Common use of Case Management Clause in Contracts

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-well- being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits and Coverages (Covered will be provided for covered Services) Blue Shield provides . The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan deductible amount does not count toward the Calendar Year Out-of-Pocket re- sponsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services Incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the contracted rate do not apply toward the Deductible and the Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Pre- scription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket responsibility.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing man- aging symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapythera- py, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request re- quest more information about these services. Principal The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits and Coverages (Covered will be provided for covered Services) Blue Shield provides . The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does not count toward the Calendar Year Out-of-Pocket Max- imum t responsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services Incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the contracted rate do not apply toward the Deductible and the Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Pre- scription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket responsibility.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-well- being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits will be provided for covered Services. The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the Plan. Charges in excess of the Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and all of his covered Dependents collectively after the Family Deductible amount has been satisfied. Note: The Deductible also applies to a newborn child or a child placed for adoption, who is covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does not count toward the Maximum Calendar Year Out-of- Pocket Maximum responsibility. The Calendar Year medical plan Deductible applies to all covered Services Incurred during a Calendar Year except for those Services as shown in the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits will be provided for covered Drugs. The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered by the Plan. Charges in excess of the contracted rate do not apply toward the Deductible and the Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is separate from the Brand Name Drug Deductible included in the Outpatient Pre- scription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Maxi- mum Calendar Year Out-of-Pocket Copayment responsibil- ity. The Member’s Copayment amounts, applicable Deductibles, and copayment maximum amounts for covered Services are shown in the Summary of Benefits. The Summary of Bene- fits also contains information on benefit and Copayment maximums and restrictions. Complete benefit descriptions may be found in the Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurancesection. Plan exclusions, and charges limitations may be found in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions Exclusions, and Reductions listed in this Evidence of Coveragesection. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may will be provided for covered Services received by Subscribers or their eligible Dependent(s) who are temporari- ly traveling outside of California within the illnessUnited States, injury Puerto Rico and U.S. Virgin Islands. (Temporarily traveling is defined as a Subscriber or medical condition, Dependent who spends in the aggregate not more than 180 days each Calendar Year out- side the State of California.) Blue Shield of California calcu- lates the Subscriber's copayment as a percentage of the Al- lowable Amount, as defined in this booklet. When covered Services are received in another state, the Subscriber's co- payment will provide Benefits be based on the most cost- effective servicelocal Blue Cross and/or Blue Shield plan's arrangement with its providers. The Copayment See the BlueCard Program section in this booklet. If you do not see a Participating Provider through the BlueCard Program, you will have to pay for the entire bill for your medical care and Coinsurance amounts submit a claim form to the local Blue Cross and/or Blue Shield plan or to Blue Shield of California for Covered Services, if applicable, are shown on payment. Blue Shield of California will notify you of its determination within thirty (30) days after the Summary receipt of Benefitsthe claim. The Summary Blue Shield of Benefits California will pay you at the Non- Preferred Provider benefit level. Remember that your co- payment is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from higher when you see a Non-Participating Providers, subscribers Preferred Provider. You will be responsible for all paying the entire difference be- tween the amount paid by Blue Shield of California and the amount billed. Charges for Services which are not covered, and charges above by Non-Preferred Providers in excess of the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are amount covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services plan, are the Subscriber's responsibility and is operating within are not in- cluded in copayment calculations. To receive the scope maximum benefits of that license or certification.your plan, please follow the procedure below. When you require Covered Services while temporarily travel- ing outside of California:

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing man- aging symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapythera- py, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request re- quest more information about these services. Principal The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits and Coverages (Covered will be provided for covered Services) Blue Shield provides . The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does count toward the Calendar Year Out-of-Pocket Maxi- mum responsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services Incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the con- tracted rate do not apply toward the Deductible and the De- ductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Prescription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket responsibility.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services Services and to make the most efficient use of plan Plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative Al- ternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this planPlan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan Plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person Mem- ber in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services Services for Members with serious illnesses. Palliative care services Services include access to physicians Physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy au- tonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions deci- sions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement De- partment to request more information about these services. Principal Benefits DEDUCTIBLES This plan’s Deductible is for services rendered by Preferred and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective serviceNon-Preferred Providers combined. The Copayment and Coinsurance amounts for Covered Services, if applicable, are Calendar Year Deductible amount is shown on in the Summary of Benefits. The Summary This Deductible must be made up of Benefits is provided withcharges covered by the Plan, and must be satisfied once during each Calendar Year. After the Calendar Year Indi- vidual Coverage Deductible is incorporated as part ofsatisfied for those Services to which it applies, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers Benefits will be responsible provided for all charges above covered Services. Charges in excess of the Allowable Amount do not apply toward the Deductible. Note: If you are enrolled in addition an Individual Deductible Plan, and have a newborn or a child placed for adoption, the child is covered for the first 31 days even if application is not made to add the indicated Copayment or Coinsurance amountchild as a Dependent on the Plan. Except While the child’s coverage is provided, you and this Dependent will be enrolled in the Family Coverage Deductible Plan. The Family Deductible amount as specifically provided herein, described in the Family Coverage Deductible section below will apply to you and this Dependent. This plan’s Deductible is for services are covered only when rendered by an individual or entity that is licensed or certified Preferred and Non-Preferred Providers combined. The Calendar Year per Member and Family Deductible amounts are shown in the Summary of Benefits. This De- ductible must be made up of charges covered by the state Plan, and must be satisfied once during each Calendar Year. Once a Family member has satisfied the Individual Calen- dar Year Deductible for those Services to provide health care services which it applies, Benefits will be provided for that Family Member. For a Family with two Family members, each Family mem- ber must satisfy the individual Calendar Year Deductible before Benefits will be provided. For a Family with three or more Family members, when two or more Family members have satisfied the Family Calendar Year Deductible, Benefits will be provided for any and is operating within all Family members. Charges in excess of the scope Allowable Amount do not apply toward the Deductible. These Calendar Year Deductibles will count towards the Calendar Year maximum out-of-pocket responsibility. The Calendar Year Deductible applies to all covered Ser- vices Incurred during a Calendar Year except for certain Services as listed in the Summary of that license or certificationBenefits.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange ar- range for alternative care benefits to avoid prolonged or repeated re- peated hospitalizations, when medically appropriate. Alternative Alter- native care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy auton- omy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department Depart- ment at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits If prior authorization is not obtained for a mental health or impatient admission or for any Non-Routine Outpatient Men- tal Health Services and Coverages (Covered Services) the services provided to the member are determined not to be a Benefit of the plan, coverage will be denied If further care at home or in another facility is ap- propriate following discharge from the Hospital, Blue Shield provides or Blue Shield’s MHSA will work with Member, the following Medically Necessary attending Physician and the Hospital discharge planner to determine the most appropriate and cost effective way to provide this care. The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, subject to applicable Deductibles, Copayments, Coinsurance, and Benefits will be provided for covered Services. The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does count toward the Calendar Year Out-of-Pocket Maxi- mum responsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services Incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the con- tracted rate do not apply toward the Deductible and the De- ductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Prescription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket responsibility.

Case Management. The Benefits Management Program may also include in- clude case management, which is a service that provides the assistance of a health care professional profes- sional to help the Member access necessary services ser- vices and to make the most efficient use of plan Plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptomssymp- toms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed in- formed decisions about therapy, as well as documenting docu- xxxxxxx their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request re- quest more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable DeductiblesDe- ductibles, Copayments, Coinsurance, Coinsurance and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions ex- clusions of the Evidence of Coverage and Health AgreementContract, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, ExceptionsExcep- tions, Exclusions and Reductions listed in this Evidence of CoverageEOC. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective cost-effec- tive service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service AgreementEOC. Except as may be specifically indicated, for services ser- vices received from Non-Participating Providers, subscribers Subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated in- dicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. Most inpatient Hospital admissions are monitored for length of stay; exceptions are noted below. The length of an inpatient Hospital stay may be extended or reduced as warranted by the Member’s condition. When a determination is made that the Member no longer requires In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- cost-effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-well- being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits and Coverages (Covered will be provided for covered Services) Blue Shield provides . The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does not count toward the Calendar Year Out-of-Pocket Max- imum responsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services Incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the contracted rate do not apply toward the Deductible and the Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Pre- scription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket responsibility.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. Unless otherwise authorized by Blue Shield or the MHSA, all Benefits must be provided by Participating Providers or MHSA Participating Providers. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- cost-effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary nec- xxxxxx services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizationshos- pitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard stand- ard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter thereaf- ter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-well- being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal The Calendar Year medical plan Deductible amounts are shown in the Summary of Benefits. After the Calendar Year medical plan Deductible is satisfied for those Services to which the Deductible applies, Benefits and Coverages (Covered will be provided for covered Services) Blue Shield provides . The Calendar Year medical plan Deducti- ble amount must be made up of charges covered by the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges Plan. Charges in excess of Benefit maximumsthe Allowable Amount do not apply toward the Deductible. The medical plan Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately, Participating Provider provisions except that the medical plan De- ductible shall be deemed satisfied with respect to the Sub- xxxxxxx and Benefits Management Program provisionsall of his covered Dependents collectively after the Family Deductible amount has been satisfied. Coverage Note: The Deductible also applies to a newborn child or a child placed for these services adoption, who is subject covered for the first 31 days even if ap- plication is not made to add the child as a Dependent on the Plan. The Calendar Year medical plan Deductible amount does not count toward the Calendar Year Out-of-Pocket Max- imum responsibility. The Calendar Year medical plan Deductible applies to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth covered Services incurred during a Calendar Year except for those Services as shown in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Calendar Year per Member Brand Name Drug Deducti- ble is shown in the Summary of Benefits. After the Calendar Year per Member Brand Name Drug Deductible is satisfied for those Drugs to which the Deductible applies, Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible provided for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amountcovered Drugs. Except as specifically provided herein, services are The Calendar Year Brand Name Drug Deductible amount must be made up of charged covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services Plan. Charges in excess of the contracted rate do not apply toward the Deductible and the Deductible must be satisfied once during each Calendar Year by or on behalf of each Member separately. Note: The Calendar Year Deductible is operating within separate from the scope of that license or certificationBrand Name Drug Deductible included in the Outpatient Pre- scription Drug Benefit. The Brand Name Drug Deductible does not count toward the Medical Plan Deductible nor toward the Subscriber’s Calen- dar Year Out-of-Pocket Maximum responsibility.

Case Management. The Benefits Management Program may also include in- clude case management, which is a service that provides the assistance of a health care professional profes- sional to help the Member access necessary services ser- vices and to make the most efficient use of plan Plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically med- ically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this planPlan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan Health Plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person Member in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptomssymp- toms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed in- formed decisions about therapy, as well as documenting docu- xxxxxxx their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request re- quest more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable DeductiblesDe- ductibles, Copayments, Coinsurance, Coinsurance and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions ex- clusions of the Evidence of Coverage and Health AgreementContract, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, ExceptionsExcep- tions, Exclusions and Reductions listed in this Evidence of CoverageEOC. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service AgreementEOC. Except as may be specifically indicated, for services ser- vices received from Non-Participating Providers, subscribers Subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated in- dicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. Unless otherwise authorized by Blue Shield or the MHSA, all Benefits must be provided by Participating Providers or MHSA Participating Providers. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- cost-effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.

Case Management. The Benefits Management Program may also include case management, which is a service that provides the assistance of a health care professional to help the Member access necessary services and to make the most efficient use of plan Benefits. The Member’s nurse case manager may also arrange for alternative care benefits to avoid prolonged or repeated hospitalizations, when medically appropriate. Alternative care benefits are only utilized by mutual consent of the Member, the provider, and Blue Shield or Blue Shield’s MHSA, and will not exceed the standard Benefits available under this plan. The approval of alternative case benefits is specific to each Member for a specified period of time. Such approval should not be construed as a waiver of Blue Shield’s right to thereafter administer this health plan in strict accordance with its express terms. Blue Shield is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. In conjunction with Covered Services, Blue Shield provides palliative care services for Members with serious illnesses. Palliative care services include access to physicians and nurse case managers who are trained to assist Members in managing symptoms, in maximizing comfort, safety, autonomy and well-being, and in navigating a course of care. Members can obtain assistance in making informed decisions about therapy, as well as documenting their quality of life choices. Members may call the Customer Service Department at the number provided on the back page of this Agreement to request more information about these services. Principal Benefits and Coverages (Covered Services) Blue Shield provides the following Medically Necessary Benefits, subject to applicable Deductibles, Copayments, Coinsurance, and charges in excess of Benefit maximums, Participating Provider provisions and Benefits Management Program provisions. Coverage for these services is subject to all terms, conditions, limitations and exclusions of the Evidence of Coverage and Health Agreement, including but not limited to, any conditions or limitations set forth in the Benefit descriptions below, and to the Principal Limitations, Exceptions, Exclusions and Reductions listed in this Evidence of Coverage. All Benefits must be Medically Necessary to be covered. If there are two or more Medically Necessary services that may be provided for the illness, injury or medical condition, Blue Shield will provide Benefits based on the most cost- effective service. The Copayment and Coinsurance amounts for Covered Services, if applicable, are shown on the Summary of Benefits. The Summary of Benefits is provided with, and is incorporated as part of, this Evidence of Coverage and Health Service Agreement. Except as may be specifically indicated, for services received from Non-Participating Providers, subscribers will be responsible for all charges above the Allowable Amount in addition to the indicated Copayment or Coinsurance amount. Except as specifically provided herein, services are covered only when rendered by an individual or entity that is licensed or certified by the state to provide health care services and is operating within the scope of that license or certification.