Common use of Centers of Excellence Clause in Contracts

Centers of Excellence. [Preferred Provider(s)] The following sections refer to charges incurred by a Covered Person for Covered Services provided at Centers of Excellence [by Preferred Providers]: 2.27.1 The Covered Person has obtained written Prior Authorization from Company or Company's agent to receive Services from a Center of Excellence [Preferred Providers] and has agreed to receive Services from such Center of Excellence [Preferred Providers] chosen by Company or Company's agent. No Prior Authorization shall be required for Emergency or PPACA Emergency cases and the Covered Person may select the Center of Excellence [Preferred Providers] where Emergency or PPACA Emergency Services shall be rendered. 2.27.2 Company is the primary payor based on the coordination of benefits provisions of this Certificate, unless the primary payor is Medicare for those Centers of Excellence located in the United States; provided, however, the Company shall be the primary payor for Centers of Excellence [Preferred Providers] outside of the United States and located in the Philippines’, Korea, Japan, or other Pacific-Asian locations. 2.27.3 For Inpatient Services which are unavailable in Guam and rendered by the Center of Excellence [Preferred Providers]. 2.27.3.1 Company shall pay 100% of these services. 2.27.3.2 Company shall waive any co-insurance for such Services. 2.27.3.3 Company shall only provide airfare for the Covered Person for the most direct route to and from the location of the Covered Person and the Center of Excellence [Preferred Providers] as determined by Company. Regardless of the location of the Covered Person, or if it is Medically Necessary to provide for a break in the trip, Company shall provide the lesser of the lowest applicable economy airfare or the lowest economy, round-trip airfare on a commercial direct flight between Guam and the Center of Excellence [Preferred Providers]. In no event shall Company provide an air ambulance. 2.27.3.4 If the Service is one of the following specific procedures or conditions: open heart surgery, oncology surgery to include but not limited to the following cancers brain, lung, liver, kidney, adrenal, nasopharyngeal, tongue, prostate, colon, genito-urinary, breast and gynecological oncology, aneurysmectomy, pneumonectomy, intra cranial surgery, acute leukemia, gamma knife or if the level of care required is NlCU Level Ill, or if the expected cost to the Company for off-island Covered Services exceeds $25,000.00, Company shall pay the air fare of one companion of the Covered Person to the Center of Excellence [Preferred Providers] under the terms set forth in §2.27.3.3. 2.27.3.5 If it is Medically Necessary that a licensed medical attendant be with the Covered Person, Company shall provide for one airline seat for such attendant under the same terms set forth in §2.27.3.3. 2.27.3.6 If the Covered Person is unable to self-care, Company shall provide for one airline seat for a qualified assistant under the same terms as §2.27.3.3. 2.27.3.7 Company may, at its option, make the travel arrangements for the Covered Person and his or her companion, attendant or assistant (if any) and purchase the airline tickets. In the event the covered person/attendant purchases the seat(s), the Company will reimburse for actual expenses incurred in purchasing Medically Necessary seat(s), but not more than the Company would have paid had it purchased the seat(s) for the companion in advance. In no event will Company reimburse for any seat(s) purchased with frequent flyer miles. 2.27.3.8 Company shall facilitate the Hospital/Physician arrangements for the Covered Person. 2.27.3.9 For Company to be liable to pay any airfare, the proposed Service to be performed at the Center of Excellence [Preferred Providers] must be a specific procedure and not merely a diagnostic work-up or to confirm or rule out the diagnosis of another Physician. 2.27.4 For Ambulatory Surgical Center Services which are unavailable in Guam and rendered by Center of Excellence [Preferred Providers]: 2.27.4.1 Company shall waive the twenty percent (20%) Co-Insurance. 2.27.4.2 Company shall facilitate the Surgicenter/Physician arrangements for the Covered Person. 2.27.5 Inpatient and Ambulatory Surgical Center Services which are unavailable in Guam and rendered by Center of Excellence [Preferred Providers]: 2.27.5.1 Company shall waive the twenty percent (20%) Co-Insurance. 2.27.5.2 Company shall facilitate the Surgicenter/Physician arrangements for the Covered Person. 2.27.6 Only those facilities identified as Centers of Excellence [Preferred Providers] in the Company's most recently updated Provider Directory will qualify for the airfare benefit.

Centers of Excellence. [Preferred Provider(s)] The following sections refer to charges incurred by a Covered Person for Covered Services provided at Centers of Excellence [by Preferred Providers]: 2.27.1 2.30.1 The Covered Person has obtained written Prior Authorization from Company or Company's agent to receive Services from a Center of Excellence [Preferred Providers] and has agreed to receive Services from such Center of Excellence [Preferred Providers] chosen by Company or Company's agent. No Prior Authorization shall be required for Emergency or PPACA Emergency cases and the Covered Person may select the Center of Excellence [Preferred Providers] where Emergency or PPACA Emergency Services shall be rendered. 2.27.2 2.30.2 Company is the primary payor based on the coordination of benefits provisions of this Certificate, unless the primary payor is Medicare for those Centers of Excellence located in the United States; provided, however, the Company shall be the primary payor for Centers of Excellence [Preferred Providers] outside of the United States and located in the Philippines’, Korea, Japan, or other Pacific-Asian locations. 2.27.3 2.30.3 For Inpatient Services which are unavailable in Guam and rendered by the Center of Excellence [Preferred Providers]. 2.27.3.1 2.30.3.1 Company shall pay 100% of these services. 2.27.3.2 2.30.3.2 Company shall waive any co-insurance for such Services. 2.27.3.3 2.30.3.3 Company shall only provide airfare for the Covered Person for the most direct route to and from the location of the Covered Person and the Center of Excellence [Preferred Providers] as determined by Company. Regardless of the location of the Covered Person, or if it is Medically Necessary to provide for a break in the trip, Company shall provide the lesser of the lowest applicable economy airfare or the lowest economy, round-trip airfare on a commercial direct flight between Guam and the Center of Excellence [Preferred Providers]. In no event shall Company provide an air ambulance. 2.27.3.4 2.30.3.4 If the Service is one of the following specific procedures or conditions: open heart surgery, oncology surgery to include but not limited to the following cancers brain, lung, liver, kidney, adrenal, nasopharyngeal, tongue, prostate, colon, genito-genito- urinary, breast and gynecological oncology, aneurysmectomy, pneumonectomy, intra cranial surgery, acute leukemia, gamma knife or if the level of care required is NlCU Level Ill, or if the expected cost to the Company for off-island Covered Services exceeds $25,000.00, Company shall pay the air fare of one companion of the Covered Person to the Center of Excellence [Preferred Providers] under the terms set forth in §2.27.3.32.28.3.3. 2.27.3.5 2.30.3.5 If it is Medically Necessary that a licensed medical attendant be with the Covered Person, Company shall provide for one airline seat for such attendant under the same terms set forth in §2.27.3.32.28.3.3. 2.27.3.6 2.30.3.6 If the Covered Person is unable to self-care, Company shall provide for one airline seat for a qualified assistant under the same terms as §2.27.3.32.28.3.3. 2.27.3.7 2.30.3.7 Company may, at its option, make the travel arrangements for the Covered Person and his or her companion, attendant or assistant (if any) and purchase the airline tickets. In the event the covered person/attendant purchases the seat(s), the Company will reimburse for actual expenses incurred in purchasing Medically Necessary seat(s), but not more than the Company would have paid had it purchased the seat(s) for the companion in advance. In no event will Company reimburse for any seat(s) purchased with frequent flyer miles. 2.27.3.8 2.30.3.8 Company shall facilitate the Hospital/Physician arrangements for the Covered Person. 2.27.3.9 2.30.3.9 For Company to be liable to pay any airfare, the proposed Service to be performed at the Center of Excellence [Preferred Providers] must be a specific procedure and not merely a diagnostic work-up or to confirm or rule out the diagnosis of another Physician. 2.27.4 2.30.4 For Ambulatory Surgical Center Services which are unavailable in Guam and rendered by Center of Excellence [Preferred Providers]: 2.27.4.1 2.30.4.1 Company shall waive the twenty percent (20%) Co-Insurance. 2.27.4.2 2.30.4.2 Company shall facilitate the Surgicenter/Physician arrangements for the Covered Person. 2.27.5 2.30.5 Inpatient and Ambulatory Surgical Center Services which are unavailable in Guam and rendered by Center of Excellence [Preferred Providers]: 2.27.5.1 2.30.5.1 Company shall waive the twenty percent (20%) Co-Insurance. 2.27.5.2 2.30.5.2 Company shall facilitate the Surgicenter/Physician arrangements for the Covered Person. 2.27.6 2.30.6 Only those facilities identified as Centers of Excellence [Preferred Providers] in the Company's most recently updated Provider Directory will qualify for the airfare benefit.