Common use of COVERED HEALTHCARE SERVICES Clause in Contracts

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits.  Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see ‌ Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits and Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Pharmacy Benefits Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to determine children from birth to thirty-six (36) months. The child must be enrolled in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider. Members not living in Rhode Island may seek services from the amount that you pay state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and any benefit limitslanguage therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits.  Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your in-network PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. • Provided by an in-network provider or out-of-network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. ‌ This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits. Ambulance Services‌ Ground Ambulance This plan covers local professional or municipal ground ambulance services when it is medically necessary to use these services, rather than any other form of transportation as required under R.I. General Law § 27-20-55. Examples include but are not limited to the following: • from a hospital to a home, a skilled nursing facility, or a rehabilitation facility after being discharged as an inpatient; • to the closest available hospital emergency room in an emergency situation; or • from a physician’s office to an emergency room. Our allowance for ground ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided. Air and Water Ambulance This plan covers air and water ambulance services when: • the time needed to move a patient by land, or the instability of transportation by land, may threaten a patient’s condition or survival; or • if the proper equipment needed to treat the patient is not available from a ground ambulance. The patient must be transported to the nearest facility where the required services can be performed and the type of physician needed to treat the patient’s condition is available. Our allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, as well as any drugs, supplies and cardiac monitoring provided.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your in-network PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits.  Provided by an in-network provider or out-of-network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits.  Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: •  Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. •  Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. •  Not listed in Exclusions Section. •  Received while a member is enrolled in the plan. •  Consistent with applicable state or federal law.  Provided by a network provider. This requirement does not apply to emergency services, and other exceptions as described in Section 6. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: •  the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; •  final Food and Drug Administration (FDA) approval; •  the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; •  submission to us of a claim meeting the criteria above; and •  generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

COVERED HEALTHCARE SERVICES. This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. • Provided with a referral from your PCP. This requirement does not apply to emergency services, self-referral services and other exceptions as described in the Summary of Medical Benefits. When you receive healthcare services or supplies from a network provider in a state other than Rhode Island, your coverage and other requirements for healthcare services may be different from those described in this agreement. In this case, you may be entitled to receive additional coverage under this health plan as required by that state’s law. You should call our customer service office for more help if this applies to you. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.