost of the generic equivalent if you or your provider request the brand name drug, when applicable. All medically necessary "dispense-as-written" prescriptions require prior approval from Blue Cross and Blue Shield of Colorado, or the member will be responsible for paying the cost difference between the brand name and generic drug cost, plus the applicable copay. 12. Membership Certificate — benefits under this program are subject to the terms, conditions, limitations and exclusions in the Certificate, including any limitations and exclusions for prescription drugs not listed under this Prescription Program. 13. Over-the-counter equivalent — we do not allow benefits for any drug that has an over-the-counter bioequivalent. 14. Appetite suppressants—drugs prescribed for weight loss or appetite suppression are not covered. 15. Non-formulary—prescription drugs which are non-formulary and determined by Blue Cross and Blue Shield of Colorado to be medically necessay require prior approval and are subject to the same copayment and limitations as prescription drugs which are listed in the formulary and offered as a benefit of the Certificate. 16. Infertility drugs —we do not allow benefits for infertility drugs. 17. Smoking cessation devices—we do not allow benefits for nicorette gum, or any other drug containing nicotine or other smoking deterrent medications. PCS3TIERAMC 3 990325 18. Brand-name equivalent—if you request a brand-name equivalent of a drug listed in the drug formulary, your benefits are limited to the cost listed in the drug formulary. 19. Sexual Dysfunction — drugs approved by the FDA or otherwise, intended for the treatment of sexual dysfunction(including drugs for the treatment of erectile dysfunction). 20. Travel— drugs needed for the purpose of international travel are not covered. 21. Preauthorization—certain drugs require preauthorization from Blue Cross and Blue Shield of Colorado. Your primary medical group or authorized provider will request approval from us. 20. Dental—benefits are not allowed for fluoride supplements or other prescription drugs for dental use. 21. Formula/vitamins—benefits are not allowed for special formula, food supplements, vitamins, or minerals, expect legend prenatal vitamins. 22. Other non-covered items —benefits are not allowed for: a. Growth hormones. b. Minoxidil (Roagine) for the treatment of alopecia. c. Tretinoin, all drug forms (e.g., Retin A), for individuals 26 years of age or older. d. Medication which is taken by or administered to an individual in whole or in part,while her or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home, or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals. 23. Package size —drugs which are produced in standard package sizes ( e.g. inhalers, creams and migraine drugs) may be limited to one copayment per standard package size. See General Limitations and Exclusions in the Certificate This Amendment is part of and to be read in conjunction with your Certificate. Insert this Amendment inside your Certificate. C. David Kikumoto Chief Executive Officer Blue Cross and Blue Shield of Colorado 4 PCS3TIERAMC ■ Welcome We are pleased to welcome you as a Member of a Blue Cross and Blue Shield of Colorado health benefit plan. You have enrolled in a high-quality program. This Membership Certificate is a guide to your coverage. Keep it in a convenient place for quick reference. This coverage Pays benefits for the majority of your health care expenses. Most of your hospital inpatient care, care received at the doctor's office, emergency care, and prescription drugs are covered. Your coverage also Pays benefits for ambulance service, home health care, hospice care, and private-duty nursing. It's a comprehensive medical care plan designed to relieve you of the burden of most major medical expenses. Special cost containment provisions have been built in to help you use your benefits to your best advantage. It is important that you become familiar with these provisions: Pre-admission Certification, Second Surgical Opinion, and Personal Benefits Management. These programs ensure that you receive medically necessary care in the most cost-effective manner. Used properly, such cost containment provisions can hold down the cost of your medical bills, and consequently keep your premium from escalating. Remember that visiting health care providers that participate with Blue Cross and Blue Shield of Colorado can also save you money. Participating health care providers have agreed to accept our Payment as Payment in full. They will file claim forms for you. We make Payment directly to them, saving you the trouble. Your doctor may well be a participating provider. All participating providers are listed for you in a handy directory. An additional benefit of your health coverage is the backing of Blue Cross and Blue Shield of Colorado. The membership card you carry is recognized and honored worldwide. We are proud of our record of service to the Colorado community, and proud to support the Caring Card. We wish you good health. C. David Kikumoto Chief Executive Officer Blue Cross and Blue Shield of Colorado 990325 Custom Plus Plan Table of Contents ■ Table of Contents The Blue Cross and Blue Shield of Colorado Special Enrollment 10 Custom Plus Certificate Late Applicants 11 Medicare-Eligible Members 11 1 Introduction 1 Certificate of Coverage 13 Conversion Privilege After Termination of 2 Definitions 3 Group Coverage 13 Alcoholism Treatment Center 3 What We Will Pay for After Your Coverage Ancillary Services 3 Ends— Extension of Benefits 14 Blue Cross and Blue Shield of Colorado . . . . 3 Certificate (Membership Certificate) 3 4 Cost Containment Features 15 Coinsurance 3 Concurrent Hospital Review 15 Coverage Notice 3 Personal Benefits Management 15 Covered Services 3 Pre-admission Certification 16 Deductible 3 Prior Benefit Authorization 18 Dependent 3 Second Surgical Opinion 19 Eligible Charge 4 Retrospective Claim Review 20 Experimental/Investigational 4 Family Membership 5 5 What We Will Pay For—Benefits 21 Group Subscriber 5 Hospital Benefits 21 Home Health Agency 5 Medical-Surgical Benefits 21 Hospice Agency 5 Deductible Requirements Under This Hospital 5 Coverage 21 Identification Card 5 Payment Allowances Under This Coverage 22 Individual Membership 5 Maximum Lifetime Benefits 24 Master Contract 5 Your Payment Responsibilities to Maximum Benefit Allowance 5 Participating and Nonparticipating Medical Emergency 6 Providers 24 Medically Necessary 6 Accidental Injuries 24 Member 6 Ambulance Services 26 Member's Benefit Year 6 Anesthesia Services 27 Member's Effective Date of Membership . . . . 6 Blood Expenses 28 Member's Original Membership Effective Chemotherapy and Radiation Therapy 28 Date 7 Cleft Palate and Cleft Lip 29 Pay, Paid, or Payment 7 Consultations 30 Physician 7 Dental Services 31 Provider 7 Hemodialysis 33 Professional Provider 7 Home Health Care 34 Other Professional Provider 7 Hospice Care 36 Facility Provider 7 Laboratory, Pathology, X-ray, and Other Facility 7 Radiology Services 39 Participating Provider 8 Maternity and Newborn Care 41 Nonparticipating Provider 8 Medical Care for General Conditions 42 Room Expenses 8 Medical Emergencies 44 Subscriber 8 Mental Illness, Alcoholism, or Drug Abuse Care 45 3 Membership Eligibility, Enrollment, Prescription Drugs and Medicines 48 Changes, and Termination 9 Preventive Child Care Services 49 Who Is Eligible for Membership 9 Private-Duty Nursing Services 50 Application for Coverage 9 Rehabilitation Therapies: How and When You May Add Dependents 9 Occupational, Physical, and Speech 51 BCP792M CRC Customer Service: (800)331-6170 or(303)831-2900 9 30325 i Table of Contents Custom Plus Plan Room Expenses and Ancillary Services 53 Travel Expenses 66 Supplies, Equipment, and Appliances 54 Vision 66 Surgery 56 War 67 Surgical Assistants 59 Workers' Compensation 67 6 What We Will Not Pay For— 7 General Provisions 68 General Limitations and Exclusions 60 Advance Benefit Confirmation 68 Acupuncture 60 Assignment of Benefits 68 Artificial Conception 60 Availability of Provider Services 68 Auto Accident Injuries 60 BlueCard Program 68 Biofeedback 60 Catastrophic Events 69 Birth Control 60 Changes to the Certificate 69 Chiropractic Services 60 Contracting Entity 69 Convalescent Care 60 Disclaimer of Liability 69 Cosmetic Surgery 60 Disclosure of Your Medical Information . . . 70 Custodial Care 61 Execution of Papers 70 Diagnostic Admissions 61 Fraudulent Insurance Acts 70 Discharge Day Expense 61 Payment in Error 70 Domiciliary Care 61 Payment of Premium by Your Employer . . . 71 Duplicate (Double) Coverage 61 Pilot Programs 71 Durable Medical Equipment 61 Release of Medically-Related Information . 71 Experimental or Investigative Procedures 61 Research Fees 72 Facility Charges 61 Reserve Funds 72 Genetic Counseling 61 Sending Notices 72 Government Institutions and Facility Services 62 Subscriber's Legal Expense Obligations 72 Hair Loss 62 Paragraph Headings 72 Hypnosis 62 Intractable Pain 62 8 How To File Claims and Appeals 73 Isolation Charges 62 How to File Claims 73 Learning Deficiency and/or Behavioral Separate Claim Forms Required 73 Problem Therapies 62 Where and When to Send Your Claim . . . . 73 Legal Payment Obligations 62 How to Appeal the Action We Have Taken Medically Necessary 62 Under This Certificate 74 Noncovered Services 63 Legal Action 75 Nonparticipating Facility Provider 63 Obesity and Weight Loss 63 9 Workers' Compensation 76 Organ Transplants 64 Personal Comfort or Convenience 64 10 Automobile No-Fault Insurance Provisions 77 Post-Termination Benefits 64 How We Coordinate Benefits With Pre-existing Conditions 64 Complying Policies 77 Prior Benefit Authorization 65 What We Will Pay 77 Private Room Expenses 65 What Happens if You Do Not Have a Report Preparations 65 Complying Policy 77 Restorative or Reconstructive Surgery 65 Routine Physicals 65 11 Third-Party Liability—Subrogation 79 Self-Inflicted Injuries 65 Our Rights When Third-Party Liability Services Not Identified 66 Exists 79 Sex-Change Operations 66 Your Obligations When Third-Party Liability Skilled Nursing Facilities 66 Exists 79 Taxes 66 Temporomandibular Joint Surgery or 12 Duplicate Coverage and Therapy 66 Coordination of Benefits 81 Therapies 66 Duplicate (Double) Coverage 81 Third-Party Liability (Subrogation) 66 Definitions 81 Transfers 66 Conditions of Coordination of Benefits . . . . 82 ii Customer Service:(800)331-6170 or(303)831-2900 BCP7S2M.CRc Custom Plus Plan Table of Contents Effect on Benefits 82 How We Determine Which Plan is Primary and Which is Secondary 82 Right to Receive and Release Necessary Information 83 Convenience of Payment 83 Right of Recovery 83 Execution of Papers 83 BCP]82M CRC Customer Service: (800)331-6170 or(303)831-2900 990325 iii Custom Plus Plan Section 1: Introduction 1 Introduction This Membership Certificate (hereinafter referred as the "Certificate") is part of the legal agreement between you (a Member) and us (Blue Cross and Blue Shield of CoIorado). As a Member, you are bound by all of the terms of this Certificate. In exchange for your premium payment, we agree to Pay for all or part of Covered Services as described in this Certificate. Our provision of benefits to you is conditional on timely receipt of premiums. The legal agreement between you and us includes the following documents: • This Certificate and any amendments made to it. • Your application and any later applications you may make. • Your Identification Card. • Your Coverage Notice. • The Master Contract between us and your employer. The above documents contain all of the terms of the legal agreement between you and Blue Cross and Blue Shield of Colorado, and supersede all other statements and contracts, oral or in writing, with respect to the subject matter of this Certificate. No change or modification to your agreement with us will be valid unless it is in writing and signed by an authorized representative of Blue Cross and Blue Shield of Colorado. Further, no course of action, usage or custom or internal policy of Blue Cross and Blue Shield of Colorado may amend or become part of our agreement with you. We record the coverage you have in our membership records. It is also identified on the Coverage Notice we send you. When you change your coverage you will receive a new Coverage Notice. You will not, however, always receive a new Identification Card. How to Read This Certificate This Certificate is designed to make it easy for you to determine your benefits. For instance, if you need to know the benefit for a surgery, turn to Section 5: What We Will Pay For—Benefits. The Surgery subsection explains what we consider to be a surgery service. The subsection also describes your benefits and eligible providers. (NOTE: Many providers are limited in the types of care or services they are licensed or certified to perform. Often, we recognize a provider as eligible for Blue Cross and Blue Shield of Colorado Payments only with respect to particular types of care.) BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 J9tietS 1 Section 1: Introduction Custom Plus Plan The last part of each BENEFITS subsection lists the most important limitations and exclusions for that particular service. Section 6: What We Will Not Pay For— General Limitations and Exclusions lists other limitations and exclusions which apply to all benefits. The items in Section 6. apply to all services and supplies, whether or not these items are listed separately within any BENEFITS subsection. If you have questions about your coverage, call Blue Cross and Blue Shield of Colorado's Customer Service Department. For your convenience, the local and toll-free customer service numbers are printed at the bottom of every page of this Certificate. Address: Blue Cross and Blue Shield of Colorado 700 Broadway Denver, Colorado 80273 Hours: 7:30 A.M. to 5:30 P.M. Phone Number: (800) 331-6170 or (303) 831-2900 For additional information on Blue Cross and Blue Shield of Colorado (including the on-line provider' directories) visit our World. Wide Web site at: http://www.bcbsco.com 2 - Customer Service:(800)331-6170 or(303)831-2900 BCP192M.CRC Custom Plus Plan Section 2: Definitions 2 Definitions This section defines certain words used throughout the Certificate. The first letter of each of these words will be capitalized whenever it is used as defined below in this text. Reading this section will help you understand the rest of the Certificate. You may also want to refer back to this section to find out exactly how — for the purposes of this Certificate —a word is used. Alcoholism Treatment Center—A detoxification and/or rehabilitation facility licensed by Colorado or another state to treat alcoholism/drug abuse. Ancillary Services—See this heading under Section 5: What We Will Pay For—Benefits, Room Expenses and Ancillary Services. Blue Cross and Blue Shield of Colorado—A nonprofit health service corporation organized under the laws of Colorado. NOTE: "We," "our," and "us" refer to Blue Cross and Blue Shield of Colorado. Certificate(Membership Certificate) This document, which explains the benefits, limitations, exclusions, terms, and conditions of your health coverage. Coinsurance—An arrangement by which a Member Pays a certain percentage of the Covered Services for his or her care after the Deductible has been met. The amount of Coinsurance the Member Pays to a Provider is calculated after the determination of the Maximum Benefit Allowance, but before we subtract any discount(s) we may have negotiated with the Provider. Coverage Notice—The document we issue to you which identifies the type of coverage you have. Covered Services— Services and supplies provided to a Member for which we have an obligation to Pay under the terms of this Certificate. Deductible—A specified amount of expense for Covered Services that the Member must Pay within each Member's Benefit Year before Blue Cross and Blue Shield of Colorado provides benefits. Dependent—Under a Subscriber's membership, a Subscriber's Dependents may include: • A legal spouse. RCP]82M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 3 Section 2: Definitions Custom Plus Plan • An unmarried child under 19 years of age, and an unmarried child under 24 years of age who is financially dependent upon the parent. At the end of the month of the limiting age, as appropriate, the child is automatically removed from the coverage as a Dependent. • An unmarried child of any age who is medically certified as disabled and dependent upon the parent. We must receive notice of the disability condition. NOTE: A child includes, natural-born children of the Subscriber or the Subscriber' spouse, adopted children, a child placed for adoption, or a child required to be covered because of a court order pursuant to state law. A child does not include grandchildren or other children unless legal guardianship has been established pursuant to state law. We may request proof that a child qualifies as an eligible Dependent. Eligible Charge—The amount used by Blue Cross and Blue Shield of Colorado to determine the Payment to a Provider for a Covered Service. The Eligible Charge is determined after any Deductible and Coinsurance amounts have been subtracted. The Eligible Charge may be different from the Maximum Benefit Allowance. Blue Cross and Blue Shield of Colorado has contracts with some Participating Providers that allow discounts in addition to the Maximum Benefit Allowance. The amount Blue Cross and Blue Shield of Colorado Pays a Participating Provider may not be the same amount that is shown on the Member's Explanation of Benefits or on the Provider's bill. Blue Cross and Blue Shield of Colorado may satisfy its responsibility for the percentage described under Section 5: What We Will Pay For—Benefits by a combination of discounts and actual Payment. Experimental/Investigational--Any treatment, procedure, drug, or device that has been reviewed by Blue Cross and Blue Shield of Colorado and found not to meet all of the eligible-for-coverage criteria below with respect to the particular illness or disease to be treated. Eligible-for-coverage criteria. 1. The technology must have final approval from the appropriate government regulatory bodies; 2. The scientific evidence as published in peer-reviewed literature must permit conclusions concerning the effect of the technology on health outcomes: 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternative; and 5. The improvements must be attainable outside the investigational settings. 4 • Customer Service:(800)331-6170 or(303)831-2900 BCP]92M.CRC Custom Plus Plan Section 2: Definitions Additionally, the service must be Medically Necessary and not excluded by any other provisions of this Certificate. Family Membership A membership that covers two or more persons (the Subscriber and one or more Dependents). Group Subscriber A Subscriber who is a Member of an established group of employees. The employer collects membership premiums on behalf of the group's employees, and complies with all provisions of the Master Contract. Home Health Agency—An agency certified by the Colorado Department of Health as meeting the provisions of Title XVIII of the F'ederal "Social Security Act," as amended, for Home Health Agencies. A Home Health Agency is primarily engaged in arranging and providing nursing services, home health aide services, and other therapeutic and related services. Hospice Agency—An agency licensed by the Colorado Department of Health to provide hospice care in this state. Hospice care is a centrally administered program of palliative, supportive, and interdisciplinary team services providing physical, psychological, spiritual, and sociological care for terminally ill individuals and their families within a continuum of inpatient care, home health care, and follow-up bereavement services available 24 hours, seven days a week. Hospital—A health institution offering facilities, beds, and continuous services 24 hours a day. The Hospital must meet all licensing and certification requirements of local and state regulatory agencies. Services provided include: • Diagnosis and treatment of illness, injury, deformity, abnormality, or pregnancy. • Clinical laboratory, diagnostic X-ray, and definitive medical treatment provided by an organized medical staff within the institution. • Treatment facilities for emergency and surgical services either within the institution or through a contractual agreement with another licensed Hospital. These contracted services must be documented by a well-defined plan and related to community needs. Identification Card—The plastic card we give you that shows such information as the Subscriber's name, number, group number, plan number, and date issued. Individual Membership—A membership covering one person (the Subscriber). Master Contract—The agreement between us and your employer stating all of the terms and provisions applicable to your group coverage. The final interpretation of any specific provision contained in this Certificate is governed by the Master Contract. BCPIB2M.CPC Customer Service:(800)331-6170 or(303)831-2900 990325 5 Section 2: Definitions Custom Plus Plan Maximum Benefit Allowance--The amount determined by Blue Cross and Blue Shield of Colorado to be a reasonable and adequate allowance for a Covered Service. Our determination of a Maximum Benefit Allowance is the maximum amount we approve for any particular service. Deductible, Coinsurance, or other cost-sharing amounts are based on this allowance and are the amounts the Member Pays to a Provider. Medical Emergency—The sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. Medically Necessary—A term used to describe technologies, services, or supplies provided by a Hospital, Physician, or Other Provider that we determine are: • Medically appropriate for the symptoms and diagnosis or treatment of the condition, illness, disease, or injury; • Provided for the diagnosis, or the direct care and treatment of the Member's condition, illness, disease, or injury; • In accordance with standards of sound medical practice and meets our technology evaluation criteria; • Not primarily for the convenience of the Member, or the Member's Provider; and • The most appropriate supply or level of service that can safely be provided to the Member. When applied to hospitalization, this further means that the Member requires acute care as an inpatient due to the nature of the services rendered or the Member's condition, and the Member cannot receive safe or adequate care as an outpatient. NOTE: The fact that a Physician may prescribe, order, recommend, or approve a service or supply does not, by itself, make it Medically Necessary or a covered expense, even though it is not specifically listed as an exclusion. Claims for services and supplies that are not Medically Necessary may be denied either before or after Payment. Member—The Subscriber or any Dependent who is enrolled for coverage under this Membership Certificate under the terms of the Master Contract. NOTE: "You" and "your" refer to the Member. Member's Benefit Year—The Member's Benefit Year commences on the Member's Effective Date of Membership as established for the employee, and expires on the following December 31; a new Member's Benefit Year commences on each subsequent January 1. 6 - Customer Service:(800)331-6170 or(303)831-2900 BCPJB2M.CFC Custom Plus Plan Section 2: Definitions Member's Effective Date of Membership—The date the Subscriber or a Dependent is enrolled on our membership records for coverage under this Membership Certificate. Member's Original Membership Effective Date— is either: • The date you first enrolled for coverage in any Blue Cross and Blue Shield Plan, as long as the coverage continued without interruption since you enrolled; or • The Member's Effective Date of Membership if the above date does not apply. Pay, Paid, or Payment— "Pay" means to satisfy a debt or obligation. After the Maximum Benefit Allowance is determined, Blue Cross and Blue Shield of Colorado or your employer's benefit plan will satisfy its percentage of the bill by an actual dollar Payment, by a negotiated Provider discount, or by combining these two methods of Payment. The Member's portion of the Payment includes Deductible, Coinsurance, or other cost-sharing amounts and, if the Provider is Nonparticipating, any amounts over the Maximum Benefit Allowance. Physician A doctor of medicine or osteopathy who is licensed to practice medicine under the laws of the state or jurisdiction where the services are provided. Certain services will also be covered when provided by a doctor of podiatry or dentistry practicing within the scope of his/her license. Provider—A person or facility that is recognized by Blue Cross and Blue Shield of Colorado as a health care Provider, and fits one or more of the following descriptions: Professional Provider—A Physician or Other Professional Provider who is recognized by Blue Cross and Blue Shield of Colorado. Other Professional Provider—A Professional Provider (except a Physician) who is recognized by Blue Cross and Blue Shield of Colorado and licensed, certified, or registered by the state or jurisdiction where services are provided to perform designated health care services. Services of such a Provider must be among those covered by this Certificate and are subject to review by a medical authority appointed by us. A professional supplier of medical supplies and equipment is considered an Other Professional Provider. Facility Provider—An Alcoholism Treatment Center, Home Health Agency, Hospice Agency, Hospital, or Other Facility which we recognize as a health care Provider. These Facility Providers may be referred to collectively as a Facility Provider or separately as an Alcoholism Treatment Center Provider, 990325BCP7S2M.CRC Customer Service: (800)331-6170 or(303)831-2900 7 Section 2: Definitions Custom Plus Plan Home Health Agency Provider, Hospice Agency Provider, Hospital Provider, or Other Facility Provider. Other Facility—A Facility Provider (except a Hospital, Alcoholism Treatment Center, Home Health Agency, or Hospice Agency) that we recognize as a Provider and that is licensed or certified to perform designated health care services by the state or jurisdiction where services are provided. Services of such a Provider must be among those covered by this Certificate and are subject to review by a medical authority appointed by us. Examples: ambulatory surgery center, dialysis center, Veteran's Administration, or Department of Defense Hospital. Participating Provider—A Facility Provider (such as a Hospital) or a Professional Provider (such as a Physician) that has entered into an agreement with us or another Blue Cross and Blue Shield Plan to bill us directly for Covered Services, and to accept our Maximum Benefit Allowance as the maximum amount the Participating Provider will bill the Member for or use to calculate Deductible, Coinsurance, or other cost- sharing amounts for Covered Services. Nonparticipating Provider— means either: • A Facility Provider, such as a Hospital, that has not entered into an agreement with us; or • A Professional Provider, such as a Physician, who has not entered into an agreement with us. If you assign benefits to a Nonparticipating Provider, Payment will be made to the Nonparticipating Provider. If you do not assign your benefits to a Nonparticipating Provider, Payment will be made to you. NOTE: If you receive services from a Nonparticipating Provider, you will be responsible for all charges, regardless of our Maximum Benefit Allowance or the amount of our Payment, if any. Room Expenses—See this heading under Section 5: What We Will Pay For—Benefits, Room Expenses and Ancillary Services. Subscriber-- The person in whose name the membership is established and to whom the Identification Card and Coverage Notice are issued. 8 Customer Service:(800)331-6170 or(303)831-2900 BCP7S2M.CRC Custom Plus Plan Section 3: Membership Eligibility, Enrollment, Changes, and Termination 3 Membership Eligibility, Enrollment, Changes, and Termination Who Is Eligible for Membership All employees who have a regular work week as specified in the group Master Contract are eligible to enroll for coverage. To find out the number of hours you must work per week in order to qualify, contact your employer. Application for Coverage Eligible employees can apply for coverage for themselves and their eligible Dependents by submitting an application within 30 days after becoming eligible. Your employer will determine the effective date of your coverage in accordance with any waiting period you may have. Some eligible employees may be subject to a six-month pre-existing waiting period as described in Section 6: What We Will Not Pay For— General Limitations and Exclusions, Pre-existing Conditions. Employees may also enroll newly acquired Dependents (such as a newborn child, a child placed for adoption, adopted child, a new spouse, or a child to be covered due to a court order) within 30 days of eligibility. See How and When You May Add Dependents below for additional information. Employees and Dependents who did not enroll within 30 days of eligibility can enroll subject to the provisions of Special Enrollment and Late Applicants below. How and When You May Add Dependents 1. To add a spouse due to marriage, you must complete a Membership Change form and the submit the request for the addition within 30 days of marriage. 2. The following rules apply for coverage of newborn children from the moment of birth and for adopted children under the age of 1.8 from the earlier of the date of adoption or placement for adoption, as certified by the public or private agency making the placement: a. Under a Family Membership, a child will be covered automatically from the date of birth or acquisition. You must notify us within 30 days of the event to ensure that the child's claims are processed.. b. Under an Individual Membership, a child will be covered automatically until the child is 31 days old, or has been with the Subscriber for 31 days. If that child is to continue membership from the 32nd day on, you must notify us within 30 days of the event. You must change to an appropriate membership within that BCPJB2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 g Section 3: Membership Eligibility, Enrollment, Changes, and Termination Custom Plus Plan same 30-day period and agree to pay premium for such coverage from the 32nd day on. NOTE: The coverage established for the child for this 31-day period is identical to that of the parent. All services provided during the first 31 days of coverage are subject to the terms of this Certificate, including the application of Deductible and/or Coinsurance. c. If the mother of the newborn is a dependent child of the Subscriber, the newborn is not automatically covered. The mother of the newborn must take one of the following actions within 30 days of her child's birth: 1) Enroll under an Individual Membership, subject to its rules and regulations. 2) Add the child to the existing Family Membership. In this case, the Subscriber must assume legal responsibility for the newborn child and present us with evidence of this obligation. d. To add a newborn child later than 30 days after birth, see Special Enrollment and Late Applicants below. Special Enrollment If the employee declined enrollment for him/herself or his/her Dependents because of other health insurance coverage, the employee and Dependents may enroll with us provided that the employee requests enrollment within 30 days after the other coverage involuntarily ends. The other coverage must be lost due to termination of employment or eligibility, reduction in the number of hours the employee works, the involuntary termination of creditable coverage, death of a spouse, legal separation, divorce, or the contribution towards the coverage terminating. Coverage with Blue Cross and Blue Shield of Colorado will be effective the day following the loss of other coverage. If the other coverage that is lost is COBRA or state continuation coverage, enrollment can only be requested after exhausting the COBRA or state continuation coverage. A special enrollment can also occur when an employee who was previously not enrolled marries or has a new child (as a result of marriage, birth, adoption, or when a child who is under the age of 18 is placed in your home for the purpose of adoption). The employee and any Dependents can enroll within 30 days of the marriage or acquisition of the Dependent. Coverage with Blue Cross and Blue Shield of Colorado will be effective the day following the marriage or acquisition (charges related to labor and delivery due to the birth are not covered). When an employee is required by court or administrative order to provide coverage for an eligible Dependent, the eligible Dependent may be enrolled within 30 days of such order. If not specified in the court order, the eligible Dependent's effective date of coverage will be the date of Blue Cross and Blue Shield of Colorado's receipt of the court order. (Blue Cross and Blue Shield of Colorado must receive a copy of the court order.) 10 Customer Service:(800)331-6170 or(303)831-2900 BCP)92M.CRC Custom Plus Plan Section 3: Membership Eligibility, Enrollment, Changes, and Termination If you have coverage elsewhere and voluntarily cancel such coverage, you will be allowed to enroll at your employer's anniversary date as long as coverage has been maintained within 90 days of enrollment and such coverage is not under COBRA or state continuation. Late Applicants Anyone eligible who did not enroll during the group's initial enrollment, within 30 days of becoming eligible, or within 30 days of a special enrollment and who has no prior coverage within 90 days of enrollment is considered a Late Applicant and can enroll subject to the Late Applicant pre-existing waiting period as described in Section 6: What We Will Not Pay For— General Limitation and Exclusions, Pre-existing Conditions. Coverage will be effective the first service date following receipt of the application. If an employee enrolls as a Late Applicant, eligible Dependents seeking coverage at the same time will also be Late Applicants. Medicare-Eligible Members Before a Member becomes age 65, or if any Member qualifies for Medicare benefits, the Member is responsible for contacting the local Social Security office to establish Medicare eligibility. You should then contact your employer to discuss coverage options. If an employee qualifies under the provisions of federal law for the working aged (TEFRA), then the working employee age 65 and over and/or his/her spouse age 65 or over may continue coverage under this health care plan. If a TEFRA-eligible Medicare beneficiary selects Medicare as his/her primary coverage, coverage under this Certificate ends for the Member. Special Medicare Secondary Payer (MSP) rules apply if a Member is receiving benefits from Medicare due to a disability or end-stage renal disease. Contact your employer for more information and for eligibility guidelines that apply to you. For groups with fewer than 20 employees and all other groups not subject to MSP provisions, when a Member becomes eligible for Medicare Part A and/or B, coverage under this Certificate will continue, but benefits will be coordinated with Medicare with this coverage being secondary to any Medicare coverage. When Coverage Under This Certificate Ends If your group is covered by provisions requiring continuation of group coverage under Colorado or Federal Law (Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)), you and your covered Dependents who lose eligibility under a group may be able to continue as group Members for a limited period of time. Contact your group for information. BCP1B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 11 Section 3: Membership Eligibility, Enrollment, Changes, and Termination Custom Plus Plan If you are voluntarily removing a Dependent, the deletion will be effective the next service date following receipt of the Membership Change form. If a Member does not elect or does not qualify for Colorado or COBRA continuation, or loses eligibility at any other time, coverage under this Certificate ends on the earliest of the following dates: 1. For any Member, including Dependents: a. When the Subscriber's employer gives us written notice of termination. If the employer fails to timely remove an ineligible Member, we reserve the right to recoup any benefit Payments made on behalf of such person. Coverage will be terminated on the next monthly service date. b. Upon the Subscriber's death. NOTE: Surviving eligible Dependents remain covered through the last paid billing period.. Also, any surviving Dependent has the right to select conversion coverage for himself/herself under then- available coverages, rates, and benefits. A written application for such continuation must be received by us within three calendar months after the death of the Subscriber. c. When we do not receive the premium payment on time. d. When there is a misrepresentation or improper use of the Master Contract, Certificate, or Identification Card, the improper filing of claims, or false or incomplete information is presented on any enrollment forms. You are liable for any benefit Payments made as a result of such improper actions. e. When Medicare becomes the Member's primary coverage unless the Member is in a group with fewer than 20 employees. See Medicare-Eligible Members in this section for additional information. f. When the Member is no longer eligible for this group coverage under the terms of the Master Contract. g. The date group coverage under this Certificate is discontinued for the entire group, or the employee's enrollment classification. 2. For a Dependent: a. When the Dependent child marries. b. At the end of the last paid billing period for Dependent coverage. c. When the Dependent no longer qualifies as a Dependent by definition. d. The date of a final divorce decree or legal separation for a Dependent spouse. e. When the Subscriber notifies us in writing to end coverage for a Dependent. 12 . Customer Service:(800)331-6170 or(303)831-2900 BCP]92M.CRC Custom Plus Plan Section 3: Membership Eligibility, Enrollment, Changes, and Termination We will not refund membership premium paid in advance on behalf of the deleted Member if: a. We do not receive the Membership Change form within 30 days of the effective date of change. b. We have Paid any claims on behalf of the deleted Member. Colorado or COBRA continuation coverage ends on the earliest of any of the above dates and in addition coverage ends: 1. When the Member becomes covered under another group health plan (as an employee or otherwise). 2. When the Member becomes eligible under other group coverage or 18 months after termination of employment, whichever occurs first. 3. When the Member becomes entitled to Medicare benefits, including Medicare disability (COBRA and Colorado law) or Medicaid benefits (Colorado law). 4. The date on which an employee whose COBRA coverage was extended to 29 months is determined under the Social Security Act to no longer be disabled. 5. When the Colorado or COBRA continuation period expires. Certificate of Coverage When a Member leaves Blue Cross and Blue Shield of Colorado, they are entitled to receive a certificate of coverage, which will identify the length of the Member's credited coverage with Blue Cross and Blue Shield of Colorado. This certificate of coverage is needed when the Member enrolls with another plan that may impose a pre-existing condition waiting period. Conversion Privilege After Termination of Group Coverage You and your eligible Dependents who were covered under the group health program may change to group conversion coverage with us for any reason, other than replacement by the employer with another group policy, or fraud and abuse in procuring and using the coverage. We must receive your application for group conversion coverage within 30 days after group coverage is terminated. You must pay the group conversion premium from the date of such termination. Group conversion coverage is not available to former employees of a group and their Dependents in the following situations: a. When an employee is not a group Member by virtue of not having been covered under the group plan at the time of termination of coverage. b. When a Dependent was not covered through the group at the time of the employee's termination of coverage. BCP792M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 13 Section 3: Membership Eligibility, Enrollment, Changes, and Termination Custom Plus Plan c. When the group cancels and replaces your coverage with another insurance carrier or self-insures. d. When there is fraud and abuse in procuring and using coverage. e. When an employee or Dependent is eligible for Medicare Part A and/or Part B at the time of eligibility for group conversion coverage. Contact Blue Cross and Blue Shield of Colorado for coverage options available. NOTE: If you do not want or are not eligible for conversion coverage, we will consider applications for enrollment of Members as new nongroup Members under then-available coverages, rates, and benefits. We will accept your application subject to applicable rules for nongroup coverage. What We Will Pay for After Your Coverage Ends — Extension of Benefits Under the terms of this Certificate, we will continue to Pay an allowance for covered Hospital and Physician services directly related to and provided during your inpatient stay for up to 12 months after your coverage ends. Covered Services for mental illness, alcoholism, or drug abuse in a Hospital or Alcoholism Treatment Center, however, are limited to 45 days per Member's Benefit Year. In order to qualify for this benefit extension, you must meet all three of these conditions: 1. You are an inpatient in a Hospital, Hospice, or Alcoholism Treatment Center when coverage ends. 2. Your inpatient stay remains uninterrupted. 3. Your inpatient stay is Medically Necessary. Benefits will cease upon any interruption of your inpatient stay or leave of absence from the facility, regardless of the date of discharge. NOTE: A transfer from one inpatient facility to another for continuous treatment is not considered to be an interruption of your inpatient stay, unless a period of one day or more elapses between the date of discharge from one facility and the date of admission to another. We will not Pay for any services provided before your coverage begins or after your coverage ends except under the conditions listed above. NOTE: For benefit amounts when using a Nonparticipating Provider, see Section 5: What We Will Pay For— Benefits. 14 "' - Customer Service:(800)331-6170 or(303)831-2900 6CP782M.CRC Custom Plus Plan Section 4: Cost Containment Features 4 Cost Containment Features This section describes steps you must take prior to receiving certain services or supplies so that we can determine if benefits are payable under the terms of this Certificate. This section also describes additional features such as personal benefits management and second surgical opinions. Concurrent Hospital Review We may review your medical care while you are in the Hospital to help ensure that you are receiving appropriate and Medically Necessary Hospital services. If you are admitted to the Hospital for a Medical Emergency, it is in your best interest for a family member, the Hospital, or your Physician to notify Blue Cross and Blue Shield of Colorado so that we can assist with management of your Hospital benefits and planning for covered medical services after discharge. Your attending Physician, the Hospital Utilization Review Committee, or Blue Cross and Blue Shield of Colorado may determine that further hospitalization is not Medically Necessary. The Hospital will give you timely notice of such a determination. If you or your Physician disagrees with this determination, you, your Physician, or the Hospital will notify us and we will review the determination. We will notify both you and the Hospital of our decision. If you elect to remain in the Hospital after you have been notified that further Hospital care is not Medically Necessary, we will not allow benefits for the rest of your stay. We will send written notification of our decision to you, your attending Physician, and the Hospital. You will be responsible for all charges incurred after the recommended day of discharge. You or your representative may appeal our Concurrent Hospital Review decision by following the medical procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. NOTE: For benefit amounts when using a Nonparticipating Provider, see Section 5: What We Will Pay For—Benefits. Personal Benefits Management Our personal benefits management program identifies cost-effective alternative services which may be provided to Members on a voluntary basis. Whenever it is appropriate, we investigate and recommend alternative care settings such as your own home or an outpatient office. Extensions or exceptions to regular contract benefits are authorized only when a Covered Service can be replaced with a less-costly, noncovered service. BCP]82M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 15 Section 4: Cost Containment Features Custom Plus Plan Personal benefits management is considered on a case-by-case basis. Our case managers, all experienced registered nurses, identify patients who might ultimately benefit from an alternative care setting or extension of the benefit period. If your case seems appropriate for the program, the nurse consultant will discuss your care with your health care Providers. With help from Blue Cross and Blue Shield of Colorado, you, your family, and your doctor will decide the most cost-effective and appropriate means of providing your care. All personal benefits management ceases upon termination of your coverage. Commonly managed cases include high-risk mothers and infants, Members with traumatic head and spinal cord injuries, end-stage cancer, and AIDS. You or your representative may appeal our personal benefits management decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Pre-admission Certification Pre-admission certification is a program designed to help control medical costs by encouraging the use of outpatient services whenever possible. Inpatient admissions for medical care and for selected surgical procedures must be pre-certified by us prior to admission to the Hospital to ensure that you receive care in the most medically appropriate and cost-effective setting. To obtain pre-admission certification, you must ask your Physician to complete a pre-admission certification form and submit it to us for review. Forms are available upon request from our Customer Service office. We will review your case and send you a written confirmation of our decision within two working days of receipt of the form. If the inpatient admission is approved, all benefits normally available under your coverage will be provided. If we do not approve the inpatient admission, Hospital room expenses for your inpatient stay will not be Paid. Failure to obtain pre-admission certification will result in denial of the Hospital room expenses, regardless of the medical necessity of the admission. Pre-admission certification is required for all elective (nonemergency) medical care provided in an inpatient setting and for the surgical procedures listed below. Pre-admission certification is not required for accidents, maternity care, medical emergencies, mental illness, alcoholism, or drug abuse care. Pre-admission certification is required prior to a Hospital admission for the following surgical procedures. Antral puncture and inferior turbinate fracture — repair of punctured sinus and/or broken bone in the nasal cavity 16 Customer Service: (800)331-6170 or(303)831-2900 BCP7B2M.CRC Custom Plus Plan Section 4: Cost Containment Features Blepharoplasty— reconstruction of the eyelid* Breast biopsy— sample of breast tissue Bronchoscopy—examination of the lung passages with a bronchoscope Cystoscopy— direct visual examination of the urinary tract with a cystoscope Fracture, closed reduction— setting of broken bones without a surgical incision Gastrointestinal endoscopy inspection of the stomach and/or the intestinal tract with an endoscope Gynecological procedures - Examination under anesthesia - Cryotherapy therapeutic use of cold - Dilation and curettage (D&C) — removal of growths or other material from the wall of the uterus - Hysterosalpingogram —X-ray of the uterus and fallopian tubes - Removal of intrauteri.ne device (IUD) - Hymenotomy — surgical incision of the hymen - Hysteroscopy inspection of the uterus with a special instrument - Laparoscopy—examination of the interior of the abdomen with a special instrument - Culdoscopy —visual exam of the female pelvic area with a special instrument Hammertoe — deformed toe Mammoplasty— reconstruction of the breast* Manipulation of joints Meatotomy—incision of the urinary pathway to enlarge it Muscle and cervical node biopsy — tissue sample in neck region Myringotomy— surgery of the ear drum Otoplasty reconstruction of the ear lobe* Otoscopy —exam of ear Rectal polypectomy— surgical removal of rectal polyps Removal of benign lesions, cysts, and neuromas Removal of fingernail or toenail Resection of hand or foot bone Small skin graft Sterilization procedures, male or female Tenotomy—cutting of a tendon Therapeutic abortion Urethral dilation—widening of the urinary tract *Surgery for cosmetic reasons is not covered. You or your representative may appeal our pre-admission certification decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. NOTE: For benefit amounts when using a Nonparticipating Provider, see Section 5: What We Will Not Pay For—Benefits. BCP782M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 17 Section 4: Cost Containment Features Custom Plus Plan Prior Benefit Authorization Prior benefit authorization is a determination by us, prior to your receipt of certain specified services, that such services meet all of the eligible-for- coverage criteria listed under ExperimentaUlnvestigational (see Section 2: Definitions) and are in compliance with the provisions of this Certificate. When a service requires our prior benefit authorization according to the terms of this Certificate, your Physician must submit to us a written request for prior authorization. Telephone requests cannot be accepted, and oral authorizations will not be honored. To facilitate the timely discharge of patients to home health care or hospice care, we will give prior benefit authorization over the telephone for a minimal number of days of service. The prior benefit authorization forms must be submitted immediately after the telephone approval. We will give you and the Provider of service written confirmation of benefits before the date on which services are performed. Our approval letters are valid for 180 days and apply only to the procedure specified. Any subsequent procedures must also be submitted in writing by the Provider and approved by us prior to the date of the service. If the approved procedure is not done within that time period, then your Physician must submit another prior benefit authorization request for us to review. A new written approval letter must then be issued. A prior authorization of benefits does not guarantee that benefits will be allowed for the services. We will review your claims against the terms of this Certificate and the circumstances of your case as originally authorized to determine benefits. To receive benefits for the following services, they must be authorized in advance of the date of services. Failure to obtain our prior benefit authorization will result in denial of benefits. 1. Bone marrow transplants and peripheral stem cell transplants. 2. Cosmetic and restorative/reconstructive surgery. 3. Dental-related services for cleft palate or cleft lip. 4. Growth hormone therapy. 5. Home health care. 6. Hospice care. 7. Implantable hearing devices such as an electromagnetic bone conductor or cochlear implant, including any necessary training required to use the device. 8. Maxillofacial surgery (surgery on bones of face, jaw, cheeks). 18 a Customer Service:(800)331-6170 or(303)831-2900 ecpm2M.cac Custom Plus Plan Section 4: Cost Containment Features 9. Orthognathic surgery (upper and lower jaw augmentation). 10. Pre-term delivery prevention programs such as home uterine monitoring and drug intervention. 11. Surgery for obesity. 12. X-ray and surgical procedures for the diagnosis and treatment of impotence. 13. Speech therapy. You or your representative may appeal our prior benefit authorization decision by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. NOTE: For benefit amounts when using a Nonparticipating Provider, see Section 5: What We Will Pay For— Benefits. Second Surgical Opinion The second surgical opinion program enables you to obtain another professional opinion prior to having elective surgery. Such a second opinion may lead to the use of alternative medical treatment rather than surgery. We will allow up to our Maximum Benefit Allowance for the second surgical opinion. If the second opinion does not confirm the need for surgery and you are still undecided as to the appropriate method for treating your condition, we will also Pay for a third surgical opinion. If the second opinion confirms the need for the procedure, all benefits available under your coverage will be allowed. If the second opinion is not obtained, or if neither the second nor third opinions confirm the need for surgery, and you decided to have the procedure, benefits for the surgeon and assistant surgeon will be allowed at 50 percent of the Maximum Benefit Allowance. You are responsible for the remainder of the charges. This program only applies to elective surgery. It does not apply to emergencies. Elective surgery can be scheduled at the Member's convenience without jeopardizing the Member's life or causing serious impairment to the Member's bodily functions. If your Physician recommends surgery for you or a Dependent for one of the following surgical procedures, you MUST obtain a second surgical opinion: • Adenoidectomy • Bone surgery of the foot • Coronary by-pass • Gallbladder removal • Hernia repair • Hemorrhoidectomy BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 19 Section 4: Cost Containment Features Custom Plus Plan • Hysterectomy • Knee cartilage surgery • Laminectomy (back surgery) • Prostatectomy or transurethral resection of the prostate • Tonsillectomy You or your representative may appeal our benefit determination by following the procedure outlined in How to Appeal the Action We Have Taken Under This Certificate. Retrospective Claim Review Retrospective review of claims consists of reviewing services after they have been provided to determine that services were provided as prior authorized, to evaluate claim charges, and to evaluate appropriateness of services billed. Medical records may be requested by Blue Cross and Blue Shield of Colorado and reviewed by Blue Cross and Blue Shield of Colorado medical consultants to assist in Payment decisions. 20 ° , Customer Service:(800)331-6170 or(303)831-2900 BCP192M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 5 What We Will Pay For — Benefits This section describes the services and supplies covered by this Membership Certificate, and the benefits allowed on each of them. Benefits are payable only for Covered Services and supplies that are Medically Necessary and meet the eligible-for-coverage criteria under the definition of Experimental/Investigational. Please see these definitions in Section 2: Definitions. All benefit items listed in this Section 5 are subject to the following provisions and Section 4: Cost Containment Features and Section 6: General Limitations and Exclusions. Section 6. of this Certificate explains the services, supplies, situations, or related expenses for which we cannot allow Payment. If you submit a claim for a service or supply not listed on the following pages as either a benefit or an exclusion, we will review your claim to determine whether the service or supply qualifies as a benefit. Hospital Benefits This portion of your coverage Pays for the services and supplies described in this section when they are provided by the following Facility Providers: • Alcoholism Treatment Centers • Home Health Agencies • Hospice Agencies • Hospitals • Other Facilities Benefits for services and supplies provided by Facility Providers are based on the facility's semiprivate room rates and ancillary charges, or appropriate Maximum Benefit Allowance limitations. Medical-Surgical Benefits This portion of your coverage Pays for the Medically Necessary services and supplies described in this section when they are provided by the following Professional Providers: • Physicians • Other Professional Providers Benefits for most services and supplies provided by Professional Providers are Paid according to a Maximum Benefit Allowance. Deductible Requirements Under This Coverage The Deductible is the amount you pay your Physician, Hospital, or Other Professional Provider first in a Member's Benefit Year, before we begin paying your covered medical expenses. BCP]92M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 21 Section 5: What We Will Pay For—Benefits Custom Plus Plan Your Coverage Notice identifies the type of coverage you have, the effective date of your coverage, Deductible and Coinsurance requirements and payment percentages and supplemental coverages to your basic health coverage that may have been purchased. Under a Family Membership, your family Deductible amount may be satisfied in one of the following ways: 1. When one family Member meets one-half of the family Deductible, he/she will be eligible for benefits. The remaining family Members will be eligible for benefits when they collectively satisfy the balance of the family Deductible. 2. When two family Members each meet one-half of the family Deductible, the remaining family Members will also be eligible for benefits. 3. When no one family Member meets one-half of the family Deductible, but the family Members collectively meet the entire family Deductible, then all family Members will be eligible for benefits. Carryover Deductible Credit--If you have not met your required Member's Benefit Year Deductible and your Covered Services during the last three months of the Member's Benefit Year are less than (or equal to) the required Deductible amount, the eligible expenses you incur during the last three-month period will be carried over to your individual Deductible requirement for the new Member's Benefit Year. If the Member's Benefit Year Deductible is exceeded at any time during the year, including the last three months of the Member's Benefit Year, carryover deductible credit will not be given. If you have a Family Membership, carryover deductible credit will be applied to each individual of the family contract as described above. Portability of Deductible—When you change to another Blue Cross and Blue Shield of Colorado health plan, you may be able to apply expenses incurred while under your old coverage to satisfy the Deductible requirement of your new coverage, based on the particular benefit design purchased. For details, please contact our Customer Service office. Payment Allowances Under This Coverage After you meet the required Deductible, we will Pay the following allowances for Covered Services in each Member's Benefit Year: 1. Under an Individual Membership, we will Pay 80 percent of the first $5,000 of eligible charges and 100 percent of any remaining eligible charges. This payment allowance excludes inpatient or outpatient care or supplies received at a Nonparticipating Hospital Provider or Nonparticipating Other Facility Provider in the state of Colorado, unless care or supplies were received as a result of a Medical 22 ,4 ` Customer Service:(800)331-6170 or(303)831-2900 BCPr92M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Emergency. The payment allowance also excludes care or supplies received for mental illness, alcoholism, or drug abuse. 2. Under a Family Membership,we will Pay 80 percent of the first $5,000 of eligible charges for each family Member up to $10,000 per family and 100 percent of'any remaining eligible charges. This payment allowance excludes inpatient or outpatient care or supplies received at a Nonparticipating Hospital Provider or Nonparticipating Other Facility Provider in the state of Colorado, unless care or supplies were received as a result of a Medical Emergency. The payment allowance also excludes care or supplies received for mental illness, alcoholism, or drug abuse. NOTE: No more than $5,000 per individual family Member can be applied toward the $10,000 family maximum. 3. For inpatient care or supplies received from a Nonparticipating Hospital Provider within the State of Colorado, benefits will be the lesser of$500 per day for the room and ancillary charges or the actual charge, and shall be subject to the Deductible and all other provisions of the Certificate. When care is provided for a Medical Emergency, services and supplies will.be Paid according to 1. or 2. above. 4. For inpatient mental illness, or alcoholism, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for up to 45 full days of inpatient care and supplies, or 90 partial days, or any combination of full and partial days equivalent to 45 full days, counting two partial days as one full day. 5. For inpatient drug abuse, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for 30 full days per Member's Benefit Year of inpatient care and supplies, or 60 full days per lifetime. BCP7S2M.CRC Customer Service: (800)331-6170 or(303)831-2900 Sti0325 23 Section 5: What We Will Pay For—Benefits Custom Plus Plan 6. For outpatient care or supplies received from a Nonpartici- pating Hospital Provider or Nonparticipating Other Facility Provider within the State of Colorado, benefits will be 50 percent of the eligible charges and shall be subject to the Deductible and all other provisions of the Certificate. When care is provided for a Medical Emergency, services and supplies will be Paid according to 1. or 2. above. 7. For outpatient mental illness, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum payment of$1,250. 8. For outpatient alcoholism, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum payment of$500. 9. For outpatient drug abuse, benefits will be subject to the Deductible and Paid at 50 percent of eligible charges for outpatient care and supplies, up to a maximum payment of$250. Maximum Lifetime Benefits Under this benefit design, the maximum lifetime payment allowance for all Covered Services is $1,000,000 per Member. Your Payment Responsibilities to Participating and Nonparticipating Providers Participating If you choose a Participating Professional Provider or Participating Facility Provider, we will Pay the Provider directly for services and supplies covered under this Certificate. These Participating Providers agree to accept our Maximum Benefit Allowance as Payment in full for Covered Services. For Covered Services, you pay only the Deductible and Coinsurance amounts, and charges which exceed maximum payment limits. Your Participating Provider may request payment for Deductible and/or Coinsurance amounts at the time services are rendered. Nonparticipating— If you choose a Nonparticipating Provider, we will Pay you directly for Covered Services unless you assign your benefits to the Provider. You will be responsible to the Provider of services for all charges, regardless of our Maximum Benefit Allowance or the amount of our Payment to you or the Provider. For inpatient care or supplies received from a Nonparticipating Hospital Provider within the state of Colorado, benefits will be the lesser of$500 per day for the room and ancillary charges or the actual charge, and shall be subject to the Deductible and all other provisions of the Certificate. For outpatient care or supplies received from a Nonparticipating Hospital Provider or Nonparticipating Other Facility Provider within the state of Colorado, benefits will be 50 percent of the eligible charges, and shall be subject to the Deductible. When care is provided for a Medical Emergency, these payment allowances are not applicable. 24 " Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits • Accidental Injuries Definition Accidental injuries—internal or external injuries caused by a source outside the body, requiring treatment for trauma rather than for illness-related conditions. (Examples: strains, animal bites, burns, contusions, and abrasions.) Additional Accident Benefits Additional Accident Benefits are allowed for Covered Services needed to treat accident-related injuries. This part of your coverage provides benefits before those listed below under Hospital Benefits and Medical- Surgical Benefits. The following guidelines explain your Additional Accident Benefits: 1. The accident must have occurred on or after the Member's Effective Date of Membership. NOTE: This guideline applies regardless of any pre-existing conditions clause or waiver thereof. 2. We allow a maximum of$500 per Member for Covered Services provided within 90 days from the date of the accident. 3. Additional Accident Benefits renew only at the time of a separate accident. 4. No Deductible or Coinsurance will be taken against this $500 Additional Accident Benefits provision. 5. Additional Accident Benefits are not subject to payment limitations based on either the Member's Benefit Year or lifetime benefit maximum. 6. Services included in Additional Accident Benefits are the same as those described below. Hospital Benefits Inpatient: Benefits include the charges for a semiprivate room and covered ancillary services. For a more detailed explanation, please refer to Medical Care for General Conditions and Room Expenses and Ancillary Services. NOTE: If you receive outpatient medical care as the result of an accident and are admitted to the Hospital as an inpatient on the same day, then your outpatient (emergency room) charges will be included in the Hospital bill with the inpatient services you also received. Outpatient: Medical care provided by a Hospital or Other Facility is covered. BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 25 Section 5: What We Will Pay For—Benefits Custom Plus Plan Medical-Surgical Benefits Inpatient: Benefits are allowed according to the guidelines established under Medical Care for General Conditions. Please refer to that section for further information. Outpatient: Medical care provided by a Physician or Other Professional Provider is covered. Please refer to Medical Care for General Conditions for additional information. Limitations and Exclusions Surgical Services—When an accident results in the need for surgery or fracture care, the first $500 of Covered Services will be Paid according to the Additional Accident Benefits guidelines. Further benefits for covered surgical services will be Paid according to the benefits and guidelines established in the Surgery subsection of this Certificate. See General Limitations and Exclusions • Ambulance Services Definition Ambulance— a specially designed and equipped vehicle used only for transporting the sick and injured. It must have customary safety and lifesaving equipment such as first-aid supplies and oxygen equipment. The vehicle must be operated by trained personnel and licensed as an ambulance. Hospital Benefits When the Member cannot be safely transported by any other means, we will cover reasonable charges for the following Hospital ambulance services: 1. Transportation to the closest Hospital with appropriate facilities, or from one Hospital to another for Medically Necessary inpatient care. 2. Transportation to the closest Hospital with appropriate facilities, for Medically Necessary outpatient care for an injury or illness resulting from an accident or a Medical Emergency. 3. When there is no Hospital in the local area that can provide Covered Services, we will cover ambulance transportation (ground or air) to the closest Hospital outside the local area which can provide Medically Necessary Covered Services. We will only Pay benefits when evidence clearly shows that the Hospital to which a patient is transported is the closest one having the appropriate specialized treatment facilities, equipment, or staff Physicians. 26 Customer Service:(800)331-6170 or(303)831-2900 BCPZB2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits After the Deductible and Coinsurance amounts have been applied, benefits for ambulance services will be allowed up to a maximum of: • $350 per trip for ground ambulance. • $2,500 per trip for air ambulance. NOTE: We may adjust these allowances annually without advance notice. Medical-Surgical Benefits We allow our Maximum Benefit Allowance for Medically Necessary ambulance services, Paid according to the limits shown above, under Hospital Benefits. Limitations and Exclusions 1. Air Ambulance—Ground ambulance is usually the approved method of transportation. Air ambulance is a benefit only when terrain, distance, or the Member's physical condition require the services of an air ambulance. Our medical consultants determine, on a case-by-case basis, when transport by ambulance is a benefit. If our medical consultants decide that ground ambulance services could have been used, then payment will be limited to ground ambulance benefits (i.e., $350 per trip) to the closest Hospital with appropriate facilities, equipment, and staff. Commercial transport, private aviation, or air taxi services are not covered, regardless of the circumstances or their Federal Aviation Authority Certification. 2. Other Transportation Services— We will not Pay for other transportation services not specifically covered, such as private automobile, commercial or public transportation, or wheelchair ambulance. 3. Patient Safety Requirement— If you could have been transported by automobile, commercial, or public transportation without endangering your health or safety, an ambulance trip will not be covered. We will not Pay for such ambulance services even if other means of transportation were not available. See General Limitations and Exclusions • Anesthesia Services Definition Anesthesia— General anesthesia produces unconsciousness in varying degrees with muscular relaxation and a reduction or absence of pain. Regional or local anesthesia produces similar effects to a limited region of BCP]92M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 27 Section 5: What We Will Pay For—Benefits Custom Plus Plan the body without causing loss of consciousness. Anesthesia is administered by a Physician or certified registered nurse anesthetist (CRNA). Hospital Benefits Inpatient and Outpatient: Anesthesia services are a benefit when administered for covered surgery and provided by a Hospital or Other Facility. Medical-Surgical Benefits Inpatient and Outpatient: Anesthesia services are covered when administered by a Physician or CRNA, if necessary for a covered surgery. Benefit allowances are based on the complexity of the surgical procedure, the amount of time needed to administer the anesthetic, and the patient's physical condition at the time the service is provided. Limitations and Exclusions 1. Acupuncture— See this heading under General Limitations and Exclusions. 2. Hypnosis—See this heading under General Limitations and Exclusions. 3. Local Anesthesia— Our surgical benefit allowances include Payment for local anesthesia because it is considered a routine part of the surgical procedure. Thus, no additional benefits are provided for such incidental anesthesia services. 4. Standby Anesthesia— Standby anesthesia is a benefit when anesthesia services may potentially be required. These benefits depend upon the procedure and the circumstances of the case. 5. Other—The Limitations and Exclusions that apply to Surgery benefits also apply to anesthesia services. Anesthesia services received for a noncovered surgical procedure are not a benefit. See General Limitations and Exclusions • Blood Expenses Definition Blood expenses include the following items: 1. Charges for processing, transporting, handling, and administration. 2. Cost of blood, blood plasma, and blood derivatives. Hospital Benefits 28 Customer Service: (800)331-6170 or(303)831-2900 0CP782M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Inpatient and Outpatient: Covered expenses include charges made by a Hospital or Other Facility for processing, transporting, handling, and administration. We provide benefits as explained under Medical Care For General Conditions. The first three pints of blood. used during an admission are not a benefit. After the first three pints, covered expenses include charges made by a Hospital or Other Facility for the cost of blood, blood plasma, and blood derivatives. We will not Pay for any blood replaced through donor credit. Limitations and Exclusions General—The Limitations and Exclusions that apply to Surgery benefits also apply to blood expenses. If you receive blood for a noncovered surgical procedure, such blood expenses will not be allowed. See General Limitations and Exclusions • Chemotherapy and Radiation Therapy Definition Chemotherapy drug therapy administered as treatment for malignant conditions and diseases of certain body systems. Radiation therapy—X-ray, radon, cobalt, betatron, telocobalt, and radioactive isotope treatment for malignant diseases and other medical conditions. Benefits Chemotherapy and/or radiation therapy provided on an Inpatient or Outpatient basis is covered. Limitations and Exclusions Chemotherapy and Radiation Therapy— Benefits are allowed only for therapeutic services necessary for treatment of malignant diseases and other conditions for which such therapy is standard treatment. See General Limitations and Exclusions • Cleft Palate and Cleft Lip Definition Cleft palate a birth deformity in which the palate (the roof of the mouth) fails to close. Cleft lip— a birth deformity in which the lip fails to close. BCPJ82M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 29 Section 5: What We Will Pay For—Benefits Custom Plus Plan Hospital Benefits Inpatient: We will allow benefits for inpatient care in a Hospital. Benefits include charges for a semiprivate room and covered ancillary services, and are allowed as set forth under Room Expenses and Ancillary Services. Outpatient: We will allow benefits for medical and therapeutic services provided by a Hospital or Other Facility when they are necessary for the treatment of cleft palate and/or cleft lip. Covered Services include: 1. Speech therapy. 2. Otolaryngology treatment. 3. Audiological assessments. Medical-Surgical Benefits Inpatient: We will allow benefits when provided by a Physician or Other Professional Provider for oral and facial surgery and follow-up oral and reconstructive surgery. (See the Surgery subsection.) Outpatient: We will allow benefits when provided by a Physician or Other Professional Provider for the following services: 1. Speech therapy. 2. Otolaryngology treatment. 3. Audiological assessments. 4. Orthodontic treatment. 5. Prosthodontic treatment. 6. Prosthetic treatment such as obturators, speech appliances, and feeding appliances. Limitations and Exclusions 1. Benefit Eligibility—Refer to Section 3: Membership Eligibility, Enrollment, Changes, and Termination under How and When You May Add Dependents for details on newborn coverage. 2. Dental Procedures Benefits for orthodontic, prosthodontic, or prosthetic treatment are allowed when required as the result of cleft palate or cleft lip. We must give written authorization for such dental benefits in advance of the date of service. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. 3. Medically Necessary All benefits for treatment to cleft palate and/or cleft lip are limited to those which are Medically Necessary. (See Section 2., Medically Necessary.) 30 Customer Service: (800)331-6170 or(303)831-2900 SCP782M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 4. Reconstructive Surgery—Benefits for surgical procedures and related expenses are allowed when oral, facial, or reconstructive surgery is required as the result of cleft palate or cleft lip. We must give written authorization for such surgical benefits in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. See General Limitations and Exclusions • Consultations Definition Consultation— a service provided by another Physician at the request of the Physician in charge of your case. The consulting Physician often has specialized skills that are helpful in diagnosing or treating your illness or injury. Medical-Surgical Benefits Inpatient: For each covered Hospital admission for medical or surgical treatment, we will allow benefits for Physician consultations. All four of the following conditions must exist before we can allow benefits for multiple consultations during an inpatient admission. Consultations must be: 1. Required for unrelated conditions; 2. Ordered by your attending Physician; 3. Performed by a Physician with a different specialty than your attending Physician or any of the other consulting Physicians assigned to your case; and 4. Provided while you are confined as a Hospital inpatient. Outpatient: We will allow benefits for outpatient consultations. Limitations and Exclusions 1. Other Services by the Same Physician—We allow benefits for both services when the consulting Physician also performs diagnostic surgery or a surgery not requiring follow-up care. However, when the consulting Physician provides other Medically Necessary services such as anesthesia or assists at a surgery, we allow the larger of the two benefit Payments, but not both. 2. Second Surgical Opinion—The second surgical opinion program is designed to help you decide if surgery is necessary, or if other acceptable treatment methods are available for your condition. BCP7S2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 31 Section 5: What We Will Pay For—Benefits Custom Plus Plan For further details about the second surgical opinion program, please refer to Section 4: Cost Containment Features. 3. Staff Consultations— Consultations that are routinely required by rules and regulations of a Hospital or Other Facility are not covered. 4. Transfers—The transfer of a patient from one Physician to another for treatment is not considered a consultation, and is not covered as a consultation. (See Medical Care for General Conditions and Mental Illness,Alcoholism, or Drug Abuse Care, for benefits that are available when care of a patient is transferred from one Physician to another.) See General Limitations and Exclusions • Dental Services Definition Dental services— services performed for treatment of conditions related to the teeth or structures supporting the teeth. Hospital Benefits Inpatient: Dental services are covered only if you are in a Hospital for one of the following reasons. We base our benefits on the guidelines in the Surgery subsection. 1. Excision of exostosis of the jaw (removal of bony growth). 2. Surgical correction of accidental injuries to the jaws, cheeks, lips, tongue, floor of the mouth, and soft palate (provided the procedure is not done in preparation for dentures or dental prosthesis). 3. Treatment of fractures of facial bones. 4. Incision and drainage of cellulitis (inflammation of soft tissue). 5. Incision of accessory sinuses, salivary glands, or ducts. We will allow benefits for the charges for a semiprivate room and covered ancillary services in a Hospital if you have a hazardous medical condition (such as heart disease, which requires that you have an otherwise noncovered dental procedure performed in the Hospital). Outpatient: We will allow benefits for services included in the five categories listed above under Inpatient benefits, as well as for related services provided by a Hospital or Other Facility. 32 Customer Service:(800)331-6170 or(303)831-2900 9cP782M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Medical-Surgical Benefits Inpatient and Outpatient: We will allow benefits for the five categories of procedures referenced above under Inpatient Hospital Benefits when services are provided by a Physician, dentist, or oral surgeon. Our benefit allowances for surgery include payment for visits to your doctor or dentist prior to the surgery, administration of local anesthesia for surgery, and follow-up medical care. Accidental Injury Benefits—We will allow benefits for accident-related dental expenses not otherwise covered under your Hospital and Medical-Surgical Benefits when you meet all of the following criteria: 1. You are in need of dental services, supplies, and appliances because of an accident in which you sustained other bodily injuries outside the mouth or oral cavity. 2. Treatment must be for injuries to your sound natural teeth. 3. Treatment must be necessary to restore your teeth to the condition they were in immediately before the accident. 4. The first services must be performed within 90 days after your accident. 5. Related services must be performed within one year after your accident. 6. All services must be performed while your coverage is in effect. We will not Pay for restoring the mouth, teeth, or jaws because of injuries from biting or chewing. Limitations and Exclusions 1. Facility Charges— Inpatient and outpatient services at a Facility Provider due to the age of the patient and/or the nature of the dental services are not covered. 2. Hazardous Medical Conditions— If you are admitted to a Hospital for a noncovered dental procedure because you have a hazardous medical condition that makes your Hospital stay Medically Necessary, we will not Pay for the services of the Physician, dentist, or oral surgeon in relation to that noncovered dental procedure even if the Hospital charges are Paid. The Physician treating your hazardous medical condition must submit a written pre-admission certification request explaining why you must receive dental treatment in an inpatient setting. For details, please refer to the paragraph entitled Pre- admission Certification in Section 4: Cost Containment Features. 3. Restorations— Benefits for restorations are limited to those services, supplies, and appliances we determine to be appropriate in restoring BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 33 Section 5: What We Will Pay For—Benefits Custom Plus Plan the mouth, teeth, or jaws to the condition they were in immediately before the accident. We will not allow benefits for restorations, supplies, or appliances which are not covered. Examples of such noncovered items include: duplicate or "spare" dental appliances, personalized restorations, cosmetic replacement of serviceable restorations, and materials (such as precious metal) that are more expensive than necessary to restore damaged teeth. 4. Surgical Preparations for Dentures—Artificial implanted devices and bone grafts for denture wear are not covered. 5. Temporomandibular Joint Surgery or Therapy— See this heading under General Limitations and Exclusions. See General Limitations and Exclusions • Hemodialysis Definition Hemodialysis— the treatment of an acute or chronic kidney ailment during which impurities are removed from the blood with dialysis equipment. Hospital Benefits Inpatient: Hemodialysis is covered if you are an inpatient in a Hospital or Other Facility. We allow benefits as explained in Medical Care for General Conditions. Outpatient: Services are covered if you are treated in a Hospital or Other Facility. Medical-Surgical Benefits Inpatient: Services are covered if you are an inpatient in a Hospital or Other Facility. We allow benefits as explained in Medical Care for General Conditions. 34 Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M.CFO Custom Plus Plan Section 5: What We Will Pay For—Benefits Outpatient: Services are covered for treatment in a Hospital, Other Facility, or in your home. When home care replaces inpatient or outpatient dialysis treatments, we will Pay for rental or purchase of dialysis equipment (whichever is less expensive) for use in your home. See General Limitations and Exclusions • Home Health Care Definition Home health services—the following services provided by a certified Home Health Agency under a plan of care to eligible Members in their place of residence: professional nursing services; certified nurse aide services; medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, speech pathology, and audiology services. Benefits We allow benefits for home health services provided under active Physician and nursing management through a certified Home Health Agency. Registered nurses must coordinate the services on behalf of the Home Health Agency and the patient's Physician. We allow benefits only when we determine that this care is Medically Necessary and will replace an otherwise necessary Hospital inpatient admission. All claims must be accompanied by the Physician's written certification that home health services are Medically Necessary, and a copy of the treatment plan established by the Physician in collaboration with the Home Health Agency. We allow benefits for up to 60 visits by a member of the home health team each calendar year for the following services and supplies when they are prescribed by your attending Physician. NOTE: Services of up to four hours by a member of the home health care team are counted as one visit. If a session lasts longer than four hours, then each four-hour period or part of a four-hour period is treated as one visit. We allow benefits for the following services: 1. Professional nursing services performed by a registered nurse (RN). 2. Physical therapy performed by a registered physical therapist. 3. Occupational therapy performed by a properly accredited registered occupational therapist (OTR) or a certified occupational therapy assistant (COTA). BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 35 Section 5: What We Will Pay For—Benefits Custom Plus Plan 4. Respiratory and inhalation therapy performed by a therapist trained or licensed to provide these services. 5. Speech therapy and audiology given for speech disorders caused by a primary or secondary muscular or structural abnormality. Services must be provided by a properly accredited speech therapist who has received a Clinical Competence Certification or Equivalency Statement from either the American Speech and Hearing Association or the Peer Review Board of the Colorado Speech and Hearing Association. 6. Medical social services ordered by the attending Physician and provided by a qualified medical or psychiatric social worker to assist you or your family in dealing with a specific medical condition. The individual providing such services must possess at least a baccalaureate degree in social work, psychology, or counseling, or the documented equivalent in a combination of education, training, and experience. 7. Certified nurse aide services required and supervised by a registered nurse or a physical, speech, or occupational therapist. 8. Medical supplies furnished to the Member by the Home Health Agency during visits for services. 9. Nutrition counseling by a nutritionist or dietitian. 10. The following additional items and services are eligible expenses under a home health care program. However, some of these expenses may also be covered under benefits otherwise provided by this Certificate: a. Prostheses and orthopedic appliances. b. Rental or purchase of durable medical equipment. c. Expenses for prescription drugs, medicines, or insulin. Limitations and Exclusions 1. Custodial Care— See this heading under General Limitations and Exclusions. 2. Maintenance Care—Benefits are allowed only for a home health care program that we determine is Medically Necessary in place of an inpatient hospitalization. Maintenance care is not a benefit. Maintenance care is provided solely to keep the patient's condition at the level to which it has been restored, when no significant practical improvement can be expected. 3. Noncovered Services—The following list of services are not home health care benefits: a. Blood, blood plasma, or blood derivatives. b. Services provided by a Hospital. c. Services provided by a Physician. 36 4 '., Customer Service:(800)331-6170 or(303)831-2900 BCP]62M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits d. Services related to noncovered conditions and surgeries, as excluded in this Certificate. e. Services or supplies for personal comfort or convenience, including "homemaker" services. f. Services related to well-baby care. g. Food or meal services other than dietary counseling. 4. Prior Authorization—The Physician treating your condition must submit a prior benefit authorization request for any prescribed home health care services. For details, please refer to the heading Prior Benefit Authorization in the Section 4: Cost Containment Features. 5. Psychiatric Social Worker Services The services of a psychiatric social worker which are not related to a home health program prescribed by a Physician may be covered and Paid as Outpatient benefits as described under Mental Illness, Alcoholism, or Drug Abuse Care. 6. Review of Treatment—We reserve the right to review treatment plans at periodic intervals. See General Limitations and Exclusions ■ Hospice Care Definition Hospice care— an alternative way of caring for terminally ill individuals which stresses palliative care as opposed to curative or restorative care. Hospice care focuses upon the patient/family as the unit of care. Supportive services are offered to the family before and after the death of the patient. Hospice care addresses physical, social, psychological, and spiritual needs of the patient and his or her family. Benefits Benefits are allowed for hospice care provided under active Physician and nursing management through a licensed Hospice Agency which is responsible for coordinating all hospice care services, regardless of the location or facility in which such services are furnished. Hospice care is provided in the Member's home or on an inpatient basis in a licensed hospice and/or other licensed health care facility. Benefits are allowed only for a terminally ill Member with a life expectancy of six months or less, who alone or in conjunction with a family member or members, has voluntarily requested admission and been accepted into a hospice program. Hospice services include, but shall not necessarily be limited to: nursing services, Physician services, certified nurse aide services, nursing services delegated to other assistants, homemaker, physical therapy, clergy/counselors, trained volunteers, and social services. All claims must include a Physician's certification of the Member's illness, including a prognosis for life expectancy and a statement that hospice care is Medically Necessary and a copy of the Hospice Agency's treatment plan. 990325 BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 37 Section 5: What We Will Pay For—Benefits Custom Plus Plan Benefit Periods—Unless otherwise specified, the benefit period for hospice care is limited to three months. Benefits may continue at the same rate for up to two additional benefit periods if the Member continues to live beyond the prognosis for life expectancy. Under no circumstances, however, will we provide coverage for more than three benefit periods to any Member. The following services are covered: 1. Hospice day care services provided on a regularly scheduled basis in a day care facility governed by the Hospice Board of Directors to ensure the overall continuum of patient care. 2. Hospice home care services provided in the Member's home to meet the Member's physical requirements and/or to accommodate a Member's maintenance or supportive needs. This benefit is limited to $91 per day for any combination of the following services which are planned, implemented, and evaluated by the interdisciplinary team: a. Intermittent and 24-hour on-call professional nursing services provided by or under the supervision of a registered nurse (RN); b. Intermittent and 24-hour on-call social/counseling services; c. Certified nurse aide services under the supervision of a registered nurse or nursing services delegated to other persons; d. Therapies, including physical, occupational, and speech; e. Nutritional counseling by a nutritionist or dietitian.; f. Medical social services provided by a qualified individual who possesses at least a baccalaureate degree in social work, psychology, or counseling, or the documented equivalent in a combination of education, training, and experience. Such services must be provided at the recommendation of a Physician for the purpose of assisting the Member or family in dealing with a specified medical condition, and family counseling related to the Member's terminal condition; g. Inpatient respite care which provides temporary relief for the Member's family from the daily demands of care for the Member. Inpatient respite care may be provided only on an intermittent, nonroutine, short-term basis. It may be limited to periods of five days or less. The total benefit for these services shall not be less than the $91 per day benefit multiplied by ninety-one (91) days. NOTE: The preponderance of care must be nursing care (at least half) and care must be provided for a period of at least eight hours in one calendar day. Home health aide and homemaker services, or both, may be provided to supplement nursing care. 38 Customer Service: (800)331-6170 or(303)831-2900 BCPIB2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 3. The following benefits are not subject to or included in the dollar limitation specified in paragraph 2., above. a. Short-term inpatient (acute) care or continuous home care which may be required during a period of crisis, for pain control, or for acute intervention alternatives and chronic symptom management. Benefits are limited to a separate 30-day period for such care, require prior authorization of the interdisciplinary team, and may, except for emergencies, require prior benefit authorization by us. Please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. b. Diagnostic testing; c. Medical supplies, including prescription drugs and biologicals; d. Oxygen and respiratory supplies; e. Prostheses and orthopedic appliances; f. Rental or purchase of durable medical equipment; g. Bereavement support services for the family during the three- month period following the death of the Member, and this benefit is limited to a $1,077 total payment. h. Transportation; i. Physician services; j. Homemaker services provided the Member in the home, which include: • general household activities including the preparation of meals and routine household care; and • teaching, demonstrating, and providing Member and family members with household management techniques that promote self-care, independent living, and good nutrition. Limitations and Exclusions 1. Noncovered Services— The following items and services are not covered expenses under this hospice care program. However, some of these expenses may be covered under benefits otherwise provided by this Certificate: a. Blood, blood plasma, or blood derivatives. b. Services provided by a Hospital. c. Services related to noncovered conditions and surgeries, as excluded in this Certificate. d. Services related to well-baby care. 2. Review of Treatment—We reserve the right to review treatment plans at periodic intervals. 3. Prior Benefit Authorization—We must give written authorization for hospice care benefits in advance of the date of service. See Prior Benefit Authorization in Section 4: Cost Containment Features. See General Limitations and Exclusions BCP782M CRC Customer Service:(800)331-6170 or(303)831-2900 990325 39 Section 5: What We Will Pay For—Benefits Custom Plus Plan • Laboratory, Pathology, X-ray, and Radiology Services Definition Laboratory and pathology services testing procedures required for the diagnosis or treatment of a condition. Generally, these services involve the analysis of a specimen of tissue or other material which has been removed from the body. Diagnostic medical procedures requiring the use of technical equipment for evaluation of body systems are also considered laboratory services. Examples: electrocardiograms (EKGs) and electroencephalograms (EEGs). X-ray and radiology services--services including the use of radiology, nuclear medicine, and ultrasound equipment to obtain a visual image of internal body organs and structures, and the interpretation of these images; including Mammogram services—the X-ray examination of the breast to detect breast cancer; and Low-dose mammography the X-ray examination of the breast using equipment dedicated specifically to mammography, including but not limited to the X-ray tube, filter, compression device, screens, and film and cassettes, with an average radiation exposure delivery of less than one rad mid-breast, with two views for each breast. Prostate screening—provides testing, to identify prostate cancer in the absence of any abnormal symptoms. Hospital Benefits Inpatient: Services are covered when provided by a Hospital or Other Facility. Benefits are allowed as set forth under Medical Care for General Conditions and Mental Illness,Alcoholism, or Drug Abuse Care. Outpatient: Services are covered when provided by a Hospital or Other Facility. Medical-Surgical Benefits Inpatient and Outpatient: Services are covered when provided by a Physician, independent pathology laboratory, or independent radiology laboratory. Limitations and Exclusions 40 •: . Customer Service:(800)331-6170 or(303)831-2900 BCP)82M CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 1. Mammogram Services-- Mammogram benefits are not subject to the Deductible or Coinsurance requirements of the Certificate. We will allow up to a $75 maximum benefit for outpatient screening by low-dose mammography for the presence of breast cancer in adult women, according to the following guidelines: - A single baseline mammogram for women 35 years of age and under 40 years of age. - One mammogram every two calendar years for women 40 years of age and under 50 years of age; or once each calendar year for women with risk factors to breast cancer, as determined by your attending Physician. - One mammogram each calendar year for women between 50 to 65 years of age. NOTE: We may adjust this $75 allowance annually without advance notice. 2. Mental Illness, Alcoholism, or Drug Abuse— Outpatient laboratory and X-ray services for the diagnosis or treatment of these conditions are subject to the outpatient benefit limits described in Mental Illness, Alcoholism, or Drug Abuse Care. 3. Noncovered Services—If a service is not covered or is not a benefit, we will not Pay for laboratory, pathology, X-ray, and radiology services related to the nonbenefit service. 4. Physician Charges—Benefits for laboratory and X-ray services provided by a Physician while you are an inpatient or outpatient in a Hospital or Other Facility are allowed only when our records show that the Physician has one of the following agreements with the facility: a. The Hospital or Other Facility will bill only for technical services such as charges for use of equipment; or b. The Hospital or Other Facility will not submit any charges for laboratory or X-ray services. 5. Prostate Screening— Prostate screening is not subject to the Deductible or Coinsurance requirements of the Certificate. We will allow up to a $65 maximum benefit each Member's Benefit Year for outpatient screening for the early detection of prostate cancer in adult men, according to the following guidelines: a. In persons 50 years of age or older, and in high-risk persons 40 years of age and up to 50 years of age. b. Services must be conducted by a medical professional and screening must include at least two (2) separate tests: (i) A prostate specific antigen ("PSA") blood test; and (ii) A digital rectal examination. NOTE: We may adjust this $65 allowance annually without advance notice. BCP782M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 41 Section 5: What We Will Pay For—Benefits Custom Plus Plan 6. Routine Physicals— See this heading under General Limitations and Exclusions. 7. Weight Loss Programs—We will not pay for laboratory or X-ray services related to weight loss programs. For details, see General Limitations and Exclusions, Obesity and Weight Loss. See General Limitations and Exclusions ■ Maternity and Newborn Care Definition Maternity services— services required by a Member for the diagnosis and care of a pregnancy and for delivery services. Delivery services include: 1. Normal delivery. 2. Caesarean section. 3. Spontaneous termination of pregnancy prior to full term. 4. Therapeutic or elective termination of pregnancy prior to full term. 5. Complications of pregnancy and childbirth. Newborn services include: 1. Routine Hospital nursery charges for a newborn well baby. 2. Routine Physician care of a newborn well baby in the Hospital after delivery. Hospital Benefits Inpatient: Benefits include charges for a semiprivate room and covered ancillary services, and are allowed as set forth under Medical Care for General Conditions. Routine Hospital nursery charges are also covered. Outpatient: Covered charges include: 1. Pre-natal medical care. 2. A Hospital or Other Facility's charges for use of labor, delivery, recovery, and nursery rooms. 3. Laboratory and X-ray services related to pre-natal or post-natal care. Medical-Surgical Benefits Inpatient: The following services are covered when billed by a Physician: 1. Delivery services (post-natal medical care is included in the allowance for delivery services). , 42 ; �. , Customer Service:(800)331-6170 or(303)831-2900 BCPZB2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 2. Professional component for interpretation of laboratory and X-ray results. 3. Routine inpatient care of the newborn child and pediatrician standby care at a Caesarean section. (See Limitation No. 5. below.) Outpatient: The following services are covered when billed by a Physician: 1. Pre-natal medical care. 2. Delivery services (post-natal medical care is included in the allowance for delivery services). 3. Laboratory and X-ray services related to pre- or post;natal care. Limitations and Exclusions 1. Artificial Conception— See this heading under General Limitations and Exclusions. 2. Continuous Coverage--Maternity benefits are available only when continuous coverage is maintained throughout the period of care. 3. Genetic Counseling— See this heading under General Limitations and Exclusions. 4. Inpatient Hospital Benefits A separate inpatient Hospital benefit will be allowed for the newborn child only when the child is transferred from one Facility Provider to another, or effective the date the mother is discharged from the Facility Provider and the child remains as an inpatient. 5. Newborn Child Benefits-- Please refer to Section 3: Membership Eligibility, Enrollment, Changes, and Termination under How and When You May Add Dependents for details on newborn coverage. See General Limitations and Exclusions ■ Medical Care for General Conditions Definition Inpatient medical care— nonsurgical services provided by a Physician to a patient occupying a Hospital bed. Outpatient medical care— nonsurgical services provided in the Physician's office, the outpatient department of a Hospital or Other Facility, or your home. BCP)92M.CRC Customer Service:(800)331-6170 or(303)831-2900 990.3, 5 43 Section 5: What We Will Pay For—Benefits Custom Plus Plan General conditions—conditions not related to mental illness, alcoholism, or drug abuse. Hospital Benefits Inpatient: We will allow benefits for inpatient care in a Hospital. Benefits include charges for a semiprivate room and covered ancillary services, and are allowed as set forth under Room Expenses and Ancillary Services. Outpatient: We will allow benefits for medical care provided by a Hospital or Other Facility when it is necessary for the treatment of an illness, disease, or injury. Medical-Surgical Benefits Inpatient: We will allow benefits for inpatient care provided by a Physician in a Hospital for: 1. A condition requiring only medical care; or 2. A condition that, during an admission for surgery, requires medical care not normally related to the surgery performed. We will allow inpatient benefits for one attending Physician per covered hospitalization. (See Consultation benefits for a description of the benefits available for a consulting Physician.) Outpatient: We will allow benefits for medical care provided by a Physician when necessary for the treatment of an illness, disease, or injury. Limitations and Exclusions 1. Biofeedback— We will not pay for biofeedback or related services. 2. Birth Control Devices— See this heading under General Limitations and Exclusions. 3. Convalescent Care— See this heading under General Limitations and Exclusions. 4. Custodial Care— See this heading under General Limitations and Exclusions. 5. Diagnostic Admissions— See this heading under General Limitations and Exclusions. 6. Discharge Day Expense-- See this heading under General Limitations and Exclusions. 7. Domiciliary Care— See this heading under General Limitations and Exclusions. 44 Customer Service:(800)331-6170 or(303)831-2900 BCP7S2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 8. Isolation Charges See this heading under General Limitations and Exclusions. 9. Private Room Expenses—See this heading under General Limitations and Exclusions. 10. Routine Physicals—See this heading under General Limitations and Exclusions. 11. Temporomandibular Joint Surgery or Therapy— See this heading under General Limitations and Exclusions. 12. Therapeutic or Rehabilitative Admissions— If you are admitted to the Hospital as an inpatient primarily for the purpose of receiving therapeutic or rehabilitative treatment (such as physical, occupational, or oxygen therapy), then charges related to such an admission will not be covered. 13. Therapies—See this heading under General Limitations and Exclusions. 14. Transfers—See this heading under General Limitations and Exclusions. 15. Vision—See this heading under General Limitations and Exclusions. 16. Weight Loss Programs-- Services and supplies related to weight loss are not covered. For details, see General Limitations and Exclusions, Obesity and Weight Loss. See General Limitations and Exclusions ■ Medical Emergencies Definition Medical emergency—The sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. Hospital Benefits Inpatient: Benefits include charges for a semiprivate room and covered ancillary services, and are Paid as set forth under Medical Care for General Conditions. If you receive outpatient emergency services in a Hospital and are admitted as an inpatient on the same day, then outpatient charges will be included in the Hospital's bill for inpatient services. When your inpatient care at a Nonparticipating Hospital Provider in the state of Colorado is no longer considered a Medical Emergency by us, BCPIB2M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 45 Section 5: What We Will Pay For—Benefits Custom Plus Plan benefits for the remainder of your stay will be Paid at $500 per day for the semiprivate room and ancillary charges or the actual charge, whichever is less. Outpatient: Outpatient services are covered as any other outpatient medical care when provided by a Hospital or Other Facility. (See Medical Care for General Conditions.) Medical-Surgical Benefits Inpatient: Inpatient benefits are Paid as set forth under Medical Care for General Conditions. Outpatient: Outpatient services are covered as any other outpatient medical care when provided by a Physician. (See Medical Care for General Conditions.) See General Limitations and Exclusions • Mental Illness, Alcoholism, or Drug Abuse Care Definition Mental illness conditions— are those that have a psychiatric diagnosis or that require specific psychotherapeutic treatment, regardless of the underlying condition (e.g., depression secondary to diabetes or primary depression). Anorexia Nervosa and Bulimia Nervosa, eating disorders, are classified as manifest mental disorders. Alcoholism or drug abuse conditions— are those requiring rehabilitation treatment from alcohol or drug abuse. Inpatient care charges— charges billed by a Physician, Hospital, or Alcoholism Treatment Center for services provided while you are confined as an inpatient in a Hospital or Alcoholism Treatment Center. Partial hospitalization for mental illness or alcoholism is also considered to be inpatient care. Partial hospitalization is no less than three and no more than 12 hours of continuous psychiatric care in a Hospital. Outpatient care charges—charges billed by a Physician, Hospital, Alcoholism Treatment Center, Other Professional Provider, or Other Facility for services provided in the Physician's or Other Professional Provider's office, the outpatient department of a Hospital, Alcoholism Treatment Center, Other Facility, or your home. 46 ? Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Benefits Inpatient mental illness or alcoholism: We will allow benefits for a limited number of inpatient days and/or partial hospitalization days in each Member's Benefit Year as specified below (subject to the Deductible and Paid at 50 percent of the Maximum Benefit Allowance), for the treatment of mental illness or alcoholism in a Hospital. Treatment of alcoholism may also be in an.Alcoholism Treatment Center. Benefits include charges for a semiprivate room and covered ancillary services. (See Room Expenses and Ancillary Services.) Partial hospitalization benefits only apply when you are receiving therapy in the Hospital for no less than three and no more than 12 hours a day. Benefits for hospitalization are limited to the equivalent of a total of 45 full inpatient days, counting two partial days as one full inpatient day. Benefits for inpatient care delivered by a Physician or Other Professional Provider are limited to 45 days of visits of any length. Inpatient Physician benefits are limited to one attending Physician per covered hospitalization. Inpatient drug abuse: We will allow benefits for a total of 30 full inpatient days in a Member's Benefit Year (subject to the Deductible and Paid at 50 percent of the Maximum Benefit Allowance), for the treatment of drug abuse in a Hospital. Inpatient Physician benefits are limited to one attending Physician per covered hospitalization. Lifetime benefits are limited to 60 days of inpatient care. Outpatient: If you receive outpatient treatment for mental illness, alcoholism, or drug abuse from a Physician, Other Professional Provider, Hospital, Alcoholism Treatment Center, or Other Facility, benefits will be subject to the Deductible and Paid at 50 percent of the Maximum Benefit Allowance for each Member as described below. Maximum payments in each Member's Benefit Year of: • $1,250 for mental illness; • $500 for alcoholism; and • $250 for drug abuse. Limitations and Exclusions 1. Alcoholism Care— We will not Pay for any inpatient or outpatient care if you do not complete the full continuum of care developed for you by the Physician, Hospital, Alcoholism Treatment Center, or Other Facility. Certification that you have completed the full continuum of care must be included with the claim. Admissions solely for detoxification, which do not include rehabilitation, are limited to three per Member each Member's Benefit Year. 2. Alcoholism Treatment Center(Out-of-State) Benefits provided for care in out-of-state Alcoholism Treatment Centers will be limited to BcP792M.CRc Customer Service:(800)331-6170 or(303)831-2900 990325 47 Section 5: What We Will Pay For—Benefits Custom Plus Plan the maximum benefits allowed for in-state Alcoholism Treatment Centers. 3. Biofeedback— See this heading under General Limitations and Exclusions. 4. Custodial Care— See this heading under General Limitations and Exclusions. 5. Diagnosis—Benefits for mental illness are provided only for the diagnoses of manifest mental disorders. These disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, published by the American Psychiatric Association. 6. Diagnostic Services—Laboratory and X-ray services performed on an outpatient basis for the diagnosis and treatment of mental illness, alcoholism, or drug abuse are Paid at 50 percent of covered charges and are included in the outpatient maximum benefit limitations per Member's Benefit Year, as described under Benefits, Outpatient, above. 7. Discharge Day Expense-- See this heading under General Limitations and Exclusions. 8. Domiciliary Care— See this heading under General Limitations and Exclusions. 9. Duration of Care— We will only Pay for services that can be expected to reduce mental illness, alcoholism, or drug abuse in a reasonable period of time as determined by us or our medical consultants. 10. Educational Credits—We will not Pay for psychoanalysis or psychotherapy that you can use as credit toward earning a degree or furthering your education or training, no matter what the diagnosis is or what symptoms may be present. 11. Learning Deficiency and/or Behavioral Problem Therapies See this heading under General Limitations and Exclusions. 12. Private Room Expenses--Under no circumstances will private room benefits be allowed for treatment of mental illness, alcoholism, or drug abuse. See this heading under General Limitations and Exclusions. 13. Professional Services—Mental Illness— Professional services for mental illness must be performed by a Physician, licensed clinical psychologist, or Other Professional Provider who is properly licensed or certified to engage in the independent practice of psychotherapy. Other Professional Providers (except registered nurses or licensed clinical social workers) must be acting under the direct supervision of a Physician or a licensed clinical psychologist. All claims must include evidence of such supervision. All Providers, whether performing services or supervising the services of others, must be acting within the scope of their respective licenses. 48 Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 14. Professional Services in Alcoholism Treatment Center—We will not Pay for the services of an independent Physician or Other Professional Provider if such care is provided in an Alcoholism Treatment Center. Such professional care should be provided by a salaried employee of the Alcoholism Treatment Center. 15. Therapies— See this heading under General Limitations and Exclusions. 16. Transfers— See this heading under General Limitations and Exclusions. See General Limitations and Exclusions ■ Prescription Drugs and Medicines Definition Prescription drugs and medicines— those that require a Physician's written prescription for purchase and are given for the treatment or diagnosis of a covered medical condition. They must be listed in the United States Pharmacopoeia, the National Formulary, or the Homeopathic Pharmacopoeia, and must be evaluated as "effective" in the current edition of the American Medical Association's Drug Evaluations. All drugs and medicines must be approved by the Food and Drug Administration, and must not be identified as Experimental/Investigational. Insulin is also a covered prescription medicine. Hospital Benefits Inpatient: We allow benefits when billed by a Hospital or Other Facility. Benefits are set forth under Medical Care for General Conditions. Outpatient: We allow benefits for prescription drugs and medicines when purchased from a Hospital at the lesser of contract amount, billed charge, or average wholesale price. Medical-Surgical Benefits We allow benefits for prescription drugs and medicines when purchased from an independent pharmacy, Physician, Other Professional Provider or Other Facility Provider at the lesser of contract amount, billed charge, or average wholesale price. Home intravenous (I.V.) therapy is also a benefit. 990325 HCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 49 Section 5: What We Will Pay For—Benefits Custom Plus Plan Limitations and Exclusions 1. Birth Control— See this heading under General Limitations and Exclusions. 2. Growth Hormone Therapy— We must give written authorization for such therapy in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. 3. Nonprescription Items—We will not Pay outpatient benefits for drugs or medicines (or the generic equivalent) that can be purchased without a written prescription, even if the Physician has prescribed such over-the-counter medications. 4. Prescription Drugs—Any drug which is used for any other purpose than the purpose for which the Food and Drug Administration has approved is not covered. 5. Reasonable Charges— If the purchase of generic drugs and medicines is appropriate, then we reserve the right to limit benefits to the cost of such generic items. 6. Smoking Cessation— We will not Pay for chewing gum, nicotine patches, or other preparations for smoking cessation. 7. Supply—Benefits will not be allowed for prescription drugs or medicines purchased in greater amounts than the appropriate dosage. Supplies that will not be used until the next Member's Benefit Year are not covered. See General Limitations and Exclusions ■ Preventive Child Care Services Definition Preventive Care services provided by a Physician for the prevention of disease. This includes well-child visits for the purpose of monitoring health. Well-child visit— a visit that includes the following components: age- appropriate physical exam (but not a complete physical exam unless this is age-appropriate), history, anticipatory guidance, and education (e.g., examine family functioning and dynamics, injury prevention counseling, discuss dietary issues, review age-appropriate behaviors, etc.), and growth and development assessment. For older children, this also includes safety and health education counseling. Medical-Surgical Benefits 50 Customer Service: (B00)331-6170 or(303)831-2900 BCP]82M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Outpatient: The following benefits are not subject to a Deductible, but are subject to any Coinsurance provisions as described in the Certificate. Services are covered for age-appropriate routine immunizations and well- child care visits provided during one visit in accordance with the following guidelines: All Children Routine immunizations in accordance with our (through age 12) current guidelines Age 0-12 Months 5 well-child visits 1 PKU (phenylketonuria) Age 13-35 Months 2 well-child visits Age 3-6 3 well-child visits Age 7-12 3 well-child visits Limitations and Exclusions Diagnostic Testing—Any other diagnostic tests related to preventive care provided in addition to the age-appropriate health maintenance visit or well-child visit are not covered. 1. Exams Age-appropriate visits that exceed the recommended limits above, or are provided beyond the course of one visit, and routine exams related to sports, insurance, school, or camp are not covered. 2. Inpatient or Emergency Room Cam— We will not Pay for preventive care services received while you are an inpatient or in the emergency room of a Hospital or Other Facility. 3. Other—The above benefits apply only for those services related to Preventive Child Care Services. Coverage of services provided for the treatment of an illness or an injury is described under other provisions of the Certificate. See General Limitations and Exclusions • Private-Duty Nursing Services Definition Private-duty nursing services— services that require the training, judgment, and technical skills of an actively practicing registered nurse (RN) or licensed practical nurse (LPN). Such services must be prescribed by your attending Physician for the continuous medical treatment of your condition. BCP7S2M CRC Customer Service:(800)331-6170 or(303)831-2900 990325 51 Section 5: What We Will Pay For—Benefits Custom Plus Plan Medical-Surgical Benefits Inpatient: We will allow benefits for private-duty nursing services only when your condition ordinarily requires that you be placed in an intensive or coronary care unit, but the Hospital does not have such facilities. (See Limitation No. 4. below.) Outpatient: We will allow benefits for private-duty nursing services in your home or other outpatient location. (See Limitation No. 4. below.) Limitations and Exclusions Alternative Care—We will not allow benefits for nursing services ordinarily provided by a Hospital staff or its intensive care or coronary care units. 1. Claims Review All claims are subject to review to ensure that private-duty nursing services are absolutely required.. The fact that private-duty nursing services are a benefit under this Certificate does not guarantee that any or all services will be covered. 2. Custodial Care See this heading under General Limitations and Exclusions. 3. Family Members—We will not allow benefits for services provided by a family member, regardless of the circumstances. 4. Maximum Payment Limits— Private-duty nursing benefits are limited to a maximum combined inpatient and outpatient Payment of$2,000 each Member's Benefit Year, up to a maximum lifetime benefit of $5,000. This lifetime payment limit is included in the $1,000,000 lifetime limit for all other benefits. 5. Physician's Certification--All claims for private-duty nursing services must include a Physician's certification that such services are Medically Necessary. The billing must also indicate the nurse's degree and license number. See General Limitations and Exclusions • Rehabilitation Therapies: Occupational, Physical, and Speech Definition Occupational therapy—the use of educational, vocational, and rehabilitative techniques to improve a patient's functional ability to live independently. Physical therapy— the use of physical agents to treat disability resulting from disease or injury. Physical agents used include heat, cold, electrical 52 - ' ' Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits currents, ultrasound, ultraviolet radiation, massage, and therapeutic exercise. Speech therapy(also called speech pathology)— services used for diagnosis and treatment of speech and language disorders. Hospital Benefits Inpatient and Outpatient: When provided by a Hospital or other facility the following types of therapy are covered as set forth under Medical Care for General Conditions: 1. Occupational therapy. 2. Physical therapy. 3. Speech therapy. Medical-Surgical Benefits Outpatient: When prescribed and/or provided by a Physician, the following types of therapy are covered: 1. Occupational therapy when your Physician requires that a properly accredited occupational therapist (OT) or certified occupational therapy assistant (COTA) perform such therapy. 2. Physical therapy performed by a Physician or registered physical therapist. 3. Speech therapy performed by a licensed and accredited speech/ language pathologist, for a condition that is a direct result of a diagnosed neurological, muscular, or structural abnormality affecting the organs of speech. Benefits are limited per illness or injury to a maximum of sixty (60) treatment sessions per Members Benefit Year, for a maximum of three (3) Members Benefit Years. Audio diagnostic testing is covered, and is excluded from the sixty (60) treatment session maximum. Benefits are limited to those recommended by the Physician for medical conditions that, in the judgement of the Physician and Blue Cross and Blue Shield of Colorado will result in significant improvement with treatment and would not normally be expected to improve without intervention. Services require prior benefit authorization, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. Limitations and Exclusions 1. Occupational and Physical Therapy-- We will not Pay for occupational or physical therapy services to maintain function at the level to which it has been restored, or when no further significant practical improvement is achieved. BCP]62M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 53 Section 5: What We Will Pay For—Benefits Custom Plus Plan 2. Speech Therapy— We will not Pay for speech therapy or diagnostic testing related to the following conditions: a. Learning disorders whether or not they accompany mental retardation. b. Stuttering, at any age. c. Behavioral disorders. d. Personality, developmental, behavioral, voice, or rhythm disorders when these conditions are not the direct result of a diagnosed neurological, muscular, or structural abnormality involving the speech organ. e. Long-term therapy (speech therapy is considered long term if the Physician does not believe significant improvement is possible within 60 sessions). f. Deafness. See General Limitations and Exclusions • Room Expenses and Ancillary Services Definition Room expenses— expenses that include the cost of your room, general nursing services, and meal services for yourself. Ancillary services services and supplies (in addition to room services) that Hospitals, Alcoholism Treatment Centers, and Other Facilities bill for and regularly make available for the treatment of the Member's condition. Such services include, but are not limited to: 1. Use of operating room, recovery room, emergency room, treatment rooms, and related equipment. 2. Intensive and coronary care units. 3. Drugs and medicines, biologicals (medicines made from living organisms and their products), and pharmaceuticals. 4. Dressings and supplies, sterile trays, casts, and splints. 5. Diagnostic and therapeutic services. 6. Blood processing and transportation costs, blood handling charges, and administration (the cost of blood, blood plasma, and blood derivatives is not included). 54 - Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Hospital Benefits Inpatient: Semiprivate room charges and ancillary services provided by a Hospital or Alcoholism Treatment Center are covered when you are admitted for a covered condition. Benefits are Paid as set forth under Medical Care for General Conditions and Mental Illness, Alcoholism, or Drug Abuse Care. An inpatient Hospital admission requires the recommendation of a Physician. Outpatient: Ancillary services billed by a Hospital or Other Facility are covered. For additional outpatient Hospital Benefits, see the following sections: 1. Hemodialysis. 2. Laboratory, Pathology, X-ray, and Radiology Services. 3. Rehabilitation Therapies: Occupational, Physical, and Speech. Limitations and Exclusions 1. Diagnostic Admissions--- See this heading under General Limitations and Exclusions. 2. Discharge Day Expense— See this heading under General Limitations and Exclusions. 3. Isolation Charges— See this heading under General Limitations and Exclusions. 4. Mental Illness, Alcoholism, or Drug Abuse Care— For details on how benefits for room expenses and ancillary services related to these special conditions are Paid, see Mental Illness, Alcoholism, or Drug Abuse Care. 5. Personal or Convenience Items— See this heading under General Limitations and Exclusions. 6. Private Room Expenses-- See this heading under General Limitations and Exclusions. See General Limitations and Exclusions • Supplies, Equipment, and Appliances Definition Durable medical equipment— any equipment that can withstand repeated use, is made to serve a medical purpose, is useless to a person who is not ill or injured, and is appropriate for use in the home. BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 55 Section 5: What We Will Pay For—Benefits Custom Plus Plan Medical supplies expendable items (except prescription drugs) required for the treatment of an illness or injury. Prosthesis any device that replaces all or part of a missing body organ or body member. Orthopedic appliance a rigid or semirigid support used to eliminate, restrict, or support motion in a part of the body that is diseased, injured, weak, or deformed. Hospital Benefits Inpatient: We will allow benefits for the following items as set forth under Medical Care for General Conditions: 1. Medical supplies used while you are in the Hospital. 2. Use of durable medical equipment owned by the Hospital while you are hospitalized. Outpatient: Covered expenses include medical supplies used during covered outpatient visits. (See Medical Care for General Conditions.) Medical-Surgical Benefits The following expenses are covered: 1. Durable medical equipment—we will Pay reasonable charges for the rental or purchase of durable medical equipment, whichever is less expensive. However, equipment rental will be allowed up to the purchase price only. When the purchase of durable medical equipment is covered, we will also Pay for repair, maintenance, replacement, and adjustment. 2. Medical supplies, including but not limited to: a. Colostomy bags and other supplies required for their use. b. Catheters. c. Dressings for cancer, diabetic and decubitus ulcers (bed sores), and burns. d. Syringes and needles for administering covered drugs, medicines, or insulin. 3. The following prostheses and orthopedic appliances are covered, as well as their fitting, adjustment, repair, and replacement because of wear or a change in your condition necessitating a new appliance: a. Artificial arms, legs, or eyes. b. Leg braces, including attached shoes. c. Arm and back braces. d. Maxillofacial prostheses. e. Cervical collars. f. Surgical implants. 56 Customer Service: (800)331-6170 or(303)831-2900 BCP1B2M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits 4. Either one set of prescription eyeglasses or one set of contact lenses (whichever is appropriate for your medical needs) is covered when necessary to replace the human lenses absent at birth or lost through intraocular surgery or ocular injury. Further replacement is covered only if your Physician recommends a change in prescription. We will also cover contact lenses when prescribed by your Physician as the only method of treatment available to you for the treatment of Keratoconus. 5. Oxygen we will allow benefits for oxygen and the equipment needed to administer it (one permanent and one portable unit per patient). Limitations and Exclusions 1. Deluxe or Luxury Items-- If the supply, equipment, or appliance you order includes more features or is more expensive than you need for your condition, then we will allow only up to our Maximum Benefit Allowance for the item that would have met your medical needs. (Examples of deluxe or luxury items: motorized equipment when manually operated equipment can be used, wheelchair sidecars, contact lenses when prescription glasses can be used, and "fashion" eyeglass frames or lenses.) We cover deluxe equipment only when additional features are required for effective medical treatment, or to allow you to operate the equipment without assistance. 2. Equipment—Items such as air conditioners, purifiers, humidifiers, exercise equipment, whirlpools, waterbeds, biofeedback equipment, and self-help devices that are not medical in nature are not covered, regardless of the relief they may provide for a medical condition. 3. Hearing Aids— Prescriptions for hearing aids and related services and supplies are not covered. 4. Hospital Beds— We will not Pay for hospital beds (including water beds or other floatation mattresses) prescribed for chronic back pain. 5. Medical Supplies— Items that do not serve a useful medical purpose, or that are used for comfort, convenience, personal hygiene, or first aid are not covered. (Examples: Support hose, bandages, adhesive tape, gauze, and antiseptics.) 6. Orthopedic Devices— Orthopedic shoes are covered only when they are used with an attached leg brace. Orthotics and arch supports are not covered, regardless of the relief they may provide for a medical condition. 7. Physician's Certification — With all supplies, equipment, and appliances, we require a Physician's certification that such items are a J.10� BCP782M.CRC Customer Service: (800)331-6170 or(303)831-2900 1t'/� 57 Section 5: What We Will Pay For—Benefits Custom Plus Plan necessary expense and are medically required for the Member's condition. 8. Reasonable Charges— Benefits for all supplies, equipment, and appliances are limited to charges that are reasonable in relation to your condition and to the average charges billed by most suppliers for comparable items. 9. Replacements— We will not Pay for replacement, upgrade, or improved supplies, equipment, and appliances without documentation of medical necessity. See General Limitations and Exclusions • Surgery Definition Surgery—an operating (cutting) procedure for treatment of disease or injury. Treatments for fractures and dislocations are also considered to be surgeries. Hospital Benefits Inpatient: We will allow benefits for a semiprivate room and covered ancillary services as set forth under Medical Care for General Conditions. Outpatient: Services provided by a Hospital or Other Facility are covered. Medical-Surgical Benefits Inpatient and Outpatient: The benefit allowance for surgery performed by a Physician includes Payment for pre-operative visits, local administration of anesthesia, follow-up care, and recasting. More than one surgery performed by one or more Physicians during the course of only one operative period is called a "multiple surgery." Because allowances for surgery include benefits for pre- and post-surgical care, total benefits for multiple surgeries are reduced so that pre- and post- surgery allowances of the major surgery are not duplicated. Multiple surgery benefits for procedures performed on the same day, under the same anesthesia, which require a significant increase in time and/or skill will be allowed according to our multiple surgery guidelines. For more information, contact our Customer Service department. Incidental procedures are not processed by our multiple surgery guidelines. An incidental procedure is performed during the same operative session as the primary procedure, but requires little or no additional resources on the part of the surgeon. No additional benefits are available for incidental procedures, beyond those allowed for the primary procedure. 58 ' Customer Service:(800)331-6170 or(303)831-2900 BCP782M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits Limitations and Exclusions 1. Ambulatory Surgery—We will not Pay for inpatient Hospital room charges or other charges that would not be incurred if you could have safely had surgery performed in the Physician's office or in the outpatient department of a Hospital or Other Facility. 2. Cochlear Implantation--A device implanted in the ear to facilitate communication for the profoundly hearing impaired. We must give written authorization for such surgery benefits in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. 3. Convalescent Care— See this heading under General Limitations and Exclusions. 4. Cosmetic Surgery—See this heading under General Limitations and Exclusions. 5. Custodial Care— See this heading under General Limitations and Exclusions. 6. Dental Surgery—For a complete description of benefits allowed for dental surgery, see Dental Services. 7. Diagnostic Admissions--- See this heading under General Limitations and Exclusions. 8. Incidental Surgical Procedures—Additional benefits are not allowed for procedures that are routinely performed during the course of the main surgery. Example: appendectomy during a hysterectomy. 9. Isolation Charges See this heading under General Limitations and Exclusions. 10. Obesity and Weight Loss—We will Pay for surgery required as the result of obesity only when we give prior benefit authorization. For details, please see this heading under General Limitations and Exclusions. 11. Organ Transplants See this heading under General Limitations and Exclusions. 12. Orthognathic(Jaw) Surgery—The only circumstance under which benefits will be allowed for upper or lower jaw augmentation or reduction procedures is when restoration is required as the result of an accidental injury which occurred after the Member's Original Membership Effective Date. NOTE: This limitation applies regardless of any pre-existing conditions clause or waiver thereof. We must give written authorization for such surgery benefits in advance of the date of services. For details, please refer to the BCP7S2M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 59 Section 5: What We Will Pay For—Benefits Custom Plus Plan heading Prior Benefit Authorization in Section 4: Cost Containment Features. 13. Private Room Expenses-- See this heading under General Limitations and Exclusions. 14. Restorative or Reconstructive Surgery— See this heading under General Limitations and Exclusions. 15. Second Surgical Opinion--The second surgical opinion program is designed to help you decide if surgery is necessary, or if other acceptable treatment methods are available for your condition. For details about the second surgical opinion program, please refer to Section 4: Cost Containment Features. 16. Sex-Change Operations-- See this heading under General Limitations and Exclusions. 17. Sterilization Reversals— Reversals of sterilization procedures are not covered. 18. Temporomandibular Joint Surgery or Therapy See this heading under General Limitations and Exclusions. 19. Vision See this heading under General Limitations and Exclusions. See General Limitations and Exclusions IN Surgical Assistants Definition Assistant surgery— required surgical services provided by an assistant to the primary surgeon during a covered surgical procedure. Medical-Surgical Benefits Inpatient and Outpatient: Covered when services are provided by an assistant credentialed by a Hospital to provide such services. This benefit is limited to one assistant and i.s allowed only for those procedures identified by us as requiring an assistant. Limitations and Exclusions 1. Assistant Surgery and Other Services by Same Physician— The following rules apply when the assistant surgeon also bills for other services that are benefits under this Certificate: a. When the assistant surgeon also bills for medical care for the same condition that requires surgery, an allowance will be Paid only for care provided up to the date of surgery. 60 ' Customer Service:(800)331-6170 or(303)831-2900 BCP182M.CRC Custom Plus Plan Section 5: What We Will Pay For—Benefits b. When the assistant surgeon bills for medical care for a condition that is not related to the reason for surgery, both medical care and assistant surgery services are covered. 2. Eligible Procedures—Assistant surgery benefits are available only for surgical procedures of such complexity that they require an assistant, as determined by us. When an assistant is present only because the Hospital or Other Facility requires such services, assistant surgery benefits are not allowed. 3. Hospital Residents, Interns, and Employees—If assistant surgery is performed by a resident, intern, or other salaried employee or person paid by the Hospital, we will not allow Medical-Surgical Benefits for the assistant surgery. 4. Other—The Limitations and Exclusions that apply to Surgery benefits also apply to surgical assistant services. Assistant surgery expenses for noncovered surgical procedures will not be Paid. See General Limitations and Exclusions BCP]82M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 61 Section 6: What We Will Not Pay For- General Limitations and Exclusions Custom Plus Plan 6 What We Will Not Pay For — General Limitations and Exclusions These General Limitations and Exclusions apply to all benefits described in this Certificate. We will not allow benefits for any of the following services, supplies, situations, or related expenses: Acupuncture— Services related to acupuncture, whether for medical or anesthesia purposes. Artificial Conception—Any service, supply, or drug used in conjunction with or for the purpose of an artificially induced pregnancy, such as artificial insemination, "test tube" fertilization, drug-induced ovulation, or other artificial methods of conception. Auto Accident Injuries— Services or supplies resulting from an automobile accident that are covered under applicable No-Fault insurance laws. (See Section 10:Automobile No-Fault Insurance Provisions for further information.) Biofeedback— Services related to biofeedback. Birth Control—Hormones, devices for birth control purposes, their insertion or removal, and related services. Chiropractic Services—Any services or supplies provided or prescribed by a chiropractor are not covered. Convalescent Care—Benefits for care provided during the period of recovery from illness, injury, or surgery are limited to those normally received for a specific condition, as determined by our medical consultants. Benefits for convalescent care are included in the Physician's or surgeon's reimbursement. Cosmetic Surgery Cosmetic surgery is beautification or aesthetic surgery to improve an individual's appearance by surgical alteration of a physical characteristic. Cosmetic surgery for psychiatric or psychological reasons, or to change family characteristics, or conditions due to aging is not covered. Benefits for cosmetic surgery and related expenses are allowed only when such surgery is required as the result of accidental injury. We must give written authorization for such surgery benefits in advance of the date of services. For details, please refer to the paragraph entitled Prior Benefit Authorization in Section 4: Cost Containment Features. • 62 - Customer Service:(800)331-6170 or(303)831-2900 BCP1S2M.CRC Custom Plus Plan Section 6: What We Will Not Pay For—General Limitations and Exclusions Custodial Care— Services to assist the Member in activities of daily living, not requiring the continuous attention of skilled medical or paramedical personnel, are not covered, regardless of where they are furnished, and by whom they were recommended. Diagnostic Admissions—If you are admitted as an inpatient to a Hospital for diagnostic procedures, and could have received these services as an outpatient without endangering your health, then we will not Pay for Hospital room charges or other charges that would not have been incurred if you had received the services as an outpatient. Discharge Day Expense—We do not consider a discharge day as a day in the Facility. Charges from the Facility for the discharge day are not covered. Domiciliary Care— Care provided in a residential institution, treatment center, half-way house, or school because a Member's own home arrangements are not appropriate, and consisting chiefly of room and board, is not covered, even if'therapy is included. Duplicate(Double) Coverage— If you are covered by more than one health coverage membership, then total benefit payments will not be more than 100 percent of total covered expenses. (See Section 12: Duplicate Coverage and Coordination of Benefits for further information.) Durable Medical Equipment— For details, see this heading under Supplies, Equipment, and Appliances, Limitations and Exclusions. Experimental or Investigative Procedures—Any treatment, procedure, drug, or device that has been found by Blue Cross and Blue Shield of Colorado not to meet the eligible-for-coverage criteria, which are listed and defined in Section 2: Definitions under Experimental/Investigational. The determination that a service is not considered eligible for coverage or is Experimental/Investigational can be made by Blue Cross and Blue Shield of Colorado either before or after the service is rendered. We do not cover treatment or procedures which are Experimental/Investigational, or which are not proven to be effective, as determined by our medical director and/or appropriate medical/surgical authorities selected by us. Facility Charges— We do not cover any charge made by a Facility Provider, whether Participating or Nonparticipating, which is not reasonable in comparison with charges billed by similar Facility Providers. Genetic Counseling We do not cover services related to genetic counseling, such as discussion of family history or tests results to determine the sex or physical characteristics of an unborn child. Government Institutions and Facility Services—We do not cover outpatient services and supplies furnished by a military medical facility operated by, for, or at the expense of federal, state, or local governments or BCP782M.CAC Customer Service: (800)331-6170 or(303)831-2900 990325 63 Section 6: What We Will Not Pay For- General Limitations and Exclusions Custom Plus Plan their agencies, unless we authorize payment in writing before the services are performed. Services and supplies furnished by a Veterans Administration facility for a service-connected disability are not covered. Hair Loss— We do not cover drugs, wigs, artificial hairpieces, hair transplants or implants even if there is a Physician prescription, and a medical reason for hair loss. Hypnosis— Services related to hypnosis, whether for medical or anesthesia purposes, are not covered. Intractable Pain— We do not cover services or supplies for the treatment of intractable pain. Intractable pain means a pain state in which the cause of the pain cannot be removed and for which no relief or cure can be found. Isolation Charges—We will only Pay private room expenses under your Hospital Benefits if your medical condition requires that you be isolated to protect you or other patients from exposure to dangerous bacteria or diseases. Conditions that qualify for isolation benefits include severe burns and conditions that require isolation according to public health laws. Learning Deficiency and/or Behavioral Problem Therapies We do not cover special education, counseling, therapy, or care for learning deficiencies or behavioral problems for any reason. Legal Payment Obligations— We do not allow benefits for services for which you have no legal obligation to pay, or charges made only because benefits are available under this Certificate. We will not allow benefits for services for which the Member has received a professional or courtesy discount, or for services provided by the Member upon him/herself, or by a family member. Medically Necessary—You are liable for expenses for services and supplies that are not Medically Necessary (as defined in Section 2: Definitions). Our decision as to whether a service or supply is Medically Necessary is based upon the opinions of our medical or surgical consultants as to what is "approved and generally accepted medical or surgical practice." The fact that a Physician may prescribe, order, recommend, or approve a service does not, of itself, make it Medically Necessary or an allowable expense, even though it is not specifically listed as an exclusion. Claims for services that are not Medically Necessary may be denied either before or after Payment. Noncovered Services—Any services, supplies, or drugs related to noncovered services or complications arising from such noncovered services are not a benefit (such as noncovered artificial conception, cosmetic 64 " Customer Service: (800)331-6170 or(303)831-2900 BCP782M.CRC Custom Plus Plan Section 6: What We Will Not Pay For— General Limitations and Exclusions surgery, sex-change operations, and Experimental/Investigational procedures). Nonparticipating Facility Provider We only cover up to specified limits for charges made by a Nonparticipating Hospital Provider or Other Facility Provider. For inpatient care or supplies received from a Nonparticipating Hospital. Provider within the state of Colorado, benefits will be the lesser of$500 per day for the room and ancillary charges or the actual charge, and shall be subject to the Deductible and all other provisions of the Certificate. For outpatient care or supplies received from a Nonparticipating Hospital Provider or Nonparticipating Other Facility Provider within the state of Colorado, benefits will be 50 percent of the eligible charges, and shall be subject to the Deductible. When care is provided for a Medical Emergency, these payment allowances are not applicable. Obesity and Weight Loss Obesity in itself is not considered an illness or disease, and benefits are not allowed solely for its evaluation and treatment. Benefits will only be allowed for obesity when a surgical procedure is required due to morbid obesity. Morbid obesity is defined as a condition in which persistent and uncontrollable weight gain causes a threat to life because the Member is either: • twice or more the ideal weight, or • 100 pounds or more above the ideal weight, whichever is greater. Ideal weight is determined by accepted standard weight tables for frame, age, height, and sex. Surgery benefits will not be allowed unless written authorization is given by us in advance of the date of surgery, regardless of the medical necessity for the surgery. Benefits will not be authorized unless: 1. The condition of morbid obesity has existed for at least five years; and 2. Nonsurgical methods of accomplishing weight reduction have been tried under Physician supervision for at least three years; and 3. Conditions such as high blood pressure, pulmonary insufficiency (lung disease), arteriosclerosis (hardening of the arteries), diabetes, coronary artery disease, and the like indicate a need for surgery. We must give written authorization for such surgery benefits in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. Surgery benefits will not be provided for subsequent procedures to correct further injury or illness resulting from the Member's noncompliance with prescribed medical treatment. BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 990325 65 Section 6: What We Will Not Pay For- General Limitations and Exclusions Custom Plus Plan Organ Transplants— Only the following transplant procedures will be covered: 1. Corneal (eye) transplant. 2. Kidney (renal) transplant. 3. Bone marrow transplant. (For coverage under this Certificate, we must give written authorization for such bone marrow transplant in advance of the date of service. For details, please see the heading Prior Benefit Authorization in Section, 4: Cost Containment Features.) 4. Peripheral stem cell transplant. (For coverage under this Certificate, we must give written authorization for such peripheral stem cell transplant in advance of the date of service. For details, please see the heading Prior Benefit Authorization in Section 4: Cost Containment Features.) If you are a recipient of an organ transplant and are charged for services furnished to the donor, we will Pay donor charges for transplants covered under this Certificate. No other organ transplant procedures, related services, or drugs are covered under this Certificate. Personal Comfort or Convenience— We do not cover services and supplies used primarily for your personal comfort or convenience that are not related to the treatment of your condition. (Examples: guest trays, beauty or barber shop services. gift shop purchases, long-distance telephone calls, television, admission kits, and personal laundry services.) Post-Termination Benefits— We do not cover hospitalization, services, supplies, or other benefits of this Certificate which are provided to you after your coverage terminates, even if the hospitalization, services, or supplies were made necessary by an accident, illness, or other event which occurred before or while coverage was in effect. The only exception to this provision is found in Section 3: Membership Eligibility, Enrollment, Changes, and Termination. Pre-existing Conditions—A pre-existing condition for Late Applicants is any condition (whether physical or mental) regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period immediately preceding the Member's date of enrollment. Pregnancy is not a pre-existing condition for Late Applicants. We will not Pay for services or supplies related to a pre-existing condition for six consecutive months after the date of enrollment if you enroll as part of a new group with us, and your employer offered no prior health coverage, or you have no prior coverage within 90 days of the new group effective date. 66 •4 Customer Service:(800)331-6170 or(303)831-2900 eca7ezm.cac Custom Plus Plan Section 6: What We Will Not Pay For—General Limitations and Exclusions We will not Pay for services or supplies related to a pre-existing condition for 18 consecutive months after the date of enrollment if you have no prior coverage within 90 days of enrollment, and you waived coverage with us initially, did not enroll within 30 days of eligibility, did not enroll within 30 days of a special enrollment, or were not enrolled with your employer's previous health insurance carrier and you enroll as part of a new group with us. NOTE: New entrants, special entrants, a newly adopted child, newborn child, or children placed for adoption are not subject to the pre-existing condition exclusion if enrolled within 30 days of eligibility. Prior Benefit Authorization-- We must give written authorization for certain services in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. Private Room Expenses—If you have a private room in a Hospital or Alcoholism Treatment Center for any reason other than isolation, covered charges are limited to the semiprivate room rate, whether or not a semiprivate room is available. Under no circumstances will private room benefits be allowed for treatment of mental illness, alcoholism, or drug abuse. Report Preparations— Charges for preparing medical reports, itemized bills, or claim forms. Restorative or Reconstructive Surgery— Restorative or reconstructive surgery restores or improves bodily function to the level experienced before the event which necessitated the surgery or, in the case of a congenital defect, to a level considered normal. Such surgery may have a coincidental cosmetic effect. Benefits for restorative or reconstructive surgery and related expenses are allowed only when such surgery is required as the result of a congenital anomaly, accidental injury, disease process, or its treatment. We must give written authorization for such benefits in advance of the date of services. For details, please refer to the heading Prior Benefit Authorization in Section 4: Cost Containment Features. Routine Physicals— Services related to routine physical or screening exams and immunizations are Paid only as outlined under the Preventive Child Care Services subsection. Self-Inflicted Injuries We will not Pay for services or supplies necessitated by injuries which a Member intentionally inflicted upon him or herself. BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 -1410325 67 Section 6: What We Will Not Pay For- General Limitations and Exclusions Custom Plus Plan Services Not Identified—Any service or supply not specifically identified as a benefit in this Certificate. Sex-Change Operations— Services or supplies related to sex-change operations, reversals of such procedures, or complications of such procedures. Skilled Nursing Facilities Services or supplies provided by Skilled Nursing Facilities, Extended Care Facilities, or similar institutions. Taxes— Sales, service, or other taxes imposed by law that apply to benefits covered under this Certificate. Temporomandibular Joint Surgery or Therapy—Medical or surgical services related to temporoman.dibular joint therapy or surgery, regardless of the reason(s) such services are necessary. Therapies—Therapies and self-help programs not specifically covered under this Certificate include, but are not limited to: 1. Recreational, sex, primal scream, sleep, and Z therapies. 2. Self-help, stress management, smoking cessation, and weight-loss programs. 3. Transactional analysis, encounter groups, and transcendental meditation (TM). 4. Sensitivity or assertiveness training and rolfing. 5. Religious or marital counseling. 6. Holistic medicine and other wellness programs. 7. Educational programs such as diabetic instruction, behavior modification, cardiac class. arthritis class. 8. Myotherapy or massage therapy. Third-Party Liability(Subrogation)— Services or supplies resulting from a condition or injury for which someone else is legally responsible. (See Section 11: Third-Party Liability— Subrogation for further information.) Transfers—The transfer of a patient from one Physician to another for inpatient care of the same condition is covered when the days each Physician is responsible for care are not duplicated. Travel Expenses— Travel expenses for you or your Physician. Vision—We do not Pay for any routine eye examinations, routine refractive examinations, eyeglasses, contact lenses, or prescriptions for such services and supplies. We do not Pay for any surgical, medical, or 68 • Customer Service:(800)331-6170 or(303)831-2900 BCP7S2M.CRC Custom Plus Plan Section 6: What We Will Not Pay For—General Limitations and Exclusions Hospital services and/or supplies rendered in connection with radial keratotomy or any procedure designed to correct farsightedness, nearsightedness, or astigmatism. We will Pay for eyeglasses or contact lenses and the necessary prescriptions as defined in Supplies, Equipment, and Appliances. War— Services or supplies required for disease or injuries resulting from war, civil war, insurrection, rebellion, or revolution. Workers'Compensation— Services or supplies resulting from a work-related illness or injury. (See Section 9: Workers' Compensation for further information.) 990325 BCPJ82M.CRC Customer Service: (800)331-6170 or(303)831-2900 69 Section 7: General Provisions Custom Plus Plan 7 General Provisions Advance Benefit Confirmation If you wish to know what benefits will be Paid before receiving a service or sending a claim to us, we may require you to submit a written request for such information. In some cases, we may require a written statement from your Physician identifying the circumstances of your case and the specific services that will be provided. An advance confirmation of benefits does not guarantee benefits if the actual circumstances of your case differ from those originally described. When submitted, your claims will be reviewed in accordance with the terms of this Certificate or any other coverage which applies on the date of service. Assignment of Benefits All benefits in this Certificate will be Paid directly to Participating Providers. We will Pay Nonparticipating Providers directly when the Member assigns benefits in writing to the Provider. We may require that a copy of the executed assignment of benefits agreement be submitted with the claim. If the Member does not assign the benefits, we will Pay the Member directly. These Payments fulfill our obligation to the Member for these services. Availability of Provider Services We make no guarantee as to the kind of room or the services that will be available at the Hospital, Alcoholism Treatment Center, or Other Facility you choose. Neither do we guarantee that the services of a Participating Facility or Professional Provider will be available. BlueCard Program When you obtain health care services through the BlueCard Program outside the geographic area Blue Cross and Blue Shield of Colorado serves, the amount you pay for covered services is usually calculated on the lower of: • The actual billed charges for the covered services, or • The negotiated price that the on-site Blue Cross and/or Blue Shield Plan passes on to us. Often, this "negotiated price" will consist of a simple discount. But sometimes it is an estimated final price that factors in expected settlements or other nonclaims transactions with your health care provider or with a specific group of providers. The negotiated price may also be a discount from billed charges that reflects average expected savings. The estimated or average price may be prospectively adjusted to correct for over- or underestimation of past prices. 70 . Customer Service:(800)331-6170 or(303)831-2900 BCP)B2M CRC Custom Plus Plan Section 7: General Provisions In addition, laws in a small number of states require Blue Cross and/or Blue Shield Plans to use a basis for calculating your Payment for Covered Services that does not reflect the entire savings realized or expected to be realized on a particular claim.. When you receive covered health care services in those states, your required payment for these services will be calculated using their statutory methods. Catastrophic Events In case of fire, flood, war, civil disturbance, court order, strike, or other cause beyond our control, we may be unable to process your claims on a timely basis. No suit or action in law or equity may be taken against us because of a delay caused by any of these events. Changes to the Certificate We may amend this Certificate when authorized by an officer of Blue Cross and Blue Shield of Colorado. We will give your employer any amendments within 60 days following the effective date of the amendment. No employee of Blue Cross and Blue Shield of Colorado may change this Certificate by giving incomplete or incorrect information, or by contradicting the terms of this Certificate. Any such situation will not prevent us from administering this Certificate in strict accordance with its terms. Contracting Entity The Subscriber hereby expressly acknowledges his/her understanding that the Certificate constitutes a contract solely between the Subscriber and Blue Cross and Blue Shield of Colorado, which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, the Blue Cross and Blue Shield Association permitting Blue Cross and Blue Shield of Colorado to use the Blue Cross and Blue Shield Service Mark in the state of Colorado, and that Blue Cross and Blue Shield of Colorado is not contracting as the agent of the Blue Cross and Blue Shield Association. The Subscriber further acknowledges and agrees that he/she has not entered into the Certificate based upon representations by any person other than Blue Cross and Blue Shield of Colorado and that no person, entity, or organization other than Blue Cross and Blue Shield of Colorado shall be held accountable or liable to the Subscriber for any of Blue Cross and Blue Shield of Colorado's obligations created under the Certificate. This paragraph shall not create any additional obligations whatsoever on the part of Blue Cross and Blue Shield of Colorado other than those obligations created under other provisions of the Certificate. Disclaimer of Liability We have no control over any diagnosis, treatment, care, or other service provided to a Member by any Facility or Professional Provider, and we are BCPJS2M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 71 Section 7: General Provisions Custom Plus Plan not liable for any loss or injury caused by any health care Provider by reason of negligence or otherwise. Disclosure of Your Medical Information Ordinarily, we cannot release your medical information without your written consent. That information is strictly confidential. We may, however, release your medical information without notice or consent when: 1. Requested in connection with utilization summaries or review provided to a third party, such as your employer, if that third party funds all or a part of the cost of your claims. 2. Peer and utilization review boards and our medical consultants need such information to ensure that you are getting appropriate and Medically Necessary care and services that are covered under this Certificate. 3. We receive a judicial or administrative subpoena for such information. 4. The Colorado Division of Insurance requests such information. 5. The information is required for: a. Workers' Compensation proceedings; b. No-Fault auto insurance cases; c. Third-party liability (subrogation) proceedings; and d. Coordination of benefits. We cannot release to you information provided to us by a Provider without the Provider's written consent. Execution of Papers On behalf of yourself and your Dependents you must, upon request, execute and deliver to us any documents and papers necessary to carry out the provisions of this Certificate. Fraudulent Insurance Acts It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts, or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. 72 Customer Service:(800)331-6170 or(303)831-2900 BCP7B2M.CRC Custom Plus Plan Section 7: General Provisions Payment in Error If we make an erroneous benefit Payment, we may require you, the Provider of services, or the ineligible person to refund the amount paid in error. We reserve the right to correct Payments made in error by offsetting the amount Paid in error against new claims. We also reserve the right to take legal action to correct Payments made in error. Payment of Premium by Your Employer If your employer fails to timely submit premium payments to us, your coverage will terminate as of the end of the last paid billing period. If your employer has contracted with us to Pay claims under a special financial arrangement, claims administration may be handled in one of the following ways: 1. Funds for Payment of your claims are held by your employer, and are used to Pay submitted claims. If the claims funds agreed upon by your employer and us are not maintained by your employer, Payments for submitted claims will not be made. 2. Funds for Payment of your claims are paid to us by your employer. If the claims funds agreed upon by your employer and us are not remitted by your employer, Payments for submitted claims will not be made. Claims not Paid because of insufficient claims funds should be submitted for payment to and are the liability of your employer. Pilot Programs We may occasionally develop pilot programs to test different benefits or recognize different Providers. The fact that a pilot program may exist does not guarantee that all Members are eligible for pilot program benefits, or that such benefits will be permanent. Release of Medically-Related Information You must provide us with whatever information is necessary to determine benefits on your claims. We may obtain information from any insurance company, organization, or person when such information is necessary to carry out the provisions of this Certificate. Such information may be exchanged without consent of or notice to the Member. 1. You agree to cooperate at all times (including while you are hospitalized) by allowing us access to your medical records to investigate claims and verify information provided in your application and/or health statement. If you do not cooperate with us, you forfeit your right to benefit Payments on claims subject to investigation and acknowledge our right to cancel your coverage. 2. To help us determine which services and supplies qualify for benefits, you authorize all Providers of health care services or supplies to BCP782M.CRC Customer Service: (800)331-6170 or(303)831-2900 990325 73 Section 7: General Provisions Custom Plus Plan provide us with any medically related information pertaining to your treatment. 3. You waive all provisions of law which otherwise restrict or prohibit Providers of health care services or supplies from disclosing or testifying to such information. Research Fees We reserve the right to charge an administrative fee when extensive research is necessary to reconstruct information that has already been provided to you in explanations of benefits, letters, or other forms. Reserve Funds No Member is entitled to share in any reserve or other funds that may be accumulated or established by us, unless a right to share in such funds is granted by our board of directors. Sending Notices All notices to the Subscriber are considered to be sent to and received by the Subscriber when deposited in the United States mail with postage prepaid and addressed to either: 1. The Subscriber at the latest address appearing on our membership records; or 2. The Subscriber's employer. Subscriber's Legal Expense Obligations You and your Dependents are liable for any actions which may prejudice our rights under this Certificate. If we must take legal action to uphold our rights and prevail in that action, we will be entitled to receive and you will be required to pay our legal expenses, including attorney's fees and court costs. Paragraph Headings The paragraph and section headings used throughout this Certificate are for reference only. They are not to be used by themselves for interpreting the provisions of the Certificate. 74 Customer Service:(800)331-6170 or(303)831-2900 6CP782M CRC Custom Plus Plan Section 8: How To File Claims and Appeals 8 How To File Claims and Appeals This section explains how to file claims to obtain benefits, and what to do if you disagree with the action taken on your claim. How to File Claims 1. When a Participating Facility or a Participating Professional Provider bills us for Covered Services, we will Pay them the appropriate benefit directly. Payment is subject to any applicable Deductible or Coinsurance requirements. If you assign your benefits to a Provider, payment will be Paid to the Provider. NOTE: Blue Cross Plans have a system which processes claims for inpatient Hospital admissions when you receive services in Participating Hospitals outside Colorado. 2. If a Provider does not bill us directly, you must file your own claim, or if you do not assign your benefits to a Provider. To obtain claim forms, contact our Customer Service Center. You must complete the claim form and attach the itemized bill from the Provider. Balance due statements, cash register receipts, and cancelled checks are not acceptable. All information on the claim form and itemized bill must be readable. If information is missing on your claim form or is not readable, it will be returned to you. The information contained on the itemized bills will be used to determine benefits, so it must support information reported on the submitted claim form. The claim form contains detailed instructions on how to complete the form and what information is necessary. Separate Claim Forms Required 1. A separate claim form is required for each Provider for which you are requesting reimbursement. If you assign your benefits to the Provider, we may require that a copy of the executed assignment of benefits agreement be submitted with each claim form. 2. A separate claim form is required for each Member when charges for more than one family Member are being submitted. Where and When to Send Your Claim Make copies of the bills for your own records and attach the original bills to the completed claim form. Submit the bills and the claim form to: Blue Cross and Blue Shield of Colorado 700 Broadway Denver, Colorado 80273 BCP782M CRC Customer Service:(800)331-6170 or(303)831-2900 990325 75 Section 8: How To File Claims and Appeals Custom Plus Plan Your claim must be filed within 365 days after the date of service. Any claims filed after this limit will be refused. Your claim should be processed within 60 days after we receive it. How to Appeal the Action We Have Taken Under This Certificate If you have a complaint concerning the action we have taken based on the utilization review guidelines,you can appeal the decision. Utilization review means our evaluation of the medical necessity or appropriateness of the service. The determination to approve or deny an admission or service is based upon the pre-admission certification guidelines, second surgical opinion guidelines, preauthorization review, or concurrent hospital review. 1. If you disagree with our utilization review decision, you or your designated representative can call our Customer Service office for a reconsideration. Be sure to include any additional information that will help support your reason for appealing the decision. We will give you or your representative a response within one working day if care is for a current or future admission or medical service. Reviews for past admissions or medical services will be done within 21 working days. 2. If you are not satisfied with the outcome of the decision, you or your designated representative can submit a written appeal within 60 days of our notice to you of the decision. Be sure to include any additional information that will help support your reason for appealing the decision. The appeal will be answered within 21 working days after receipt of the request. The appeal will be reviewed by a committee including a Physician and another clinical expert. We will schedule the committee meeting at a time convenient for you or your representative to attend either in person or by telephone. 3. If you are not satisfied with the committee's decision of your first appeal, you or your designated representative can submit a second written appeal within 60 days of our notice to you of the decision. Be sure to include any additional information that will help support your reason for appealing the decision. This appeal will be reviewed by a committee of appropriate medical experts who are not employed by Blue Cross and Blue Shield of Colorado. We will schedule the committee meeting at a time convenient for you or your designated representative to attend either in person or by telephone. This committee will meet within 45 working days of receipt of the appeal. A decision will be provided within five working days of the committee's meeting. We will act upon the committees's decision. 4. We will hold an emergency committee meeting if a response is required immediately because of a medical emergency. 76 Customer Service: (800)331-6170 or(303)831-2900 BCP782M.CRC Custom Plus Plan Section 8: How To File Claims and Appeals If your question or complaint does not involve our utilization review guidelines, follow these steps on how to appeal the action Blue Cross and Blue Shield of Colorado has taken on a claim: 1. Call our Customer Service office for an explanation and a review of your case. 2. If you are not satisfied with the explanation given, send us a written appeal within 60 calendar days of the decision. Be sure to include any additional information that will help support your reason for appealing the decision. Our appeal committee will send a written response to your appeal within 21 working days after receipt of your letter. We will schedule the committee meeting at a time convenient for you or your designated representative to attend either in person or by telephone. If because of a delay beyond our control, we cannot make a decision within 21 working days, we will send you written notice of the delay. 3. If you are not satisfied with the committee's decision, you may submit a second written appeal within 60 days of our notice to you of the decision. This appeal will be reviewed by a committee of appropriate experts who are not employees of Blue Cross and Blue Shield of Colorado. We will schedule the committee meeting at a time convenient for you or your representative to attend either in person or by telephone. The committee will send a written response to your appeal within 45 working days after receipt of your appeal. We will act upon their decision. If, because of a delay beyond our control, a final decision cannot be make within 45 working days, we will send you written notice of the delay. Send all letters of appeal to: Blue Cross and Blue Shield of Colorado Customer Service Appeals 700 Broadway Denver, CO 80273 Legal Action Before you take legal action on a claim decision: 1. You must first follow the appeal process outlined above in How to Appeal the Action We Have Taken Under This Certificate. 2. You must meet all the requirements of this Membership Certificate. 3. No action in law or in equity shall be brought to recover on this Certificate prior to expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this Certificate. No such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished. BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 9903745 77 Section 9: Workers'Compensation Custom Plus Plan 9 Workers' Compensation This section explains how benefits may be Paid on claims for services resulting from a work-related illness or injury. 1. Services and supplies resulting from work-related illness or injury are not a benefit under this Certificate. This exclusion from coverage applies to expenses resulting from occupational accidents or sickness covered under: a. Occupational disease laws. b. Employer's liability. c. Municipal, state, or federal law. d. Workers' Compensation Act. In order to recover benefits for a work-related illness or injury, you must pursue your rights under the Workers' Compensation Act or any of the above provisions which may apply to your situation. This includes filing an appeal with the Industrial Commission. Conditional claims may be Paid by us during the appeal process if you sign a reimbursement agreement to reimburse us for 100 percent of benefits Paid for you. 2. We will not Pay benefits for services and supplies resulting from a work-related illness or injury even if other benefits are not paid because: a. You fail to file a claim within the filing period allowed by the applicable law. b. You obtain care which is not authorized by Workers' Compensation insurance. c. Your employer fails to carry the required Workers' Compensation insurance. In this case, your employer becomes liable for any employee's work-related illness or injury expenses. d. You fail to comply with any other provisions of the law. 78 -. " Customer Service:(800)331-6170 or(303)831-2900 BCPIB2M.CRC Custom Plus Plan Section 10:Automobile No-Fault Insurance Provisions 10 Automobile No-Fault Insurance Provisions This section explains how we will coordinate the benefits of this Certificate with the benefits of an automobile No-Fault insurance policy. A complying policy is an insurance policy approved by the Colorado Division of Insurance that provides at least the minimum coverage required by law, and one which is subject to the Colorado Auto Accident Reparations Act (No-Fault). Any state or federal law providing similar benefits through legislation or No-Fault statute is also considered a complying policy. How We Coordinate Benefits With Complying Policies 1. Your benefits under this Certificate will be coordinated with the minimum coverages required under the Colorado Auto Accident Reparations Act (No-Fault), 10-4-701 through 10-4-723, Colorado Revised Statutes 1973, as amended. 2. If a complying policy provides coverages in excess of the minimums required by state law, then we will coordinate benefits with those coverages in effect. What We Will Pay 1. We will Pay up to the complying policy's deductible amount for those services which are covered under this Certificate. 2. After we Pay up to the complying policy's deductible amount, the complying policy is primary and is responsible for all benefits payable under the No-Fault statute. If there is more than one complying policy, each will have to pay its maximum No-Fault statutory coverages before we will become liable for any further Payments. 3. If there is a complying policy in effect, and you waive or fail to assert your rights to such benefits, we will not Pay benefits which could be available under a complying policy. 4. We may require proof that the complying policy has paid all benefits required by law prior to making any Payments to you. Upon Payment, we will be entitled to exercise our rights under this Certificate and under the No-Fault law. You must fully cooperate with us to make sure that the complying policy has paid all required benefits. We may require you to take a physical examination in disputed cases. What Happens if You Do Not Have a Complying Policy We will not Pay benefits to the extent of minimum benefits required by the No-Fault law for injuries received by the Member, while he/she is riding in BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 99U325 79 Section 10:Automobile No-Fault Insurance Provisions Custom Plus Plan or operating a motor vehicle which he or she owns if it is not covered by an automobile No-Fault complying policy as required by law. However, we will Pay benefits under the terms of the Certificate for injuries sustained by a Member who is a nonowner operator, passenger, or pedestrian involved in a motor vehicle accident if that Member is not covered by a complying policy. In that event, we may exercise our rights under Section 11: Third-Party Liability — Subrogation. This Auto No-Fault Act shall apply only where allowed under state law. 80 Customer Service: (800)331-6170 or(303)831-2900 9CP7B2M.CRC Custom Plus Plan Section 11: Third-Party Liability—Subrogation 11 Third-Party Liability — Subrogation Third-party liability exists when someone else is legally responsible for your condition or injury. We will not Pay for any services or supplies under this Certificate for which a third party is liable. We may, however, provide benefits under these conditions: • When it is established that a third-party liability does not exist; or • When you guarantee in writing to reimburse us if the third party later settles with you for any amount, or if you recover any damages in court. Our Rights When Third-Party Liability Exists When a third party is or may be liable for the costs of any covered expenses payable to you or on your behalf under this Certificate, we have subrogation rights. This means that we have the right, either as co-plaintiffs or by direct suit, to enforce your claim against a third party for the benefits paid to you or on your behalf. When you fail to cooperate in satisfying our subrogation interest, and we must file a lawsuit against you or the third party in order to enforce our rights under this provision, you or any Dependent receiving benefits under this Certificate shall be responsible for attorneys' fees and costs incurred by us. Your Obligations When Third-Party Liability Exists If a third party is or may be liable for the costs of any expenses payable to you or on your behalf under this Certificate, then you must do the following: 1. Promptly notify us of your claim against the third party. 2. You and your attorney must provide for the amount of benefits Paid by us in any settlement with the third party or the third party's insurance carrier. 3. If you receive money for the claim by suit, settlement, or otherwise, you must fully reimburse us for the amount of benefits provided you under this Certificate. You may not exclude recovery for our health care benefits from any type of damages or settlement recovered by you. 4. Cooperate in every way necessary to help us enforce our subrogation rights. 5. You may not take any action that might prejudice our subrogation rights. BCP792M.CRC Customer Service: (800)331-6170 or(303)831-2900 y903Z5 81 Section 11: Third-Party Liability—Subrogation Custom Plus Plan NOTE: Failure to comply with your obligations under this section may result in termination of your Blue Cross and Blue Shield of Colorado membership. 82 Customer Service:(800)331-6170 or(303)831-2900 BCP782M CRC Custom Plus Plan Section 12: Duplicate Coverage and Coordination of Benefits 12 Duplicate Coverage and Coordination of Benefits This section explains how we coordinate benefits when you have coverage with more than one group or group-type health insurance or health benefits plan. Duplicate (Double) Coverage Duplicate (double) coverage under this Certificate and under any other group or group-type health insurance or health benefits plan or blanket coverage. The total benefits received by you, or on your behalf, from all plans combined for any claim for Covered Services will not exceed 100 percent of the total covered charges. A group or Subscriber has one month to notify us that duplicate coverage is not desired. If notification is not received within this one-month period, no retroactive refund in premium payments will be granted. Definitions For this section the following terms are used: 1. Plan refers to any of these that provides benefits or services for, or because of, medical or dental care or treatment: a. Group insurance or group-type coverage, including coverage provided by group practice, pre-payment, individual practice coverage, or self-funded plans and group health maintenance organization coverage. "Plan" also includes coverage provided by exclusive or preferred provider organizations, but excludes school accident-type coverage. b. Coverage under labor management trusteed plans, union welfare plans, and employer organization plans. c. Coverage under a governmental program required or provided by law, except Medicaid. We consider each policy, contract, or other arrangement for benefits a separate "plan." That part of any such contract or agreement which reserves the right to take the benefits or services of other plans into consideration in determining its own benefits is also considered to be a separate "plan." 2. Primary Plan refers to the plan which has first responsibility (liability) for a claim. The primary plan must pay up to its full liability. 3. Secondary Plan refers to the plan (or plans) which has second responsibility (liability) for a claim. yy03'e5 BCP7B2M.CRC Customer Service:(800)331-6170 or(303)831-2900 83 Section 12: Duplicate Coverage and Coordination of Benefits Custom Plus Plan Conditions of Coordination of Benefits The provisions of this section establish the primary and secondary plans. When we are the primary plan, we Pay benefits under the terms of this Certificate. When we are the secondary plan, we Pay only the difference between benefits that would be payable by the primary plan and the amount that would be payable under this Certificate in the absence of a coordination of benefits provision, so long as that difference is not more than we would normally Pay. Effect on Benefits You have an obligation to provide us with current and accurate information regarding the existence of other coverage. Benefits payable under another plan include benefits that would be payable under that plan whether or not a claim is made and include benefits that would have been paid but were refused because the claim was not sent to the plan on a timely basis. Your benefits under this Certificate will be reduced by the amount that such benefits would duplicate benefits payable under the Primary Plan. How We Determine Which Plan is Primary and Which is Secondary We will determine the primary plan and secondary plan according to the following rules. These rules are considered and applied in sequence. When any rule establishes one plan as primary and one as secondary, the subsequent rules do not apply. 1. A plan is primary if it does not have order of benefit determination rules or it has rules which differ from those permitted by Colorado law. 2. A plan is primary if the Member claiming benefits is the person in whose name the policy is issued but is not a Dependent under that coverage. 3. If both plans cover the Member as a Dependent, the benefits of the plan of the parent whose birthday occurs earlier in the year are primary before those of the plan of the parent whose birthday falls later in that year. However, if both parents have the same birthday (month and day, not year), then the benefits of the plan that has covered the parent and Dependent(s) longest is primary over the plan which has covered the other parent and Dependent(s) for a shorter period of time. a. When parents are separated or divorced, the primary plan is that of the parent who has been ordered by a court decree to provide medical, dental, or other health care coverage for the child. You must provide us with a copy of such a court decree upon our request. 84 ._ Customer Service:(800)331-6170 or(303)831-2900 0CP782M.CRC Custom Plus Plan Section 12: Duplicate Coverage and Coordination of Benefits b. When the parents are separated or divorced, and the parent with custody of the child has not remarried, the custodial parent's plan is primary. The plan of the parent without custody is secondary. c. When the parents are divorced and the parent with custody has remarried, the custodial parent's plan is primary. The stepparent's plan is secondary, and the plan of the parent without custody pays after the stepparent's plan. 4. The benefits of a plan which covers a person as an employee who is neither laid-off nor retired (or as that employee's Dependent) are determined before those of a plan which covers that person as a laid-off or retired employee (or as that employee's Dependent). 5. When the above rules do not establish the order of benefit determination, the plan which has covered the Member for the longest period of time is primary. Right to Receive and Release Necessary Information We may release to or obtain from any insurance company or other organization or person any information which we may need to carry out the terms of this section. You will furnish to us such information as may be necessary to carry out the terms of this section. Convenience of Payment When payments that would have been made under this Certificate have already been made under another plan, we reserve the right to pay directly to the other plan any amounts that are necessary to carry out the intent of this section. Any such payments to the other plan will be considered as benefits paid to you or on your behalf for Covered Services under this Certificate. Right of Recovery If we have overpaid for Covered Services under this provision, we shall have the right, by offset or otherwise, to recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were made, at anytime within 18 months from the date of payment. Execution of Papers You must, upon request, execute and deliver those materials and papers that may be necessary to carry out the provisions of this section. 99035 BCP782M.CRC Customer Service:(800)331-6170 or(303)831-2900 85 Hello