Common use of Continuity of Care Clause in Contracts

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a course of treatment for a serious and complex condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the Complaint and Appeal Procedures section of this Certificate.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life- threatening illness or condition, is are past the twenty- fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty- fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-check- up within the first six (6) weeks of delivery. Specialist as PCP If You have been diagnosed with a chronic, disabling, or life- threatening illness, You may contact customer service at the right toll- free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal any the decision made for a request for benefits under this subsection as explained described in the Complaint and Appeal Procedures section Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out- of- Network Services You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court- ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non- Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non- Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non- PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. Provider Communication HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. Your Responsibilities • You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided to HMO at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. Refusal to Accept Treatment You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as incompatible with continuance of the Provider- patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in a manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a course of treatment for a serious and complex condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the Complaint and Appeal Procedures COMPLAINT AND APPEAL PROCEDURES section of this Certificate.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: •  You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life- threatening illness or condition, is are past the twenty- fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; •  the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and •  the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty- fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-check- up within the first six (6) weeks of delivery. Specialist as PCP If You have been diagnosed with a chronic, disabling, or life- threatening illness, You may contact customer service at the right toll- free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in COMPLAINT AND APPEAL PROCEDURES. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out- of- Network Services You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court- ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non- Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply.  The request must be from a Participating Provider.  Reasonably requested documentation must be received by HMO.  The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition.  When HMO has allowed Referral to a non- Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services.  Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non- PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. Provider Communication HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. Your Responsibilities  You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection as explained Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief.  You shall notify HMO immediately of any change of address for You or any of Your covered Dependents.  You understand that HMO is acting in the Complaint reliance upon all information You provided to HMO at time of enrollment and Appeal Procedures section of afterwards and represents that information so provided is true and accurate.  By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof.  You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. Refusal to Accept Treatment You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as incompatible with continuance of the Provider- patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in a manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or postlife-operative visits for a serious acute disease or condition), and (2) for a chronic threatening illness or condition, is are past the twenty-fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty-fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- follow-up check-up within the first six (6) weeks of delivery. Specialist as PCP If You have been diagnosed with a chronic, disabling, or life-threatening illness, You may contact customer service at the right toll-free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal any the decision made for a request for benefits under this subsection as explained described in the Complaint and Appeal Procedures section Procedures. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out-of-Network Services You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court-ordered Dependents living outside the Service Area may use non-Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non-Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non-Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non-PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. Provider Communication HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. Your Responsibilities • You shall complete and submit an application or other forms or statements that may be reasonably requested. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. Refusal to Accept Treatment You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as incompatible with continuance of the Provider-patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in a manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. If You you are under the care of a Participating Provider who stops participating in HMO’s networkNetwork provider for one of the medical conditions below, (and the Network provider caring for you is terminated from the Network by us for reasons other than failure cause, we can arrange, at your request and subject to meet applicable quality standardsthe provider's agreement, including medical incompetence or professional behaviorfor continuation of Covered Health Care Services rendered by the terminated provider for the services and time periods shown below. Co-payments, Co-insurance, deductibles, or other cost sharing components will be the same as you would have paid for fraud), HMO a provider currently contracting with us. Medical conditions and time periods for which ongoing treatment by such a terminated Network provider will continue coverage for that Provider’s Covered Services if all be covered under the following conditions are metPolicy are: • You are undergoing a An active course of treatment begun before the provider terminated. Treatment by the terminated provider may continue for a serious and complex condition, You up to 90 days. • A Pregnancy that has reached the second or third trimester. Treatment by the terminated provider may continue until the postpartum services directly related to the pregnancy are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a completed. SAMPLE • A specified course of treatment directly related to the treatment of an advanced illness or a related condition that began before the date of the provider's termination. Continuity of care may last for the pregnancyremainder of the Covered Person's life or until coverage under the Policy terminates. If you are informed that your provider is no longer part of the UnitedHealthcare network of providers, and you believe that you may qualify for continuity of care with that provider, contact us at the telephone number on the back of your ID card. Outpatient Prescription Drugs Schedule of Benefits When Are Benefits Available for Prescription Drug Products? Benefits are available for Prescription Drug Products at a Network Pharmacy and are subject to Co-payments and/or Co-insurance or other payments that vary depending on which of the tiers of the Prescription Drug List the Prescription Drug Product is placed. Benefits for Prescription Drug Products are available when the Prescription Drug Product meets the definition of a Covered Health Care Service. What Happens When a Brand-name Drug Becomes Available as a Generic? If a Generic becomes available for a Brand-name Prescription Drug Product, the tier placement of the Brand-name Prescription Drug Product may change. Therefore, your Co-payment and/or Co-insurance may change or you will no longer have Benefits for that particular Brand-name Prescription Drug Product. How Do Supply Limits Apply? Benefits for Prescription Drug Products are subject to the supply limits that are stated in the "Description and Supply Limits" column of the Benefit Information table. For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. SAMPLE Note: Some products are subject to additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change. This may limit the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply, or may require that a minimum amount be dispensed. You may find out whether a Prescription Drug Product has a supply limit for dispensing by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. Do Prior Authorization Requirements Apply? Before certain Prescription Drug Products are determined dispensed to you, you are required to obtain prior authorization from us or our designee. The reason for obtaining prior authorization from us is to determine whether the Prescription Drug Product, in accordance with our approved guidelines, is each of the following: • It meets the definition of a Covered Health Care Service. • It is not an Experimental or Investigational or Unproven Service. We may also require you to obtain prior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approved guidelines, was prescribed by a Specialist. If you do not obtain prior authorization from us before the Prescription Drug Product is dispensed, you will be terminally illresponsible for paying all charges and no Benefits will be paid. A serious The Prescription Drug Products requiring prior authorization are subject, from time to time, to our review and complex condition change. There may be certain Prescription Drug Products that require you to notify us directly rather than your Physician or pharmacist. You may find out whether a particular Prescription Drug Product requires notification/prior authorization by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. If you do not obtain prior authorization from us before the Prescription Drug Product is one dispensed, you can ask us to consider reimbursement after you receive the Prescription Drug Product. You will be required to pay for the Prescription Drug Product at the pharmacy. You may seek reimbursement from us as described in the Policy in Section 5: How to File a Claim. When you submit a claim on this basis, you may pay more because you did not obtain prior authorization from us before the Prescription Drug Product was dispensed. The amount you are reimbursed will be based on the Prescription Drug Charge, less the required Co-payment and/or Co-insurance and any deductible that applies. Benefits may not be available for the Prescription Drug Product after we review the documentation provided and we determine that the Prescription Drug Product is not a Covered Health Care Service or it is an Experimental or Investigational or Unproven Service. We may also require prior authorization for certain programs which may have specific requirements for participation and/or activation of an enhanced level of Benefits related to such programs. You may access information on available programs and any applicable prior authorization, participation or activation requirements related to such programs by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. Does Step Therapy Apply? Certain Prescription Drug Products for which Benefits are described under Section 10: Outpatient Prescription Drugs of the Policy are subject to step therapy requirements. In order to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether a Prescription Drug Product is subject to step therapy requirements by contacting us at xxx.xxxxx.xxx/xxxxxxxx or the telephone number on your ID card. Your Right to Request an Exception When a Medication is Not Listed on the Prescription Drug List (1PDL) When a Prescription Drug Product is not listed on the PDL, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours. Please note, if your request for an acute illnessexception is approved by us, is serious enough to require specialized medical treatment to avoid you may be responsible for paying the reasonable possibility of death applicable Co- payment and/or Co-insurance based on the Prescription Drug Product tier placement, or permanent harm care (for at the second highest tier. For example, You are currently receiving chemotherapyif you have a 5-tier plan, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • then the Provider submits a request to HMO to continue coverage of Your care that identifies 4th tier would be considered the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the Complaint and Appeal Procedures section of this Certificatesecond highest tier.

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: •  You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life- threatening illness or condition, is are past the twenty- fourth (i24th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • Sample  the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and •  the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth twenty- fourth (13th24th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-check- up within the first six (6) weeks of delivery. Specialist as PCP If You have been diagnosed with a chronic, disabling, or life- threatening illness, You may contact customer service at the right toll- free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO’s requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal the decision as described in COMPLAINT AND APPEAL PROCEDURES. If Your request is approved, the Specialist’s designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any decision made Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out- of- Network Services You may obtain Covered Services from Providers who are not part of HMO’s network of Participating Providers when receiving Emergency Care. Also, court- ordered Dependents living outside the Service Area may use non- Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non- Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP’s Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO’s entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply.  The request must be from a Participating Provider.  Reasonably requested documentation must be received by HMO.  The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. Sample  When HMO has allowed Referral to a non- Participating Provider, HMO will reimburse the non- Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services.  Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non- PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a request for benefits Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. Provider Communication HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider’s contract with HMO has terminated or that the Provider will no longer be providing services under HMO. Your Responsibilities  You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this subsection as explained Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief.  You shall notify HMO immediately of any change of address for You or any of Your covered Dependents.  You understand that HMO is acting in the Complaint reliance upon all information You provided to HMO at time of enrollment and Appeal Procedures section of afterwards and represents that information so provided is true and accurate.  By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof.  You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. Refusal to Accept Treatment You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as incompatible with continuance of the Provider- patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in a manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider’s judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.

Continuity of Care. ‌ The CHC-MCO must provide continuity of care to Participants who are receiving LTSS as follows:‌  For a Participant who is a NF resident on his/her Effective Date of Enrollment and the First Enrollment Effective Date of any Enrollment into the CHC program in the zone in which the Participant resides, the continuity of care period will run from the Participant’s Effective Date of Enrollment into the CHC-MCO for the duration of the Participants’ residency in the Nursing Facility. The CHC-MCO must enter into a contract or payment arrangement with the resident’s NF to make payments for the Participant’s Nursing Facility services, whether or not the Nursing Facilities is in the CHC-MCO network The CHC-MCO must provide services and payment for all Participants who are in an NF on the date of Enrollment even if the NF does not enroll as a provider.Provider. The CHC-MCO is prohibited from interfering with a Participant’s choice of NF. This continuity of care period shall continue so long as the Participant remains a resident of the same NF and shall apply to each enrollment into a CHC-MCO, whether at the first effective date of enrollment or at some time later in the operation of the CHC program if the Participant chooses to transfer to a CHC-MCO.‌  For a Participant who is receiving LTSS through an HCBS Waiver program on his or her Effective Date of Enrollment, the continuity of care period for continuation of services provided under all existing PCSPs through all existing service Providers will run from the Effective Date of Enrollment into the CHC-MCO for 180 days or until a comprehensive needs assessment has been completed and a PCSP has been developed and implemented, whichever date is later. If You are under a Participant chooses to transfer to a different CHC-MCO, the care receiving CHC-MCO must continue to provide the previously authorized services for 60 days or until a comprehensive needs assessment has been completed and a PCSP been developed and implemented, whichever date is later.‌  For a Participant who is receiving LTSS but whose LTSS Provider leaves the CHC-MCO Provider Network, the CHC-MCO must continue to allow the Participant to receive services for a 60 day period and must pay that Provider until such time as an alternative Network Provider can be identified and begins to deliver the same LTSS services as the former Provider.‌  For all Participants, the Continuity of a Participating Provider who stops participating in HMO’s networkCare period for continuation of healthcare Providers, (for reasons other than failure to meet applicable quality standardsservices, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s Covered Services if all the following conditions are met: • You are undergoing a and any ongoing course of treatment is governed by the requirements outlined in Section 2117 of Article XXI of the Insurance Company Law of 1921, as amended, 40 P.S. §991.2117, regarding continuity of care requirements and 28 PACode §9.684 and 31 PA Code §154.15. The CHC-MCO must comply with the procedures outlined in Medical Assistance Bulletin 99-03-13, Continuity of Care for a serious Recipients Transferring Between and complex conditionAmong Fee-for-Service and Managed Care Organizations, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt ensure continuity of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment Prior Authorized Services for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or postindividuals age twenty-operative visits for a serious acute disease or condition), and (2) for a chronic illness or condition, is (i) life-threatening, degenerative, disabling or potentially disabling, or congenital, and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up within the first six (6) weeks of delivery. You have the right to appeal any decision made for a request for benefits under this subsection as explained in the Complaint and Appeal Procedures section of this Certificate.one

Continuity of Care. If You are under the care of a Participating Provider who stops participating in HMO’s 's network, (for reasons other than failure to meet applicable quality standards, including medical incompetence or professional behavior, or for fraud), HMO will continue coverage for that Provider’s 's Covered Services if all the following conditions are met: • You are undergoing have a course of treatment for a serious and complex disability, acute condition, You are undergoing institutional or inpatient care, You are scheduled to undergo nonelective surgery from the Provider (including receipt of postoperative care from such Provider with respect to such surgery), You are pregnant or undergoing a course of treatment for the pregnancy, or You are determined to be terminally ill. A serious and complex condition is one that (1) for an acute illness, is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm care (for example, You are currently receiving chemotherapy, radiation therapy, or post-operative visits for a serious acute disease or condition), and (2) for a chronic life‐threatening illness or condition, is are past the thirteenth (i13th) life-threatening, degenerative, disabling or potentially disabling, or congenital, week of pregnancy; and (ii) requires specialized medical care over a prolonged period of time; • the Provider submits a written request to HMO to continue coverage of Your care that identifies the condition for which You are being treated and, where required, and indicates that the Provider reasonably believes that discontinuing treatment could cause You harm; and • the Provider agrees to continue accepting the same reimbursement that applied when participating in HMO’s 's network, and not to seek payment from You for any amounts for which You would not be responsible if the Provider were still participating in HMO’s 's network. Continuity coverage shall continue until the treatment is complete but shall not extend for more than ninety (90) days (or more than nine (9) months if You have been diagnosed with a terminal illness) beyond the date the Provider’s 's termination takes effect. If You are past the thirteenth (13th) week of pregnancy when the Provider’s 's termination takes effect, coverage may be extended through delivery, immediate postpartum care and the follow- up check-up follow‐up check‐up within the first six (6) weeks of delivery. Specialist as PCP If You have been diagnosed with a chronic, disabling, or life‐threatening illness, You may contact customer service at the right toll‐free telephone number on Your identification card to get information to submit for approval from the HMO Medical Director to choose a Participating Specialist as Your PCP. The Medical Director will require both You and the Participating Specialist interested in serving as Your PCP to sign a certification of medical need, to submit along with all supporting documentation. The Participating Specialist must meet HMO's requirements for PCP participation and be willing to accept the coordination of all Your healthcare needs. If Your request is denied, You may appeal any the decision made for a request for benefits under this subsection as explained described in the Complaint and Appeal Procedures section Procedures. If Your request is approved, the Specialist's designation as Your PCP will not be effective retroactively. As used herein, “life threatening,” means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. Availability of Providers HMO cannot guarantee the availability or continued participation of a particular Provider. Either HMO or any Participating Provider may terminate the Provider contract or limit the number of Members that will be accepted as patients. If the PCP initially selected cannot accept additional patients, You will be given an opportunity to make another PCP selection. You must then cooperate with HMO to select another PCP. Out‐of‐Network Services You may obtain Covered Services from Providers who are not part of HMO's network of Participating Providers when receiving Emergency Care. Also, court‐ordered Dependents living outside the Service Area may use non‐Participating Providers. If Covered Services are not available from Participating Providers within the access requirements established by law and regulation, HMO will allow a Referral by Your PCP to a non‐Participating Provider, if approved by HMO. If Your PCP is in a Limited Provider Network, in determining whether a Covered Service is available through Participating Providers, HMO will first consider Participating Providers in the PCP's Limited Provider Network. If the Covered Service is not available in the Limited Provider Network, then HMO's entire network will be considered. You will not be required to change Your PCP or Participating Specialist Providers to receive Covered Services that are not available from Participating Providers within the Limited Provider Network, but the following apply. • The request must be from a Participating Provider. • Reasonably requested documentation must be received by HMO. • The Referral will be provided within an appropriate time, not to exceed five business days, based on the circumstances and Your condition. • When HMO has allowed Referral to a non‐Participating Provider, HMO will reimburse the non‐Participating Provider at the usual and customary rate or otherwise agreed rate, less the applicable Copayment(s). You are responsible only for the Copayments for such Covered Services. • Before HMO denies a Referral, a review will be conducted by a Specialist of the same or similar specialty as the type of Provider to whom a Referral is requested. Inpatient Care by Non‐PCP During an inpatient stay at a Participating Hospital, Skilled Nursing Facility or other Participating facility, it may be appropriate for a Physician other than Your PCP to direct and oversee Your care, if Your PCP does not do so. However, upon discharge, You must return to the care of Your PCP or have Your PCP coordinate care that may be Medically Necessary. Provider Communication HMO will not prohibit, attempt to prohibit or discourage any Provider from discussing or communicating to You or Your designee any information or opinions regarding Your health care, any provisions of the Health Benefit Plan as it relates to Your medical needs or the fact that the Provider's contract with HMO has terminated or that the Provider will no longer be providing services under HMO. Your Responsibilities • You shall complete and submit to HMO an application or other forms or statements that HMO may reasonably request. You agree that all information contained in the applications, forms and statements submitted to HMO due to enrollment under this Certificate or the administration herein shall be true, correct, and complete to the best of Your knowledge and belief. • You shall notify HMO immediately of any change of address for You or any of Your covered Dependents. • You understand that HMO is acting in reliance upon all information You provided to HMO at time of enrollment and afterwards and represents that information so provided is true and accurate. • By electing coverage pursuant to this Certificate, or accepting benefits hereunder, all Members who are legally capable of contracting, and the legal representatives of all Members who are incapable of contracting, at time of enrollment and afterwards, represent that all information so provided is true and accurate and agree to all terms, conditions and provisions hereof. • You are subject to and shall abide by the rules and regulations of each Provider from which benefits are provided. Refusal to Accept Treatment You may, for personal reasons, refuse to accept procedures or treatment by a Participating Provider. Participating Providers may regard such refusal to accept their recommendations as incompatible with continuance of the Provider‐patient relationship and as obstructing the provision of proper medical care. Participating Providers shall use their best efforts to render all necessary and appropriate Professional Services in a manner compatible with Your wishes, insofar as this can be done consistent with the Participating Provider's judgment as to the requirements of proper medical practice. If You refuse to follow a recommended treatment or procedure, and the Participating Provider informed You of his belief that no professionally acceptable alternative exists, neither HMO nor any Participating Provider shall have any further responsibility to provide care for the condition under treatment.