Common use of Autism Spectrum Disorder Clause in Contracts

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Child or well-baby screening and/or o Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions section. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o Total parenteral and enteral nutrition as the sole source of nutrition o Medical Drugs: (Medications obtained through the medical benefit): Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be required to be obtained from our In-network Specialty Pharmacy vendor. Some Medical Drugs will require Prior Authorization before they can be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a healthcare provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ ten-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o Diagnosis of autism; and Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o Total parenteral and enteral nutrition as the sole source of nutrition o Medical Drugs: (Medications obtained through the medical benefit): Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be required to be obtained from our In-network Specialty Pharmacy vendor. Some Medical Drugs will require Prior Authorization before they can be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678):

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care healthcare or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network.‌ o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services/Home Intravenous Services and Supplies Supplies‌ This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at‌‌‌ (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care healthcare or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network.‌ o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network.‌ o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section. Inpatient means you have been admitted by a healthcare Practitioner/Provider to a Hospital for the purposes of receiving Hospital services. Eligible Inpatient Hospital services are acute care services provided when you are a registered bed patient and there is a room and board charge. Admissions are considered Inpatient based on Medical Drugs will Necessity, regardless of the length of time spent in the Hospital. Hospital admissions (Inpatient, non-emergent) require Prior Authorization. Inpatient Hospital benefits also include Acute medical detoxification. Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization before they can when provided by an In- network Practitioner/Provider in order to be obtainedCovered. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center Infertility‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Diagnosis and outpatient surgery facilities. C SC Call P 505‐923‐5678medically indicated treatments for physical conditions causing infertility.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: Drugs (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf.‌‌‌ o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Some Medical Drugs will require Prior Authorization before they can be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a healthcare provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Child or well-baby screening and/or o Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment Information Habilitative Services for Autism Spectrum Disorder may require Prior Authorization and your Practitioner/Provider’s approved plan is provided to our Health Services Department prior to services being obtainedof care. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies Exclusion Prior Auth Required This benefit has one or more exclusions as specified in the Exclusions section. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  • Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  • Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  • Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  • Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  • The following Home Health Care Services will Authorization request: be Covered when we approve a Prior Authorization request: o Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o Total parenteral and enteral nutrition as the sole source of nutrition o Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. CSC Call P 000-000-0000 0-000000-0000 o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxx.xxx.xxx. Some Medical Drugs will require Prior Authorization before they can be obtainedYou may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or toll-free 0-000-000-0000 Monday through Friday from 7:00 a.m. to 6:00 p.m. Hearing impaired users may call our TTY number at 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities➢ Hospital Services - Inpatient This benefit has one or more exclusions as specified in the Exclusions section. C SC Call P 505‐923‐5678Exclusion

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a healthcare provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ ten-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan‌ Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: Drugs (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the Member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network.‌‌ o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in regardless of agein accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY 711. Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section. Inpatient means you have been admitted by a health care Practitioner/Provider to a Hospital for the purposes of receiving Hospital services. Eligible Inpatient Hospital services are acute care services provided when you are a registered bed patient and there is a room and board charge. Admissions are considered Inpatient based on Medical Drugs will Necessity, regardless of the length of time spent in the Hospital. Hospital admissions (Inpatient, non-emergent) require Prior Authorization. Inpatient Hospital benefits also include Acute medical detoxification. Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization before they can when provided by an In- network Practitioner/Provider in order to be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Covered.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf.‌‌ o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Some Medical Drugs will require Prior Authorization before they can be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o Diagnosis of autism; and Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a Healthcare Provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ 10-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible Member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible Member receives a heart artery calcium score greater than zero. Heart Artery calcification is a Covered preventive benefit with no member Cost-Sharing. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o Total parenteral and enteral nutrition as the sole source of nutrition o Medical Drugs: (Medications obtained through the medical benefit): Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution and may be required to be obtained from our In-network Specialty Pharmacy vendor. Some Medical Drugs will require Prior Authorization before they can be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678):

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtainednature. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Heart Artery Calcification Scan Heart Artery calcification scans are a computed tomography scan measuring coronary artery calcium for atherosclerosis and abnormal artery structure and function. These scans are Covered for individuals between the ages of 45-65 years and that have an intermediate risk of developing coronary heart disease as determined by a healthcare provider based upon a score calculated from an evidence-based algorithm widely used in the medical community to access a persons’ ten-year cardiovascular disease risk, including a score calculated using a pool cohort equation. The scans are Covered only once every five years if an eligible member has previously received a heart artery calcium score of zero. Coverage will not be provided for future heart artery calcium scans if an eligible member receives a heart artery calcium score greater than zero. Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at ((000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY 711. Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section. Inpatient means you have been admitted by a health care Practitioner/Provider to a Hospital for the purposes of receiving Hospital services. Eligible Inpatient Hospital services are acute care services provided when you are a registered bed patient and there is a room and board charge. Admissions are considered Inpatient based on Medical Drugs will Necessity, regardless of the length of time spent in the Hospital. Hospital admissions (Inpatient, non-emergent) require Prior Authorization. Inpatient Hospital benefits also include Acute medical detoxification. Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization before they can when provided by an In- network Practitioner/Provider in order to be obtained. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Covered.

Autism Spectrum Disorder. The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care healthcare or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drugs are defined as medications Drug is any drug administered in the office or facility (including Home Health Care) that require by a Health Care Professional to administerand is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They Medical Drugs may involve unique distribution require a Prior Authorization and may be required to some must be obtained from through the specialty network.‌ o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some o You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section. Inpatient means you have been admitted by a healthcare Practitioner/Provider to a Hospital for the purposes of receiving Hospital services. Eligible Inpatient Hospital services are acute care services provided when you are a registered bed patient and there is a room and board charge. Admissions are considered Inpatient based on Medical Drugs will Necessity, regardless of the length of time spent in the Hospital. Hospital admissions (Inpatient, non-emergent) require Prior Authorization. Inpatient Hospital benefits also include Acute medical detoxification. Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization before they can when provided by an In- network Practitioner/Provider in order to be obtainedCovered. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center Infertility‌‌ This benefit has one or more exclusions as specified in the Exclusions Section. Diagnosis and outpatient surgery facilities. C SC Call P 505‐923‐5678medically indicated treatments for physical conditions causing infertility.

Autism Spectrum Disorder. ‌ The diagnosis and treatment for Autism Spectrum Disorder is covered for children, from birth to regardless of age nineteen (19) or up to age twenty-two (22) if enrolled in high school, in accordance with state mandated benefits as follows: o • Diagnosis for the presence of Autism Spectrum Disorder when performed during a Well-Well- Child or well-baby screening and/or o • Treatment through speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis (ABA) to develop, maintain, restore and maximize the functioning of the individual, which may include services that are habilitative or rehabilitative in nature Important Infor ation These services are only Covered when a treatment plan is provided to our Health Services Department prior to services being obtained. The Health Services Department will review the treatment plans in accordance with state mandated benefits. m Autism Spectrum Disorder Services must be provided by Practitioners/Providers who are certified, registered or licensed to provide these services. Limitation – Services received under the federal Individuals with Disabilities Education Improvement Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three (3) 3 to twenty-two (22) 22 years of age who have Autism Spectrum Disorder are not Covered under this Plan. H Exclusion ome Home Health Care Services/Home Intravenous Services and Supplies This benefit has one or more exclusions as specified in the Exclusions sectionSection. u Home Health Care Services are Health Care Healthcare Services provided to you when you are confined to the home due to physical illness. Home Health Care Services requires Prior Authorization and your Practitioner’s/Provider’s approved plan of care. Pri r Auth Re uired  Any Practitioner’s/Provider’s prescription and Prior Authorization must be renewed at the end of each 60-day period. We will not impose a limitation on the number of related hours per visit. o q  Home Health Care Services shall include Medically Necessary skilled intermittent Health Care Healthcare Services provided by a registered nurse or a licensed practical nurse; physical, occupational, and/or respiratory therapist and/or speech pathologist. Intermittent Home Health aide services are only Covered when part of an approved plan of care which includes skilled services.  Such services may include collection of specimens to be submitted to an approved laboratory facility for analysis. to an approved  Medical equipment, Prescription Drugs and Medications, laboratory services and supplies deemed Medically Necessary by a Practitioner/Provider for the provision of health services in the home, except Durable Medical Equipment, will be Covered. Prior Auth Required  The following Home Health Care Services will Authorization request: be Covered when we approve a Prior o Authorization request: • Home health care or home intravenous services as an alternative to Hospitalization, as determined by your Practitioner/Provider o • Total parenteral and enteral nutrition as the sole source of nutrition o • Medical Drugs: (Medications obtained through the medical benefit): A Medical Drug is any drug administered by a Healthcare Professional and is typically given in the member's home, physician’s office, freestanding (ambulatory) infusion suite, or outpatient facility. Medical Drugs are defined as medications administered in the office or facility (including Home Health Care) that may require a Health Care Professional to administer. These medications include, but are not limited to, injectable, infused, oral or inhaled drugs. They may involve unique distribution Prior Authorization and may be required to some must be obtained from through the specialty network. o For a complete list of Medical Drugs to determine which require Prior Authorization and what drugs are mandated to our In-network Specialty network, please see the Presbyterian Pharmacy vendorwebsite at xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/pharmacy.aspx or the drug list at xxxx://xxxx.xxx.xxx/idc/groups/public/%40phs/%40php/documents/phsconten t/pel_00052739.pdf. Some Medical Drugs will require Prior Authorization before they can be obtainedo You may call our Presbyterian Customer Service Center for more information at (000) 000-0000 or 0-000-000-0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Office-administered applies to all Outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent Care Center and outpatient surgery facilities. C SC Call P 505‐923‐5678Hospital Services – Inpatient This benefit has one or more exclusions as specified in the Exclusions Section.