Common use of Benefits and Coverage Clause in Contracts

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases.

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbersnum ers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstancescircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –– If the requested Out-of-network Practitioner/Provider has a well- well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases.

Benefits and Coverage. InAfter You reach Your Out-network Practitioners and Providers cannot xxxx you of-Pocket Maximum (including any required Deductible), Your Contract pays 100% of the maximum allowable amount for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration the remainder of patient visitsthe calendar year. Out-of-Pocket Maximums are accumulated separately for In-Network and Out-of-Network Care. See the Summary of Benefits and Coverage to determine Your in-network Practitioners/Coinsurance amount and in-network Out-of-Pocket Maximum. There is no annual or lifetime dollar limit for Covered Services that are Essential Health Benefits. In order to assist You in understanding the MAC language as described below, please refer to the definition of In-Network Provider and Out-of-Network Provider contained in the Definitions section of this booklet. This section describes how We determine the amount of reimbursement for Covered Services. Reimbursement for services rendered by In-Network and Out-of-Network Providers are health care Practitioners/Providers, including non- medical facilities, who is based on this plan’s MAC for the Covered Service that You receive. You will be required to pay a portion of the MAC to the extent You have not entered into an agreement with us to provide Health Care met Your Deductible or have a Copayment or Coinsurance. In addition, when You receive Covered Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Network Provider, You may be responsible for paying any difference between the MAC and the Provider’s actual charges. This amount can be significant. When You receive Covered Services from an eligible Provider, We will, to the extent applicable, apply claim processing rules to the claim submitted for those Covered Services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect Our determination of the MAC. Our application of these rules does not mean that the Covered Services You received were not Medically Necessary. It means We have determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, Your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all the procedures that were performed. When this occurs, the MAC will be based on the single procedure code rather than a separate MAC for each billed code. Likewise, when multiple procedures are performed on the same day by the same physician or outside another health care professional, We may reduce the Service Area will not MAC for those secondary and subsequent procedures because reimbursement at 100% for those procedures would represent duplicative payment for components of the primary procedure that may be Covered unless such services are not reasonably available from considered incidentalor inclusive. The allowed amount may vary depending upon whether the Provider is an In-network Practitioner/Provider Network or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Network Provider. For Covered Services performed by an In-Network Provider, except Emergency the allowed amount for this plan is the rate the Provider has agreed with Alliant to accept as reimbursement for the Covered Services. Because In-Network Providers have agreed to accept the allowed amount as payment in full for that service, they should not send You a bill or collect for amounts above the allowed amount. However, You may receive a bill or be asked to pay all or a portion of the allowed amount to the extent You have not met Your Deductible or have a Copayment or Coinsurance. Please call Customer Service at (000) 000-0000 for help in finding an In-Network Provider or visit XxxxxxxXxxxx.xxx. Providers who have not signed a contract with Us and are not in any of Our networks are Out-of-Network Providers. For Covered Services You choose to receive from Out-of-Network Providers (other than emergency services), the MAC for this plan will be one of the following as determined by Alliant: • An amount based on Our Out-Of-Network fee schedule/rate, which We have established at Our discretion, and which We reserve the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with Alliant, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data; or • An amount based on information provided by a third-party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care; or • An amount negotiated by Us or a third- party vendor which has been agreed to by the Provider. This may includerates for services coordinated through case management; or • An amount equal to the total charges billed by the Provider, but only if such charges are less than the MAC calculated by using one of the methods described above. The MAC for Out-of-Network emergency medical services is calculated as described in Title 33 of the Official Code of Georgia Annotated (OCGA) 33-20E-4; with respect to emergency services, require r Primary Care Physician request We will calculate the MAC as the greater of: • The verifiable contracted amount paid by all eligible insurers for the provision of the same or similar services as determined by the Georgia Department of Insurance. • The most recent verifiable amount agreed to by Alliant and obtain written approval (Authorization) the nonparticipating emergency medical provider for the provision of the same services during such time as such Provider was In-Network with Alliant. • Such higher amount as Alliant may deem appropriate given the complexity and circumstances of the services provided. The amount paid does not include any amount of coinsurance, copayment, or deductible You may owe. Out-of-Network Providers of emergency services may bill You for any coinsurance, copayment, or deductible You may owe according to the terms of Your policy. In the event You receive a surprise bill for nonemergency medical services from our Medical Director BEFORE services are rendered. Otherwise, you will services of an Out-of-network Practitioner/Provider are requiredNetwork provider, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by did NOT actively choose the Out-of-network Practitioner/ProviderNetwork provider prior to receiving services, We calculate the MAC as described above. Alliant reserves the right to request documentation from the Out-of-network Practitioners/Providers may require you Network provider to pay them confirm whether You received services through no choice of Your own. Choosing an In-Network Provider will likely result in full lower out-of-pocket costs to You. Please call Customer Service at the time of service. You may have to pay them and then file your claim (000)000-0000 for reimbursement with us. We will only pay this claim if the service provided was Authorized by us help in finding an In-Network Provider or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increasesvisit Our website at XxxxxxxXxxxx.xxx.

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstancescircumstances:  ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ➢ Continuity –– If the requested Out-of-network Practitioner/Provider has a well- well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases.

Benefits and Coverage. In-network Practitioners and Providers cannot xxxx bill you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require r Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  ⮚ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ⮚ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ⮚ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ⮚ Continuity –If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  ⮚ Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/Provider. Out-of-network Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  🖐 Emergency Health Care Services and/or Urgent Care services outside of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increases.

Benefits and Coverage. The In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our amounts you pay will apply toward the In-network Annual Out-of- pocket Maximum after which In-network claims will be paid at 100%. These Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visitsare not responsible for obtaining Prior Authorization (if required). You must obtain Prior Authorization (if required) for services provided by a National PPO Provider and follow all other rules regarding Out-of-network Practitioners/Providers. For additional information regarding National PPO Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us or to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an see if you need a Prior Authorization for Out-of-network Practitioner/Provider Services, please call our Presbyterian Customer Service Center prior to obtaining services Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or outside 0-000-000-0000. Hearing impaired users may call the Service Area will not be Covered unless such services are not reasonably available TTY 711. Many Health Care Services you receive from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an and Out-of-network Practitioner/Provider, except Emergency services, Practitioners and Providers require r Primary Care Physician request and obtain written approval (Authorization) some payment from our Medical Director BEFORE services you. We refer to these payments as Cost Sharing. These are rendered. Otherwise, you will services of an your Out-of-network Practitioner/Provider are requiredpocket costs and may be Deductibles, your InCoinsurance and/or Copayment amounts. Cost-network Practitioner/Provider must request Sharing and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible benefits for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed emergency health care service rendered by a specialist similar non-participating provider shall be the same as if rendered by a participating provider. Cost-Sharing and benefit limitations for medically necessary, non-emergent health care services rendered by a non- participating provider at a participating facility where the covered person had no ability or opportunity to choose to receive the type of specialist to whom the Prior Authorization service from a participating provider or where no participating provider is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatmentshall be the same as if the service was rendered by a participating provider.  Geography – Certain services are subject to an Annual Contract Year Deductible. The Annual Contract Year Deductible is the amount you and your Covered Dependents must pay for Covered Health Care Services each Contract Year before we begin to pay Covered Benefits for that Member. The Annual Contract Year Deductible may not apply to all Health Care Services. You will pay a lower Annual Contract Year Deductible amount when you visit In-network PractitionerPractitioners/Provider is not located within a reasonable distance from Providers. Refer to your residenceSummary of Benefits and Coverage for the amount of your Annual Contract Year Deductible. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-ofCovered charges for In-network Practitioner/Practitioner and Provider has a well- established professional relationship with you services only apply to the In-network Annual Contract Year Deductible limits and is providing ongoing treatment of a specific medical problem, you will be allowed do not apply to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/ProviderAnnual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. Covered charges for Out-of-network PractitionersPractitioner and Provider services only apply to the Out-of- network Annual Contract Year Deductible limits and do not apply to the In-network Annual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. For Single coverage, the annual Contract Year Deductible requirement is fulfilled when one Member meets the individual Deductible listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family the annual Contract Year Deductible must be met before benefits will be paid for the family. However, if one (family) Member reaches the Individual Deductible amount before the Family has met the annual Contract Year Family Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The annual Contract Year Family and Individual Deductible amounts are listed in the Summary of Benefits and Coverage. Certain services are subject to a Coinsurance amount. Coinsurance is the percentage of Covered charges that you and your Covered Dependents must pay directly to the Practitioner/Providers may require Provider for Covered Services after the Annual Contract Year Deductible has been met. After you to pay them in full at the time of service. You may have to your Coinsurance amount, we will pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside our percentage of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increasescharges.

Benefits and Coverage. The In-network Practitioners and Providers cannot xxxx you for any additional costs over and above your Cost Sharing amounts. We do not require our amounts you pay will apply toward the In-network Annual Out-of- pocket Maximum after which In-network claims will be paid at 100%. These Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visitsare not responsible for obtaining Prior Authorization (if required). You must obtain Prior Authorization (if required) for services provided by a National PPO Provider and follow all other rules regarding Out-of-network Practitioners/Providers. For additional information regarding National PPO Providers are health care Practitioners/Providers, including non- medical facilities, who have not entered into an agreement with us or to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an see if you need a Prior Authorization for Out-of-network Practitioner/Provider Services, please call our Presbyterian Customer Service Center prior to obtaining services Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or outside 0-000-000-0000. Hearing impaired users may call the Service Area will not be Covered unless such services are not reasonably available TTY 711. Many Health Care Services you receive from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an and Out-of-network Practitioner/Provider, except Emergency services, Practitioners and Providers require r Primary Care Physician request and obtain written approval (Authorization) some payment from our Medical Director BEFORE services you. We refer to these payments as Cost Sharing. These are rendered. Otherwise, you will services of an your Out-of-network Practitioner/Provider are requiredpocket costs and may be Deductibles, your In-network Practitioner/Provider must request Coinsurance and/or Copayment amounts. Cost Sharing and obtain Prior Authorization from our Medical Director are performed, otherwise, we will not Cover the services and you will be responsible benefits for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed emergency health care service rendered by a specialist similar non-participating provider shall be the same as if rendered by a participating provider. Cost Sharing and benefit limitations for medically necessary, non-emergent health care services rendered by a non- participating provider at a participating facility where the covered person had no ability or opportunity to choose to receive the type of specialist to whom the Prior Authorization service from a participating provider or where no participating provider is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following ircumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatmentshall be the same as if the service was rendered by a participating provider.  Geography – Certain services are subject to an Annual Contract Year Deductible. The Annual Contract Year Deductible is the amount you and your Covered Dependents must pay for Covered Health Care Services each Contract Year before we begin to pay Covered Benefits for that Member. The Annual Contract Year Deductible may not apply to all Health Care Services. You will pay a lower Annual Contract Year Deductible amount when you visit In-network PractitionerPractitioners/Provider is not located within a reasonable distance from Providers. Refer to your residenceSummary of Benefits and Coverage for the amount of your Annual Contract Year Deductible. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity –If the requested Out-ofCovered charges for In-network Practitioner/Practitioner and Provider has a well- established professional relationship with you services only apply to the In-network Annual Contract Year Deductible limits and is providing ongoing treatment of a specific medical problem, you will be allowed do not apply to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care.  Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of-network Practitioner/ProviderAnnual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. Covered charges for Out-of-network PractitionersPractitioner and Provider services only apply to the Out-of- network Annual Contract Year Deductible limits and do not apply to the In-network Annual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. For Single coverage, the annual Contract Year Deductible requirement is fulfilled when one Member meets the individual Deductible listed in the Summary of Benefits and Coverage. For double or family coverage, with two or more enrolled Members, the entire Family the annual Contract Year Deductible must be met before benefits will be paid for the family. However, if one (family) Member reaches the Individual Deductible amount before the Family has met the annual Contract Year Family Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The annual Contract Year Family and Individual Deductible amounts are listed in the Summary of Benefits and Coverage. Certain services are subject to a Coinsurance amount. Coinsurance is the percentage of Covered charges that you and your Covered Dependents must pay directly to the Practitioner/Providers may require Provider for Covered Services after the Annual Contract Year Deductible has been met. After you to pay them in full at the time of service. You may have to your Coinsurance amount, we will pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Health Care Services situation.  Emergency Health Care Services and/or Urgent Care services outside our percentage of the State of New Mexico will be Covered. For Emergency Health Care Services and/or Urgent Care services received of New Mexico, you may seek services from the nearest appropriate facility where Emergency Health Care Services / Urgent Care services may be rendered. When receiving Urgent or Emergency Health Care Services outside of the State of New Mexico you can help reduce the cost of such services by seeking care from one of our National Health Care Provider Network Practitioners/Providers. These cost savings can help minimize future premium increasescharges.