asuris direct policy individual group number: 38000001 ... · customer service for all other plans...

Asuris Direct Policy

Individual Group Number: 38000001

2018 Medical Benefits

NONDISCRIMINATION NOTICE

01012017.04PF12LNoticeNDMAAsuris

Asuris complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Asuris does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Asuris: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, and accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages If you need these services listed above, please contact: Medicare Customer Service 1-800-541-8981 (TTY: 711) Customer Service for all other plans 1-888-232-8229 (TTY: 711) If you believe that Asuris has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator below: Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355 (TTY: 711) Fax: 1-888-309-8784 [email protected] Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-232-8229 (TTY: 711) [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Language assistance

01012017.04PF12LNoticeNDMAAsuris

ATENCIÓN: si habla español, tiene a su disposición

servicios gratuitos de asistencia lingüística. Llame al

1-888-232-8229 (TTY: 711).

注意：如果您使用繁體中文，您可以免費獲得語言

援助服務。請致電 1-888-232-8229 (TTY: 711)。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ

trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-

232-8229 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 1-888-

232-8229 (TTY: 711) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad. Tumawag sa 1-888-232-8229 (TTY:

711).

ВНИМАНИЕ: Если вы говорите на русском языке,

то вам доступны бесплатные услуги перевода.

Звоните 1-888-232-8229 (телетайп: 711).

ATTENTION : Si vous parlez français, des services

d'aide linguistique vous sont proposés gratuitement.

Appelez le 1-888-232-8229 (ATS : 711)

注意事項：日本語を話される場合、無料の言語支

援をご利用いただけます。1-888-232-8229

（TTY:711）まで、お電話にてご連絡ください。

ti’go Diné

Bizaad, saad

1-888-232-8229 (TTY: 711.)

FAKATOKANGA’I: Kapau ‘oku ke Lea-

Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai

atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia.

ha’o telefonimai mai ki he fika 1-888-232-8229 (TTY:

711)

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,

usluge jezičke pomoći dostupne su vam besplatno.

Nazovite 1-888-232-8229 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom: 711)

ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-888-232-8229 (TTY: 711)។

ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡ ੇਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-232-8229 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

ACHTUNG: Wenn Sie Deutsch sprechen, stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfügung. Rufnummer: 1-888-232-8229 (TTY: 711)

ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር

ይደውሉ 1-888-232-8229 (መስማት ለተሳናቸው:- 711)፡፡

УВАГА! Якщо ви розмовляєте українською

мовою, ви можете звернутися до безкоштовної

служби мовної підтримки. Телефонуйте за

номером 1-888-232-8229 (телетайп: 711)

ध्यान दिनहुोस्: तपार्इलं ेनेपाली बोल्नहुुन्छ भने तपार्इकंो दनदतत भाषा सहायता सेवाहरू

दनिःशलु्क रूपमा उपलब्ध छ । फोन गनुुहोस ्1-888-232-8229 (दिदिवार्इ:

711

ATENȚIE: Dacă vorbiți limba română, vă stau la

dispoziție servicii de asistență lingvistică, gratuit.

Sunați la 1-888-232-8229 (TTY: 711)

MAANDO: To a waawi [Adamawa], e woodi ballooji-

ma to ekkitaaki wolde caahu. Noddu 1-888-232-8229

(TTY: 711)

โปรดทราบ: ถา้คุณพดูภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-888-232-8229 (TTY: 711)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ.

ໂທຣ 1-888-232-8229 (TTY: 711)

Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa

afaanii tola ni jira. 1-888-232-8229 (TTY: 711) tiin

bilbilaa.

شمای برا گانیرا بصورتی زبان التیتسه د،یکنی مصحبت فارسی زبان به اگر: توجه

.دیریبگ تماس (TTY: 711) 8229-232-888-1 با. باشدی م فراهم

8229-232-888-1ملحوظة: إذا كنت تتحدث فاذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم

TTY: 711)هاتف الصم والبكم )رقم

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SCHEDULE OF BENEFITS

Gold 1000 EPO Individual and Family NetworkThis Schedule of Benefits provides You with information regarding Your costs for Covered Services, the network ofProviders that You can access inside the Service Area and how Provider choice affects Your out-of-pocket costs.This Schedule of Benefits is part of Your Policy. Please read the entire Policy to understand the benefits, limitations,exclusions, and provisions of the plan.

Your costs are subject to all of the following:

● The Allowed Amount. The Allowed Amount is the amount We pay for medical Covered Services. For PediatricVision, the Allowed Amount is the amount Vision Service Plan (VSP) has agreed to pay for Covered Services.

● Coinsurance. This is the amount You pay for Covered Services when Our payment of the Allowed Amount isless than 100 percent.

● Copayments. A Copayment is a fixed dollar amount that You pay directly to a Provider at the time You receive aservice or supply.

● The Deductible. We will begin to pay benefits for Covered Services in any Calendar Year after You satisfyYour Calendar Year Deductible. You satisfy Your Deductible by incurring a specific amount of expense forCovered Services during the Calendar Year for which the Allowed Amounts total the Deductible. For the FamilyDeductible, one family member may not contribute more than the individual Deductible amount.

● The Out-of-Pocket Maximum. This is the most You pay each Year for services from Providers. Once You reachthe Out-of-Pocket Maximum, benefits will be paid at 100 percent of the Allowed Amount for the remainder of theCalendar Year. For the Family Out-of-Pocket Maximum, one family member may not contribute more than theindividual Out-of-Pocket Maximum amount.

Deductible In-Network Out-of-Network

Per Member $1,000 N/APer Family $2,000 N/A

Out-of-Pocket Maximum In-Network Out-of-Network

Per Member $7,350 N/APer Family $14,700 N/A

YOUR PROVIDERS AND OUT-OF-POCKET EXPENSESYour network is: Individual and Family.

Your Service Area is: Adams, Asotin, Benton, Chelan, Douglas, Franklin, Garfield, Grant, Kittitas, Okanogan, andWhitman Counties in the state of Washington.

This plan requires You to see Providers in Your network (In-Network Providers) to receive benefits for CoveredServices. In-Network Providers include Providers in the Individual and Family network located in the service area ofone of Our Affiliates. Services received from Providers outside Your network (Out-of-Network Providers) will not becovered except as specified below.

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● In-Network. When You have services provided by an In-Network Provider, You save the most in Your out-of-pocket expenses. Choosing this Provider option means You will not be billed for balances beyond theDeductible, Copayment and/or Coinsurance for Covered Services.

● Out-of-Network. When You see an Out-of-Network Provider, You are responsible for all expenses, except asotherwise specified below for Ambulance, Blood Bank, Detoxification, Emergency Room services, PediatricDental, and outpatient Dialysis. For these Out-of-Network services, an Out-of-Network Provider may bill You forany balances beyond Our payment level. This is sometimes referred to as balance billing.

In-Network and Out-of Network Benefits for Pediatric Vision

You control Your out-of-pocket expenses for Pediatric Vision services by choosing a VSP Doctor (In-NetworkProvider) or an Out-of-Network Provider.

● VSP Doctor (In-Network Provider). A VSP Doctor has a contract with VSP. When You choose a VSP Doctor,You save the most in Your out-of-pocket expenses. Choosing this Provider option means You will not be billedfor balances beyond the Allowed Amount.

● Out-of-Network Provider. You choose to see an Out-of-Network Provider that does not have a contract withVSP and Your out-of-pocket expenses will generally be higher than a VSP Doctor. Also, choosing this Provideroption means You may be billed for balances beyond the Allowed Amount. This is sometimes referred to asbalance billing. Any amounts You pay for Out-of-Network services in excess of the Allowed Amount do not applytoward the Out-of-Pocket Maximum.

YOUR COSTS OF THE ALLOWED AMOUNT FORSERVICES INSIDE THE SERVICE AREA

BENEFIT IN-NETWORKPROVIDERS

OUT-OF-NETWORKPROVIDERS

Office Visits – Illness or Injury● Copayment is applied to each office call/

home visit billed as such by a Primary CareProvider or Specialist

● Other professional services not billed asan office visit are covered under OtherProfessional Services

$15 Copayment per visit toa Primary Care Provider, notsubject to the Deductible

$50 Copayment per visit to aSpecialist, not subject to theDeductible

Not covered

Outpatient Laboratory and RadiologyServices● Diagnostic services not covered under

Preventive Care and Immunizations orComplex Imaging - Outpatient

After Deductible, 20%Coinsurance

Not covered

Preventive Care and Immunizations● Routine examinations, including well-baby

and well-women's care● FDA-approved contraceptive devices and

implants● Routine immunizations for adults and

children● Counseling for tobacco use cessation● Depression screening for all adults,

including screening for maternal depression● One non-Hospital grade breast pump

including accompanying supplies perpregnancy

● Breast pumps bought from approvedcommercial sellers. For more information

No charge Not covered

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including how to claim benefits fromapproved commercial sellers visit Our Website or contact Customer Service. Contactinformation is available in Your Policy.

Other Professional Services● Three teaching doses of Self-Administrable

Injectable Medications per Lifetime● Teaching doses that are applied toward

Deductible will be applied to the MaximumBenefit limit


Not covered

Acupuncture● 12 visits per Calendar Year (no visit limit

for acupuncture to treat Substance UseDisorder Conditions)

● Services that are applied toward Deductiblewill be applied to the Maximum Benefit limit

$15 Copayment per visit, notsubject to the Deductible.

Not covered

Ambulance Services● Licensed ground and air ambulance

After In-Network Deductible, 20% Coinsurance

Ambulatory Surgical Center● Outpatient services and supplies for Illness

and Injury


Not covered

Blood Bank After In-Network Deductible, 20% Coinsurance

Complex Imaging – Outpatient● CT Scans● PET Scans● Magnetic Resonance Angiograms● Single-Proton Emission Computerized

Tomography (SPECT)● Bone Density Study● MRIs


Not covered

Dental Hospitalization● Inpatient and outpatient services


Not covered

Detoxification● Services for alcoholism and drug abuse as

an Emergency Medical Condition


Diabetic Education● Self-management training and education

No charge Not covered

Dialysis – Inpatient After Deductible, 20%Coinsurance

Not covered

Dialysis – Outpatient● Initial Outpatient Treatment Period of 120

days for hemodialysis, peritoneal dialysisand hemofiltration services regardless ofdiagnosis



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Supplemental Outpatient Treatment Periodfor Dialysis (Following Initial OutpatientTreatment Period)

After Deductible, We pay125% of the Medicareallowed amount at the timeof service.

After Deductible, We pay125% of the Medicareallowed amount at the timeof service. When servicesare rendered by an Out-of-Network Provider andYou are not enrolled inMedicare Part B, You maybe responsible for somebalances, which will notapply to Your Out-of-PocketMaximum.

Durable Medical Equipment● Includes wheelchairs and oxygen

equipment● Comfort and convenience items are not

covered● Certain Durable Medical Equipment bought

from approved commercial sellers. Formore information including how to claimbenefits from approved commercial sellersvisit Our Web site or contact CustomerService. Contact information is available inYour Policy.


Not covered

Emergency Room● Services and supplies required for the

stabilization of a patient experiencing anEmergency Medical Condition


Family Planning● Includes vasectomy and contraceptive

services and supplies not covered underthe Preventive Care and Immunizationsbenefit


Not covered

Genetic Testing● Medically Necessary services only


Not covered

Habilitative Services● 30 inpatient days per Calendar Year● 25 outpatient visits per Calendar Year● Services that are applied toward Deductible

will be applied to the Maximum Benefit limit


Not covered

Home Health Care● 130 visits per Calendar Year● Services that are applied toward Deductible



Not covered

Hospice Care● 14 inpatient or outpatient respite days per

Lifetime


Not covered

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● Services that are applied toward Deductiblewill be applied to the Maximum Benefit limit

Hospital Care – Inpatient and Outpatient After Deductible, 20%Coinsurance

Not covered

Maternity Care● Prenatal and postnatal care● Delivery● Medically Necessary supplies of home birth● Complications of pregnancy● Termination of pregnancy


Not covered

Medical Foods● Including coverage for inborn errors

of metabolism and eosinophilicgastrointestinal associated disorder


Not covered

Mental Health Services After Deductible, 20%Coinsurance

Not covered

Neurodevelopmental Therapy● 25 outpatient visits per Calendar Year● No limit for inpatient days● Services that are applied toward Deductible



Not covered

Newborn Care● Well-baby hospital nursery● Initial physical examination● PKU test


Not covered

Nutritional Counseling● For all conditions including diabetes and

obesity● Nutritional therapy


Not covered

Orthotic Devices● Braces, splints, orthopedic appliances and

orthotic supplies or apparatuses● Does not include off the shelf shoe inserts

and orthopedic shoes


Not covered

Palliative Care● 30 visits per Calendar Year● Services that are applied toward Deductible



Not covered

Pediatric Dental – Preventive andDiagnostic Dental Services● Two sets of bitewing x-rays (four x-rays

total) per Calendar Year● Cephalometric films, once in a two-year

period

No charge

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● Complete intra-oral mouth x-rays, one in athree-year period

● Two visual oral assessments or screeningsper Calendar Year

● Occlusal intraoral x-rays, once in a two-yearperiod

● Two oral hygiene instruction sessions perCalendar Year, if not billed on the same dayas cleaning

● Two periodic and comprehensive oralexaminations per Calendar Year

● One panoramic mouth x-ray in a three-yearperiod

● Two cleanings per Calendar Year● Three topical fluoride applications per

Calendar Year. Additional topical fluorideapplications are covered when determinedDentally Appropriate.

Pediatric Dental – Basic Dental ServicesFillings consisting of composite and amalgamrestorations limits:● Five surfaces per tooth for permanent

posterior teeth, except for upper molars● Six surfaces per tooth for teeth one, two,

three, 14, 15 and 16● Six surfaces per tooth for permanent

anterior teeth● Restorations on the same tooth are limited

to once in a two-year period● Two occlusal restorations for the upper

molars on teeth one, two, three, 14, 15 and16

Periodontal service limits:● Complex periodontal procedures (osseous

surgery including flap entry and closure,mucogingivoplastic surgery), once perquadrant in a five-year period

● Gingivectomy and gingivoplasty, once perquadrant in a three-year period

● Periodontal maintenance, once perquadrant in a Calendar Year

● Scaling and root planing, once per quadrantin a two-year period

20% Coinsurance, not subject to the Deductible

Pediatric Dental – Major Dental ServicesCrowns and crown build-ups limits:● Indirect crowns for permanent anterior

teeth, one per tooth in a five-year period● Stainless steel crowns for primary anterior

and posterior teeth, once in a three-yearperiod

50% Coinsurance, not subject to the Deductible

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● Stainless steel crowns for permanentposterior teeth (excluding teeth one, 16, 17and 32), once in a three-year period

● Repair of crowns, limited to one per toothper Lifetime

● Dental implant crown and abutment relatedprocedures, limited to one per tooth in aseven-year period

Dentures, full and partial limits:● Adjustment and repair of dentures and

bridges, limited to one per arch in a 12-month period

● Denture rebase, limited to one per arch in athree-year period, if performed at least sixmonths from the seating date

● Denture relines, limited to one per arch ina three-year period if performed at least sixmonths from the seating date

● One complete upper and lower denture,and one replacement denture per Lifetimeafter at least five years from the seat date

● One resin-based partial denture, replacedonce within a three-year period

● Home visits, including extended care facilitycalls, limited to two calls per facility perProvider

● Repair of implant supported prosthesisor abutment, limited to one per tooth perLifetime

Pediatric VisionVision care is covered for Insureds underthe age of 19. We cover one routine visionscreening or one comprehensive eye exam,per Calendar Year, including:● Refraction● Dilation as professionally indicated● Prescribing and ordering proper lenses● Assisting in the selection of frames● Verifying the accuracy of the finished lenses● Proper fitting and adjustment of frames● Subsequent adjustments to frames to

maintain comfort and efficiency● Progress or follow-up work as necessary

LensesOne pair of standard lenses in either glass orplastic per Calendar Year, including:● Single vision● Lined bifocal● Lined trifocal● Lenticular

No charge 50% Coinsurance, notsubject to the Deductible

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● Polycarbonate● Scratch coating● UV (ultraviolet) protected lenses● Photochromic lenses; tinted lenses

Contact Lens Evaluation and Fitting ExamOne contact lens evaluation and fitting examper Calendar Year.

ContactsContacts are available once per Calendar Yearinstead of all other lenses and frames.

One of the following elective contact lens typesmay be chosen:● Standard (one pair annually)● Monthly (six-month supply)● Bi-weekly (three-month supply)● Dailies (three-month supply)

When You receive contact lenses, You will notbe eligible for any lenses and/or frames againuntil the next Calendar Year.

Necessary Contact Lenses are covered withoutfrequency limitations if You have a specificcondition for which contact lenses providebetter visual correction.

FramesFrames are available once per Calendar Year.

No charge for frames fromthe Otis & Piper EyewearCollection. All other framesYou pay the full cost of theframe minus any discount.Refer to the AdditionalDiscount provision in YourPolicy.

50% Coinsurance, notsubject to the Deductible

Pediatric Vision - Low Vision BenefitIn addition to the vision benefits describedabove, benefits are provided for special aidif vision loss is sufficient enough to preventreading and performing daily activities.

Supplemental TestingComplete low vision analysis and diagnosisevery two Calendar Years. This includes acomprehensive examination of visual functionswith the prescription of corrective eyewear orvision aids where indicated.

Supplemental AidsProfessional services as well as ophthalmicmaterials, including, but not limited to,evaluations; visual training; low vision

No charge 0% Coinsurance, not subjectto the Deductible. You paybalance of billed charges.

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prescription services; plus optical and non-optical aids every two Calendar Years.

$8 Copayment foreach Preferred GenericMedication on the EssentialFormulary, not subject to theDeductible.

You can receive a $5discount if filled at aPreferred Pharmacy.

Not covered

25% Coinsurance for eachNon-Preferred GenericMedication on the EssentialFormulary, not subject to theDeductible.

You can receive a 5%discount if filled at aPreferred Pharmacy.

Not covered

After In-Network Deductible,25% Coinsurance for eachPreferred Brand-NameMedication on the EssentialFormulary.


Not covered

After In-Network Deductible,50% Coinsurance for eachNon-Preferred Brand-NameMedication on the EssentialFormulary.


Not covered

After In-Network Deductible,40% Coinsurance foreach Preferred SpecialtyMedication on the EssentialFormulary. PreferredSpecialty Medication firstfill allowed at a Pharmacy.Additional fills must beprovided by a SpecialtyPharmacy.

Not covered

Prescription Medications – from aParticipating or Preferred Pharmacy● 90-day supply for Prescription Medications

(even if packaging includes larger supply)● 90-day supply for Self-Administrable

Injectable Medications● 30-day supply for Specialty Medications● Up to a 12-month supply for refills of FDA-

approved contraceptive drugs (may bedispensed on-site at a Provider’s office, ifavailable)

● Copayment and/or Coinsurance is based oneach 30-day supply

● Multi-month Dispensing: largest allowedquantity is the smallest supply as packagedby the drug maker

After In-Network Deductible,50% Coinsurance for eachNon-Preferred Specialty

Not covered

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Medication on the EssentialFormulary. Non-PreferredSpecialty Medication firstfill allowed at a Pharmacy.Additional fills must beprovided by a SpecialtyPharmacy.

$16 Copayment foreach Preferred GenericMedication on the EssentialFormulary, not subject to theDeductible.

Not covered

20% Copayment for eachNon-Preferred GenericMedication on the EssentialFormulary, not subject to theDeductible.

Not covered

After In-Network Deductible,20% Coinsurance for eachPreferred Brand-NameMedication on the EssentialFormulary.

Not covered

Prescription Medications – from a Mail-Order Supplier● 90-day supply for Self-Administrable

Injectable Medications● 90-day supply for Prescription Medications● Up to a 12-month supply for refills of FDA-

approved contraceptive drugs

After In-Network Deductible,45% Coinsurance for eachNon-Preferred Brand-NameMedication on the EssentialFormulary.

Not covered

20% Coinsurance for eachGeneric Medication on theEssential Formulary, notsubject to the Deductible.

Not covered

After In-Network Deductible,20% Coinsurance for eachBrand-Name Medication onthe Essential Formulary.

Not covered

Self-Administrable Cancer ChemotherapyMedications● 30-day supply

After In-Network Deductible,20% Coinsurance for eachSpecialty Medication onthe Essential Formulary.Specialty Medication mustbe provided by a SpecialtyPharmacy.

Not covered

Prosthetic Devices● Functional devices to replace a missing

body part, including artificial limbs,mastectomy bras, external or internal breastprostheses and maxillofacial prostheses


Not covered

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Reconstructive Services and Supplies● To treat a congenital anomaly● To restore a physical bodily function lost as

a result of Illness or Injury● Breast reconstruction following a

mastectomy


Not covered

Rehabilitation Services● 30 inpatient days per Calendar Year● 25 outpatient visits per Calendar Year● Services that are applied toward Deductible



Not covered

Skilled Nursing Facility (SNF) Care● 60 inpatient days per Calendar Year● Services that are applied toward Deductible



Not covered

Spinal Manipulations● Ten spinal manipulations per Calendar Year

$15 Copayment per visit notsubject to the Deductible

Not covered

Substance Use Disorder Services After Deductible, 20%Coinsurance

Not covered

Telehealth $10 Copayment per session,not subject to the Deductible

Not covered

Telemedicine After Deductible, 20%Coinsurance

Not covered

Temporomandibular Joint (TMJ) Disorders After Deductible, 20%Coinsurance

Not covered

Transplants● Transplant-related services and supplies● Donor organ procurement, including

selection, removal, storage, andtransportation


Not covered

Urgent Care Center● Office and Urgent Care Center visits for

treatment of Illness or Injury● Other professional services not billed as an

Urgent Care Center visit are covered underOther Professional Services

$50 Copayment per visit, notsubject to the Deductible

Not covered

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IntroductionAsuris Northwest Health

Street Address:528 E. Spokane Falls Blvd., Suite 301

Spokane,WA 99202

Medical/Dental Claims Address:P.O. Box 30271

Salt Lake City,UT 84130-0271

Vision Claims Address:Vision Service Plan

P.O. Box 385020Birmingham, AL 35238-5020

Medical/Dental Customer Service/Correspondence Address:P.O. Box 1827MS CS B32B

Medford, OR, 97501-9884

Vision Customer Service/Correspondence Address:Vision Service Plan

P.O. Box 997100Sacramento, CA 95899-7100

Medical/Dental Appeals Address:P.O. Box 1408

Lewiston, ID 83501

Vision Appeals Address:Vision Service Plan Insurance CompanyAttention: Complaint and Appeals Unit

P.O. Box 997100Sacramento, CA 95899-7100

POLICYThis Policy is effective December 1, 2018, for the Policyholder and Enrolled Dependents. This Policyprovides the evidence and a description of the terms and benefits of coverage and replaces any othercontract You may have received.

Asuris Northwest Health agrees to provide benefits for Medically Necessary services as described inthis Policy, subject to all of the terms, conditions, exclusions and limitations in this Policy, including theSchedule of Benefits and any endorsements affixed hereto. This agreement is in consideration of thepremium payments hereinafter stipulated and in further consideration of the application and statementscurrently on file with Us and signed by the Policyholder for and on behalf of the Policyholder and/or anyEnrolled Dependents listed in this Policy, which are hereby referred to and made a part of this Policy.

EXAMINATION OF POLICYIf, after examination of this Policy, the Policyholder is not satisfied for any reason with this Policy, theabove named Policyholder will be entitled to return this Policy within 10 days after its delivery date. If thePolicyholder returns this Policy to Us within the stipulated 10-day period, such Policy will be consideredvoid as of the original Effective Date and the Policyholder generally will receive a refund of premiumspaid, if any. (If benefits already paid under this Policy exceed the premiums paid by the Policyholder,

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We will be entitled to retain the premiums paid and the Policyholder will be required to repay Us for theamount of benefits paid in excess of premiums.) We shall pay the Policyholder an additional 10 percent ofthe refund amount if such refund is not made within 30 days of the return of this Policy to Us.

NON-GRANDFATHEREDThis coverage is a "non-grandfathered health plan" under the Patient Protection and Affordable Care Act(PPACA).

NOTICE OF PRIVACY PRACTICESWe have a Notice of Privacy Practices that is available by calling Customer Service or visiting Our Website listed below.

Brady D. CassPresidentAsuris Northwest Health

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Using Your PolicyYOUR PARTNER IN HEALTH CAREWe are pleased that You have chosen Us as Your partner in health care. It's important to have continuedprotection against unexpected health care costs. This plan provides coverage that's comprehensive,affordable and provided by a partner You can trust in times when it matters most. Your vision coverageis provided by Asuris, in collaboration with Vision Service Plan Insurance Company (VSP), whichcoordinates the provision of benefits and claims processing for the Pediatric Vision portion of this plan.

The following sections of this Policy may be useful to You:

● Schedule of Benefits: describes Your costs for Covered Services and provides important detailsregarding the Providers available to You and how using a provider affects Your benefits and out-of-pocket costs.

● Additional Membership Advantages: describes other advantages of membership with Us.● Contact Information: describes how to contact Us by phone or via Our Web site.● Understanding Your Benefits: describes Maximum Benefits, Deductibles, Copayments, and/or

Coinsurance and Out-of-Pocket Maximums.● Medical Benefits: describes in detail what is covered.● Exclusions: describes in detail what is not covered.● Preauthorization: describes Our preauthorization provision.● Policy and Claims Administration: describes preauthorization, how claims are submitted, what You

must do if a third party is responsible for an Illness or Injury, and how benefits are paid when You haveother coverage.

● Appeals and Grievances: describes what to do if You want to file an appeal or a grievance.● Who is Eligible, How to Apply and When Coverage Begins: describes who is eligible to apply and

when.● When Coverage Ends: describes what happens when You are no longer eligible for coverage.● Definitions: describes important terms used in this Policy and Schedule of Benefits. Except for the

Coordination of Benefits section, all defined terms are in the Definitions section.

ADDITIONAL MEMBERSHIP ADVANTAGESMembership advantages include access to discounts on select items and services, personalized healthcare planning information, health-related events and innovative health-decision tools, as well as a teamdedicated to Your personal health care needs. You also have access to asuris.com, an interactiveenvironment that can help You navigate Your way through health care decisions. THESE ADDITIONALVALUABLE SERVICES ARE A COMPLEMENT TO THE INDIVIDUAL POLICY, BUT ARE NOTINSURANCE.

● Go to asuris.com. It is a health power source that can help You lead a healthy lifestyle, becomea well-informed health care shopper and increase the value of Your health care dollar. Have Yourmember card handy to log on. Use the secure Web site to:

- view recent claims, benefits and coverage;- find a contracting Provider;- participate in online wellness programs and use tools to estimate upcoming healthcare costs;- discover discounts on select items and services*;- identify Participating Pharmacies;- find alternatives to expensive medicines;- learn about prescriptions for various Illnesses; and- compare medications based upon performance and cost, as well as discover how to receive

discounts on prescriptions.

*NOTE: If You choose to access these discounts, You may receive savings on an item or service thatis covered by this Policy, that also may create savings for Us. Any such discounts or coupons arecomplements to the individual Policy, but are not insurance.

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CONTACT INFORMATION● Medical/Dental Customer Service: 1 (888) 232-8229 (TTY: 711) if You have questions, would like

to learn more about Your plan, or would like to request written or electronic information regarding anyhealth care plan We offer. Phone lines are open Monday-Friday 6 a.m. to 6 p.m.

● You may also visit Our Web site: asuris.com.● Vision Provider and benefit questions: call Vision Service Plan at 1 (844) 299-3041 (hearing

impaired customers call 1 (800) 428-4833 for assistance), Monday-Friday 5 a.m. - 8 p.m. Saturday 7a.m. - 8 p.m., and Sunday 7 a.m. - 7 p.m. You may also visit VSP's Web site at vsp.com.

● For assistance in a language other than English, please call the Customer Service telephonenumber.

● Health Plan Disclosure Information. You may receive written or electronic copies of the followinghealth plan disclosure information by calling the Customer Service telephone number or access thatinformation through Our Web site at https://www.asuris.com/web/asuris_individual/all-forms.Available disclosure information includes, but is not limited to:

- A listing of covered benefits, including prescription drug benefits;- A copy of the current Formulary;- Exclusions, reductions, and limitations to covered benefits;- Our policies for protecting the confidentiality of Your health information;- Cost of premiums and Insured cost-sharing requirements;- A summary of Adverse Benefit Determinations and the Grievance Processes; and- Lists of In-Network primary care and specialty care Providers.

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Table of ContentsUNDERSTANDING YOUR BENEFITS........................................................................................................ 1

MAXIMUM BENEFITS..............................................................................................................................................1DEDUCTIBLES.........................................................................................................................................................1COPAYMENTS......................................................................................................................................................... 1PERCENTAGE PAID UNDER THIS POLICY (COINSURANCE)............................................................................1OUT-OF-POCKET MAXIMUM................................................................................................................................. 1HOW CALENDAR YEAR BENEFITS RENEW........................................................................................................2

MEDICAL BENEFITS...................................................................................................................................3PREVENTIVE CARE AND IMMUNIZATIONS......................................................................................................... 3OFFICE VISITS – ILLNESS OR INJURY................................................................................................................4OTHER PROFESSIONAL SERVICES.....................................................................................................................4ACUPUNCTURE...................................................................................................................................................... 5AMBULANCE SERVICES........................................................................................................................................ 5AMBULATORY SURGICAL CENTER......................................................................................................................5APPROVED CLINICAL TRIALS.............................................................................................................................. 5BLOOD BANK.......................................................................................................................................................... 5COMPLEX IMAGING – OUTPATIENT.................................................................................................................... 5DENTAL HOSPITALIZATION................................................................................................................................... 5DETOXIFICATION.................................................................................................................................................... 6DIABETES SUPPLIES AND EQUIPMENT..............................................................................................................6DIABETIC EDUCATION........................................................................................................................................... 6DIALYSIS .................................................................................................................................................................6DURABLE MEDICAL EQUIPMENT.........................................................................................................................6EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES).......................................................................6FAMILY PLANNING..................................................................................................................................................6GENETIC TESTING.................................................................................................................................................7HABILITATIVE SERVICES....................................................................................................................................... 7HOME HEALTH CARE............................................................................................................................................ 7HOSPICE CARE...................................................................................................................................................... 7HOSPITAL CARE – INPATIENT AND OUTPATIENT..............................................................................................7MATERNITY CARE.................................................................................................................................................. 7MEDICAL FOODS....................................................................................................................................................8MENTAL HEALTH SERVICES.................................................................................................................................8NEURODEVELOPMENTAL THERAPY................................................................................................................... 8NEWBORN CARE....................................................................................................................................................8NUTRITIONAL COUNSELING.................................................................................................................................8ORTHOTIC DEVICES.............................................................................................................................................. 8PALLIATIVE CARE...................................................................................................................................................9PEDIATRIC DENTAL .............................................................................................................................................. 9PEDIATRIC VISION .............................................................................................................................................. 14PRESCRIPTION MEDICATIONS...........................................................................................................................16PROSTHETIC DEVICES........................................................................................................................................21RECONSTRUCTIVE SERVICES AND SUPPLIES............................................................................................... 21REHABILITATION SERVICES............................................................................................................................... 21SKILLED NURSING FACILITY (SNF) CARE........................................................................................................ 21SPINAL MANIPULATIONS.....................................................................................................................................21SUBSTANCE USE DISORDER SERVICES..........................................................................................................21TELEHEALTH......................................................................................................................................................... 22TELEMEDICINE..................................................................................................................................................... 22TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS......................................................................................... 22TRANSPLANTS......................................................................................................................................................22URGENT CARE CENTER..................................................................................................................................... 23

GENERAL EXCLUSIONS.......................................................................................................................... 24PREEXISTING CONDITIONS................................................................................................................................24SPECIFIC EXCLUSIONS.......................................................................................................................................24

POLICY AND CLAIMS ADMINISTRATION...............................................................................................28

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PREAUTHORIZATION........................................................................................................................................... 28ALTERNATIVE BENEFITS.....................................................................................................................................28MEMBER CARD.....................................................................................................................................................28SUBMISSION OF CLAIMS AND REIMBURSEMENT...........................................................................................28NONASSIGNMENT................................................................................................................................................ 30CLAIMS RECOVERY............................................................................................................................................. 30RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION AND MEDICAL RECORDS..................... 30LIMITATIONS ON LIABILITY................................................................................................................................. 31RIGHT OF REIMBURSEMENT AND SUBROGATION RECOVERY ...................................................................31COORDINATION OF BENEFITS...........................................................................................................................34

APPEAL PROCESS...................................................................................................................................39APPEALS................................................................................................................................................................39VOLUNTARY EXTERNAL APPEAL - IRO............................................................................................................ 40EXPEDITED APPEALS..........................................................................................................................................40INFORMATION....................................................................................................................................................... 41ASSISTANCE......................................................................................................................................................... 41

GRIEVANCE PROCESS............................................................................................................................ 42WHO IS ELIGIBLE, HOW TO APPLY AND WHEN COVERAGE BEGINS..............................................43

WHEN COVERAGE BEGINS................................................................................................................................ 43NEWLY ELIGIBLE DEPENDENTS........................................................................................................................ 44SPECIAL ENROLLMENT.......................................................................................................................................44OPEN ENROLLMENT PERIOD.............................................................................................................................45DOCUMENTATION OF ELIGIBILITY.....................................................................................................................45

WHEN COVERAGE ENDS........................................................................................................................ 46GUARANTEED RENEWABILITY AND POLICY TERMINATION.......................................................................... 46MILITARY SERVICE...............................................................................................................................................46WHAT HAPPENS WHEN YOU ARE NO LONGER ELIGIBLE............................................................................. 46NONPAYMENT OF PREMIUM.............................................................................................................................. 46GRACE PERIOD....................................................................................................................................................47TERMINATION BY YOU........................................................................................................................................ 47WHAT HAPPENS WHEN YOUR ENROLLED DEPENDENTS ARE NO LONGER ELIGIBLE............................. 47OTHER CAUSES OF TERMINATION................................................................................................................... 48MEDICARE SUPPLEMENT................................................................................................................................... 48

GENERAL PROVISIONS........................................................................................................................... 49PREMIUMS.............................................................................................................................................................49CHOICE OF FORUM.............................................................................................................................................49GOVERNING LAW AND BENEFIT ADMINISTRATION........................................................................................49MODIFICATION OF POLICY................................................................................................................................. 49NO WAIVER........................................................................................................................................................... 49NOTICES................................................................................................................................................................ 50REPRESENTATIONS ARE NOT WARRANTIES.................................................................................................. 50WHEN BENEFITS ARE AVAILABLE..................................................................................................................... 50WOMEN'S HEALTH AND CANCER RIGHTS....................................................................................................... 50

DEFINITIONS..............................................................................................................................................51

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Understanding Your BenefitsIn this section, You will discover information to help You understand what We mean by Your MaximumBenefits, Deductibles, Copayments, and/or Coinsurance and Out-of-Pocket Maximum. Other terms aredefined in the Definitions Section at the back of this Policy and are designated by the first letter beingcapitalized.

While this Understanding Your Benefits Section defines these types of cost-sharing elements, You needto refer to the Schedule of Benefits and the Medical Benefits Section to see exactly how they are appliedand to which benefits they apply.

MAXIMUM BENEFITSSome benefits for Covered Services may have a specific Maximum Benefit. For those Covered Services,We will provide benefits until the specified Maximum Benefit (which may be a number of days, visits,services, supplies, dollar amount or specified time period) has been reached. Allowed Amounts forCovered Services provided are also applied toward the Deductible and against any specific MaximumBenefit that is expressed in this Policy. Refer to the Schedule of Benefits and the Medical Benefits Sectionto determine if a Covered Service has a specific Maximum Benefit.

DEDUCTIBLESWe will begin to pay benefits for Covered Services in any Calendar Year only after an Insured satisfiesthe In-Network Calendar Year Deductible. The Calendar Year Deductible amounts are specified on theSchedule of Benefits. The In-Network Family Calendar Year Deductible is satisfied when two or morecovered family members' Allowed Amounts for Covered Services for that Calendar Year total and meetthe Family Deductible amount.

Refer to the Schedule of Benefits to see if a particular service is subject to the Deductible. We do not payfor services applied toward the Deductible. Any amounts You pay for non-Covered Services, Copaymentsor amounts in excess of the Allowed Amount do not count toward the Deductible.

COPAYMENTSA Copayment means a fixed dollar amount that You must pay directly to a Provider for services orsupplies, including medications, at the time the service or supply is furnished. The Copayment will be thelesser of the fixed dollar amount or the Allowed Amount for the service, supply or medication. Refer to theSchedule of Benefits to understand what Copayments You are responsible for.

PERCENTAGE PAID UNDER THIS POLICY (COINSURANCE)Once You have satisfied any applicable Deductible and any applicable Copayment, We pay a percentageof the Allowed Amount for Covered Services You receive, up to any Maximum Benefit. When Ourpayment is less than 100 percent, You pay the remaining percentage (this is Your Coinsurance). YourCoinsurance will be based upon the lesser of the billed charges or the Allowed Amount. The percentageWe pay varies, depending on the kind of service or supply You received and who rendered it. Refer to theSchedule of Benefits to understand what Coinsurance amounts You are responsible for.

We do not reimburse Providers for charges above the Allowed Amount. An In-Network Provider will notcharge You for any balances for Covered Services beyond Your applicable Deductible, Copayment and/or Coinsurance amount. We generally do not cover services provided by Out-of-Network Providers; whenOut-of-Network Providers are eligible to provide Covered Services, however, Out-of-Network Providersmay bill You for any balances over Our payment level in addition to the Deductible, Copayment and/orCoinsurance amount. See the Schedule of Benefits for descriptions of Covered Services and Providers.

OUT-OF-POCKET MAXIMUMInsureds can meet the In-Network Out-of-Pocket Maximum by payments of Deductible, Copaymentand/or Coinsurance as specifically indicated on the Schedule of Benefits for Covered Services.The In-Network Out-of-Pocket Maximum amounts are specified on the Schedule of Benefits. AllEssential Benefits (ambulatory patient services, emergency services, hospitalization, maternity andnewborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and

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habilitative services and devices, laboratory services, preventive and wellness services, chronic diseasemanagement and pediatric services) will accrue to the In-Network Out-of-Pocket Maximum. Any amountsYou pay for non-Covered Services, amounts in excess of the Allowed Amount, and pediatric visionservices received from an Out-of-Network Provider do not apply toward the Out-of-Pocket Maximum. Youwill continue to be responsible for amounts that do not apply toward the Out-of-Pocket Maximum, evenafter You reach this Policy's Out-of-Pocket Maximum.

Once You reach the Out-of-Pocket Maximum, In-Network benefits will be paid at 100 percent of theAllowed Amount for the remainder of the Calendar Year.

The In-Network Family Out-of-Pocket Maximum for a Calendar Year is satisfied when two or more familymembers' Deductibles, Copayments and/or Coinsurance for Covered Services for that Calendar Yeartotal and meet the Family's Out-of-Pocket Maximum amount.

HOW CALENDAR YEAR BENEFITS RENEWMany provisions in this Policy (for example, Deductibles, Out-of-Pocket Maximum, and certain benefitmaximums) are calculated on a Calendar Year basis. Each January 1, those Calendar Year maximumsbegin again.

Some benefits in this Policy have a separate Maximum Benefit based upon an Insured's Lifetime and donot renew every Calendar Year. Those exceptions include teaching doses of Self-Administrable InjectableMedication and hospice respite care and are further detailed in the Schedule of Benefits.

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Medical BenefitsIn this section, You will learn about Your Policy's benefits. There are no referrals required before You canuse any of the benefits of this coverage, including women's health care services. For Your ease in findingthe information regarding benefits most important to You, We have listed these benefits alphabetically,with the exception of the Preventive Care and Immunizations, Office Visits – Illness or Injury and OtherProfessional Services benefits.

All covered benefits, including Essential Benefits as defined in the Definitions Section, are explained inthis Medical Benefits Section. Benefits are provided after satisfaction of the Deductible, Coinsuranceand Copayment specified on the Schedule of Benefits and are subject to the limitations, exclusions andprovisions of this Policy. In some cases, We may limit benefits or coverage to a less costly and MedicallyNecessary alternative item.

To be covered, medical services and supplies must be rendered by a Provider practicing within thescope of his or her license and must be Medically Necessary for the treatment of an Illness or Injury(except for any covered preventive care). Reimbursement may be available under Your Policy for somemedical supplies, equipment, and devices You purchase from a Provider or from an approved commercialseller, even though that seller is not a Provider. Medical supplies, equipment, and devices, such as abreast pump or wheelchair, purchased through an approved commercial seller are covered at the In-Network Provider level, with reimbursement based on the lesser of either the amount paid to an In-Network Provider for that item, or the retail market value for that item. To learn more about how to accessreimbursable retail medical supplies, equipment, and devices, please visit Our Web site or contactCustomer Service.

Please note that if You choose to access medical supplies, equipment and devices through Our Web site,We may receive administrative fees or similar compensation from the commercial seller and/or You mayreceive discounts or coupons for Your purchases. Any such discounts or coupons are complements toYour Policy, but are not insurance.

A Health Intervention may be medically indicated or otherwise be Medically Necessary, yet not be aCovered Service under this Policy. Please see the Schedule of Benefits for descriptions of Providers andsee the Definitions Section in the back of this Policy for descriptions of Medically Necessary and HealthIntervention.

PREVENTIVE CARE AND IMMUNIZATIONSWe cover preventive care services provided by a professional Provider or facility such as:

● routine physical examinations, well-baby care, women’s care, and health screenings includingscreening for obesity in patients ages six and older, and appropriately offer or refer them tocomprehensive, intensive behavioral interventions to promote improvements in weight status;

● intensive multicomponent behavioral interventions for weight management;● Provider counseling and prescribed medications for tobacco use cessation;● depression screening for all adults, including screening for maternal depression;● immunizations for adults and children as recommended by the United States Preventive Service

Task Force (USPSTF), the Health Resources and Services Administration (HRSA) and the AdvisoryCommittee on Immunization Practices of the Centers for Disease Control and Prevention (CDC);

● one non-Hospital grade breast pump including its accompanying supplies per pregnancy, whenobtained from a Provider (including a Durable Medical Equipment supplier), or a comparable breastpump obtained from an approved commercial seller, even though that seller is not a Provider; and

● Food and Drug Administration (FDA) approved contraceptive devices and implants (includingthe insertion and removal of those devices and implants) and sterilization methods for women inaccordance with HRSA recommendations including, but not limited to, female condoms, diaphragmwith spermicide, sponge with spermicide, cervical cap with spermicide, spermicide, oral contraceptives(combined pill, mini pill, and extended/continuous use pill), contraceptive patch, vaginal ring,contraceptive shot/injection, emergency contraceptives (both levonorgestrel and ulipristal acetate-

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containing products), intrauterine devices (both copper and those with progestin), implantablecontraceptive rod, surgical implants and surgical sterilization.

Benefits will be covered under this Preventive Care and Immunizations benefit, not any other benefitin this Policy, if services are in accordance with age limits and frequency guidelines according to, andas recommended by, the USPSTF, the HRSA or by the CDC. In the event any of these bodies adoptsa new or revised recommendation, this plan has up to one year before coverage of the related servicesmust be available and effective under this benefit. For a complete list of services covered under thisbenefit, including information about obtaining a breast pump and instructions for obtaining reimbursementfor a breast pump purchased from an approved commercial seller, retailer, or other entity that is not aProvider, please visit Our Web site or contact Customer Service. Please note that if You choose to accessmedical supplies, equipment, and devices through Our Web site, We may receive administrative fees orsimilar compensation from the commercial seller and/or You may receive discounts or coupons for Yourpurchases. Any such discounts or coupons are complements to Your Policy, but are not insurance.

NOTE: Covered Services that do not meet these criteria will be covered the same as any other Illness orInjury.

OFFICE VISITS – ILLNESS OR INJURYWe cover office visits for treatment of Illness or Injury. All other professional services performed in theoffice, not billed as an office visit, or that are not related to the actual visit (separate Facility Fees billedin conjunction with the office visit for example) are not considered an office visit under this benefit. Forexample, We will pay for a surgical procedure performed in the office according to the Other ProfessionalServices benefit.

OTHER PROFESSIONAL SERVICESWe cover services and supplies provided by a professional Provider subject to any specified limits asexplained in the following paragraphs:

Diagnostic ProceduresWe cover services for diagnostic procedures including colonoscopies, cardiovascular testing, pulmonaryfunction studies, stress test, sleep studies and neurology/neuromuscular procedures. We cover medicalcolorectal cancer examinations and laboratory tests, including for those Insureds who are less than50 years old and at high risk or very high risk for colorectal cancer. Preventive colorectal cancerexaminations are covered under the Preventive Care and Immunizations benefit.

Medical Services and SuppliesWe cover professional services, second opinions and supplies, including the services of a Provider whoseopinion or advice is requested by the attending Provider, that are generally recognized and accepted non-surgical procedures for diagnostic or therapeutic purposes in the treatment of Illness or Injury. Servicesand supplies also include those to treat a congenital anomaly and foot care associated with diabetes.

Additionally, We cover some general medical services and supplies, such as compression stockings,active wound care supplies, and sterile gloves, when Medically Necessary. Reimbursement for coveredmedical supplies may be available under Your Policy when these supplies are obtained from anapproved commercial seller, even though that seller is not a Provider. Eligible general medical suppliespurchased through an approved commercial seller are covered at the In-Network Provider level, with Yourreimbursement based on the lesser of either the amount paid to an In-Network Provider for that item orthe retail market value for that item. To learn more about how to access reimbursable general medicalsupplies, please visit Our Web site or contact Customer Service.

Professional InpatientWe cover professional inpatient visits for Illness or Injury. If pre-arranged procedures are performedby an In-Network Provider and You are admitted to an In-Network Hospital, We will cover associatedservices (for example, anesthesiologist, radiologist, pathologist, surgical assistant, etc.) provided by Out-of-Network Providers at the In-Network benefit level. However, You may be billed for balances beyond

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any Deductible, Copayment and/or Coinsurance. Please contact Customer Service for further informationand guidance.

Radiology and LaboratoryWe cover services for treatment of Illness or Injury. This includes, but is not limited to, prostate screeningsand mammography services not covered under the Preventive Care and Immunizations benefit. NOTE:Outpatient complex imaging services are covered under the Complex Imaging – Outpatient benefit.

Surgical ServicesWe cover surgical services and supplies including the services of a surgeon, an assistant surgeon and ananesthesiologist, including coverage of cochlear implants.

Therapeutic InjectionsWe cover therapeutic injections and related supplies when given in a professional Provider's office,including teaching doses (by which a Provider educates the Insured to self-inject).

A selected list of Self-Administrable Injectable Medications is covered under the Prescription Medicationsbenefit. For a list of covered Self-Administrable Injectable Medications, visit Our Web site or contactCustomer Service.

ACUPUNCTUREWe cover acupuncture services provided by a professional Provider.

AMBULANCE SERVICESWe cover ambulance services to the nearest Hospital equipped to provide treatment when any other formof transportation would endanger Your health and the purpose of the transportation is not for personalor convenience purposes. Covered ambulance services include licensed ground and air ambulanceProviders.

AMBULATORY SURGICAL CENTERWe cover outpatient services and supplies of an Ambulatory Surgical Center, including professionalservices and facility charges, for Illness and Injury.

APPROVED CLINICAL TRIALSWe cover Your Routine Patient Costs in connection with an Approved Clinical Trial in which You areenrolled and participating subject to the Deductible, Coinsurance and/or Copayments and MaximumBenefits. If an In-Network Provider is participating in the Approved Clinical Trial and will accept You asa trial participant, these benefits will be provided only if You participate in the Approved Clinical Trialthrough that Provider. If the Approved Clinical Trial is conducted outside Your state of residence, You mayparticipate and benefits will be provided in accordance with the terms for other covered out-of-state care.

BLOOD BANKWe cover the services and supplies of a blood bank.

COMPLEX IMAGING – OUTPATIENTWe cover services and supplies for outpatient complex imaging for the treatment of Illness or Injury.Outpatient complex imaging is limited to the following imaging services: Computer Tomography (CT)Scan, Positron Emission Tomography (PET), Magnetic Resonance Angiogram (MRA), Single-ProtonEmission Computerized Tomography (SPECT), Bone Density Study and Magnetic Resonance Imaging(MRI).

DENTAL HOSPITALIZATIONWe cover inpatient and outpatient services and supplies for hospitalization for Dental Services (includinganesthesia), if hospitalization in an Ambulatory Surgical Center or Hospital is necessary to safeguard Yourhealth because treatment in a dental office would be neither safe nor effective.

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DETOXIFICATIONWe cover Medically Necessary detoxification services for alcoholism and drug abuse as an EmergencyMedical Condition and do not require pre-authorization or pre-notification.

DIABETES SUPPLIES AND EQUIPMENTWe cover supplies and equipment for the treatment of diabetes such as insulin, insulin infusion devices,test strips and insulin pumps under the Other Professional Services, Diabetic Education, Durable MedicalEquipment, Nutritional Counseling, Orthotic Devices or Prescription Medications Benefits.

DIABETIC EDUCATIONWe cover services and supplies for diabetic self-management training and education provided byProviders with expertise in diabetes. Diabetic nutritional therapy is covered under the NutritionalCounseling benefit.

DIALYSISWe cover inpatient, outpatient, and home services and supplies for dialysis.

DURABLE MEDICAL EQUIPMENTDurable Medical Equipment means an item that can withstand repeated use, is primarily used to serve amedical purpose, is generally not useful to a person in the absence of Illness or Injury and is appropriatefor use in the Insured's home. Examples include oxygen equipment and wheelchairs. Durable MedicalEquipment is not covered if it serves solely as a comfort or convenience item. We also cover applicablesales tax under this benefit for Durable Medical Equipment and mobility enhancing equipment as aCovered Service.

To be covered, Durable Medical Equipment must be rendered by a Provider practicing within the scopeof his or her license and must be Medically Necessary for the treatment of an Illness or Injury (exceptfor any covered preventive care). In some cases, We may limit benefits or coverage to a less costly andMedically Necessary alternative item. Reimbursement may also be available under Your Policy for someDurable Medical Equipment when obtained from an approved commercial seller, even though this entityis not a Provider. Eligible Durable Medical Equipment purchased through an approved commercial selleris covered at the In-Network Provider level, with Your reimbursement based on the lesser of either theamount paid to an In-Network Provider for that item or the retail market value for that item. To find waysto access Durable Medical Equipment, please visit Our Web site or contact Customer Service. Pleasenote that if You choose to access Durable Medical Equipment through Our Web site, We may receiveadministrative fees or similar compensation from the commercial seller and/or You may receive discountsor coupons for Your purchases. Any such discounts or coupons are complements to Your Policy, but arenot insurance.

EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES)We cover emergency room services and supplies, including outpatient charges for patient observationand medical screening exams that are required for the stabilization of a patient experiencing anEmergency Medical Condition. For the purpose of this benefit, "stabilization" means to provide MedicallyNecessary treatment: 1) to assure, within reasonable medical probability, no material deterioration of anEmergency Medical Condition is likely to occur during, or to result from, the transfer of the Insured from afacility; and 2) in the case of a covered female Insured, who is pregnant, to perform the delivery (includingthe placenta). Emergency room services do not need to be pre-authorized. If admitted to an Out-of-Network Hospital directly from the emergency room, services will be covered at the In-Network benefitlevel. However, You may be billed for balances beyond any Deductible, Copayment and/or Coinsurance.Please contact Customer Service for further information and guidance. See the Hospital Care benefit forcoverage of inpatient Hospital admissions.

FAMILY PLANNINGWe cover certain professional Provider contraceptive services and supplies, including, but not limited to,vasectomy under this benefit.

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For coverage of prescription contraceptives, please see the Prescription Medications benefit. You are notresponsible for any applicable Deductible, Copayment and/or Coinsurance when You fill prescriptions forFDA-approved contraceptives prescribed by Your health care Provider. For a list of such medications,please visit Our Web site or contact Customer Service.

For more information on preventive services for women, including HIV screening, HPV DNA testing, tuballigation, insertion or extraction of FDA-approved contraceptive devices, and certain patient educationand counseling services, see the Preventive Care and Immunizations benefit of this Policy or for a list ofcovered preventive services, please visit Our Web site or contact Customer Service.

GENETIC TESTINGWe cover Medically Necessary services for genetic testing.

HABILITATIVE SERVICESWe cover the range of Medically Necessary health care services and health care devices designed toassist a person to keep, learn or improve skills and functioning for daily living. Examples include servicesfor a child who isn't walking or talking at the expected age, or services to assist with keeping or learningskills and functioning within an individual's environment, or to compensate for a person's progressivephysical, cognitive, and emotional illness. These services may include physical and occupational therapy,speech-language pathology and other services for people with disabilities in a variety of inpatient andoutpatient settings. Cardiac rehabilitation, pulmonary rehabilitation, respiratory therapy, and breast cancerlymphedema services are covered under separate benefits of the plan and do not accrue to HabilitativeServices benefit limits. Day habilitation services designed to provide training, structured activities andspecialized assistance to adults, chore services to assist with basic needs, and vocational or custodialservices are not classified as habilitative services and are not covered under this Policy.

HOME HEALTH CAREWe cover home health care when provided by a licensed agency or facility for home health care. Homehealth care includes all services for patients that would be covered if the patient were in a Hospital orSkilled Nursing Facility. Durable Medical Equipment associated with home health care services is coveredunder the Durable Medical Equipment benefit.

HOSPICE CAREWe cover hospice care when provided by a licensed hospice care program. A hospice care programis a coordinated program of home and inpatient care, available 24 hours a day. This program uses aninterdisciplinary team of personnel to provide comfort and supportive services to a patient and any familymembers who are caring for a patient, who is experiencing a life threatening disease with a limitedprognosis. These services include acute, respite and home care to meet the physical, psychosocial andspecial needs of a patient and his or her family during the final stages of Illness. Respite care: We coverrespite care to provide continuous care of the Insured and allow temporary relief to family members fromthe duties of caring for the Insured. Durable Medical Equipment associated with hospice care is coveredunder the Durable Medical Equipment benefit in this Policy.

HOSPITAL CARE – INPATIENT AND OUTPATIENTWe cover the inpatient and outpatient services and supplies of a Hospital for Illness and Injury (includingservices of staff Providers billed by the Hospital). Room and board is limited to the Hospital's averagesemiprivate room rate, except where a private room is determined to be necessary. If admitted to an Out-of-Network Hospital directly from the emergency room, services will be covered at the In-Network benefitlevel. However, You may be billed for balances beyond any Deductible, Copayment and/or Coinsurance.Please contact Customer Service for further information and guidance. See the Emergency Room benefitfor coverage of emergency services, including medical screening exams, in a Hospital's emergency room.

MATERNITY CAREWe cover prenatal and postnatal maternity (pregnancy) care, childbirth (vaginal or cesarean), MedicallyNecessary supplies of home birth, complications of pregnancy, and related conditions for all femaleInsureds (including eligible dependents of dependents who have enrolled under this Policy). There is nolimit for the mother's length of inpatient stay. Where the mother is attended by a Provider, the attending

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Provider will determine an appropriate discharge time, in consultation with the mother. See the NewbornCare benefit to see how the care of Your newborn is covered. Coverage also includes termination ofpregnancy for all female Insureds.

Certain services such as screening for maternal depression, gestational diabetes, breastfeeding support,supplies and counseling are covered under Your Preventive Care benefit.

SurrogacyMaternity and related medical services received by You while Acting as a Surrogate are not CoveredServices, up to the amount You or any other person or entity is entitled to receive as payment or othercompensation arising out of, or in any way related to, You Acting as a Surrogate. By incurring and makingclaim for such services, You agree to reimburse Us the lesser of the amount described in the precedingsentence and the amount We have paid for those Covered Services (even if payment or compensation toYou or any other person or entity occurs after the termination of Your coverage under this Policy).

You must notify Us within 30 days of entering into any agreement to Act as a Surrogate and agree tocooperate with Us as needed to ensure Our ability to recover the costs of Covered Services received byYou for which We are entitled to reimbursement. To notify Us, or to request additional information on Yourresponsibilities related to these notification and cooperation requirements, contact Customer Service.Please also refer to the Right of Reimbursement and Subrogation Recovery Section of this Policy formore information.

MEDICAL FOODSWe cover medical foods for inborn errors of metabolism including, but not limited to, formulas forPhenylketonuria (PKU). We also cover Medically Necessary elemental formula when a Providerdiagnoses and prescribes the formula for an Insured with eosinophilic gastrointestinal associateddisorder.

MENTAL HEALTH SERVICESWe cover Mental Health Services for treatment of Mental Health Conditions, including Applied BehavioralAnalysis (ABA) therapy services covered for outpatient treatment of Autism Spectrum Disorders whenInsureds seek services from licensed Providers qualified to prescribe and perform ABA therapy services.Services must meet Our clinical criteria guidelines and Providers must submit individualized treatmentplans and progress evaluations.

NEURODEVELOPMENTAL THERAPYWe cover inpatient and outpatient neurodevelopmental therapy services. To be covered, such servicesmust be to restore and improve function. Covered Services are limited to physical therapy, occupationaltherapy and speech therapy and maintenance services, if significant deterioration of the Insured'scondition would result without the service. You will not be eligible for both the Rehabilitation Servicesbenefit and this benefit for the same services for the same condition.

NEWBORN CAREWe cover services and supplies, under the newborn's own coverage, in connection with nursery carefor the natural newborn or newly adoptive child. The newborn child must be eligible and enrolled, ifapplicable, as explained in the Who Is Eligible, How to Enroll and When Coverage Begins Section. Thereis no limit for the newborn's length of inpatient stay. For the purpose of this benefit, "newborn care" meansthe medical services provided to a newborn child following birth including well-baby Hospital nurserycharges, the initial physical examination and a PKU test.

NUTRITIONAL COUNSELINGWe cover nutritional counseling and therapy for all conditions including diabetic counseling and obesity.

ORTHOTIC DEVICESWe cover benefits for the purchase of braces, splints, orthopedic appliances and orthotic supplies orapparatuses used to support, align or correct deformities or to improve the function of moving parts of thebody. We do not cover orthopedic shoes, regardless of diagnosis, and off-the-shelf shoe inserts.

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To be covered, orthotic devices must be rendered by a Provider practicing within the scope of his or herlicense and must be Medically Necessary for the treatment of an Illness or Injury (except for any coveredpreventive care). In some cases, We may limit benefits or coverage to a less costly and MedicallyNecessary alternative item. Reimbursement may also be available under Your Policy for some orthoticdevices when obtained from an approved commercial seller, even though that seller is not a Provider.Eligible orthotic devices purchased through an approved commercial seller are covered at the In-Network Provider level, with Your reimbursement based on the lesser of either the amount paid to an In-Network Provider for that item, or the retail market value for that item. To learn more about how to accessreimbursable retail orthotic devices, please visit Our Web site or contact Customer Service. Please notethat if You choose to access orthotic devices through Our Web site, We may receive administrative feesor similar compensation from the commercial seller and/or You may receive discounts or coupons for Yourpurchases. Any such discounts or coupons are complements to Your Policy, but are not insurance.

PALLIATIVE CAREWe cover palliative care when a Provider has assessed that an Insured is in need of palliative careservices. For the purpose of this benefit, "palliative care" means specialized services received from aProvider in a home setting for counseling and home health aide services for activities of daily living.

PEDIATRIC DENTALWe cover pediatric Dental Services for Insureds under the age of 19. Coverage will be provided for anInsured until the last day of the month in which the Insured turns 19 years of age. We will pay benefitsunder this Pediatric Dental benefit, not any other benefit of this Policy, if a service or supply is coveredunder both.

Preventive And Diagnostic Dental ServicesWe cover the following preventive and diagnostic Dental Services:

● Bitewing x-rays● Cephalometric films● Complete intra-oral mouth x-rays● Cleanings● Diagnostic casts when Dentally Appropriate● Limited oral evaluations to evaluate the Insured for a specific dental problem or oral health complaint,

dental emergency or referral for other treatment● Limited visual oral assessments or screenings not performed in conjunction with other clinical oral

evaluation services● Occlusal intraoral x-rays● Oral hygiene instruction, if not billed on the same day as a cleaning● Periapical x-rays that are not included in a complete series for diagnosis in conjunction with definitive

treatment● Photographic images (oral and facial) when Dentally Appropriate● Periodic and comprehensive oral examinations● Problem focused oral examinations● Panoramic mouth x-rays● Sealants, limited to permanent bicuspids and molars● Space maintainers (fixed unilateral or fixed bilateral) includes:

- re-cementation of space maintainers;- removal of space maintainers; and- replacement space maintainers are covered when Dentally Appropriate.

● Topical fluoride application

Basic Dental ServicesWe cover the following basic Dental Services:

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● Complex oral surgery procedures including surgical extractions of teeth, impactions, alveoloplasty,frenulectomy, frenuloplasty, vestibuloplasty and residual root removal

● Emergency treatment for pain relief● Endodontic services consisting of:

- apexification for apical closures of anterior permanent teeth;- apicoectomy;- retrograde filling for anterior teeth;- debridement;- direct pulp capping;- pulpal therapy;- pulp vitality tests;- pulpotomy; and- root canal treatment, including: treatment with resorbable material for primary maxillary incisor

teeth D, E, F and G, if the entire root is present at treatment; treatment for permanent anterior,bicuspid, and molar teeth (excluding teeth one, 16, 17 and 32); and retreatment for the removalof post, pin, old root canal filling material, and all procedures necessary to prepare the canal withplacement of new filling material.

● Endodontic benefits will not be provided for indirect pulp capping.● Fillings consisting of composite and amalgam restorations● General dental anesthesia or intravenous sedation administered in connection with the extractions

of partially or completely bony impacted teeth and to safeguard the Insured’s health. Other servicesrelated to general anesthesia or intravenous sedation are covered as follows:

- drugs and/or medications only when used with parenteral conscious sedation, deep sedation, orgeneral anesthesia;

- inhalation of ni

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