Common use of EXTERNAL APPEAL PROCEDURE Clause in Contracts

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 Skilled Nursing Facility Services B–27 7 Home Health Care Services B–29 8 Hospice Care Services B–32 9 Mental Health and Substance Use Disorder Services B–34 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 General Provisions B–46 15 Exclusions and Limitations B–52 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 four (4) months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: SAMPLE Director, District of Columbia Department of Health Care Finance Office of Health Care Ombudsman and Bill of Rights One Judiciary Square 000 0xx Xx. XX, Xxxxx 000 Xxxxx Xxxxxxxxxx, XX 00000 If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 B–24 5 Inpatient Hospital Services B–24 B–25 6 Skilled Nursing Facility Services B–27 B–28 7 Home Health Care Services B–29 8 Hospice Care Services B–32 B–31 9 Mental Health and Substance Use Disorder Services B–34 B–33 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–39 12 B–36 11 Prescription Drugs B–43 B–40 12 Patient-Centered Medical Home B–42 13 Care Support Programs B–45 B–43 14 General Provisions B–46 B–44 15 Utilization Management B–51 16 Exclusions and Limitations B–52 B–54 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 four (4) months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: SAMPLE Director, District of Columbia Department of Health Care Finance Office of Health Care Ombudsman and Xxxx of Rights One Judiciary Square 000 0xx Xx. XX, Xxxxx 000 Xxxxx Xxxxxxxxxx, XX 00000 If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 Skilled Nursing Facility Services B–27 7 Home Health Care Services B–29 B–28 8 Hospice Care Services B–32 B–30 9 Mental Health and Substance Use Disorder Services B–34 B–32 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–35 11 Prescription Drugs B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 B–41 13 General Provisions B–46 B–42 14 Utilization Management B–48 15 Exclusions and Limitations B–52 B–51 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 B–24 5 Inpatient Hospital Services B–24 B–25 6 Skilled Nursing Facility Services B–27 B–28 7 Home Health Care Services B–29 B–30 8 Hospice Care Services B–32 B–33 9 Mental Health and Substance Use Disorder Services B–34 B–35 10 Emergency Services and Urgent Care B–37 B–38 11 Medical Devices and Supplies B–39 B–40 12 Prescription Drugs B–43 B–44 13 Patient-Centered Medical Home B–46 14 Care Support Programs B–45 14 B–47 15 General Provisions B–46 15 B–48 16 Exclusions and Limitations B–52 B–54 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 four (4) months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Bill of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the AgreementEvidence of Coverage. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred Incurred by a Member, including any extension of benefits for which the Member is eligible. Refer It is important to refer to the Agreement for additional definitions Schedule of capitalized terms included in this Description Benefits to determine the percentage of Covered Servicesthe Allowed Benefit that CareFirst will pay and any specific limits on the number of services that will be covered. SAMPLE [Name] [Title] The Schedule of Benefits also lists important information about Deductibles, the Out-of-Pocket Limit and other features that affect Member coverage, including specific benefit limitations and, if applicable, the Lifetime Maximum. President and Chief Executive Officer SECTION TABLE OF CONTENTS PAGE 1 General Provisions B-3 2 Outpatient Facility, Office, and Professional Office Services B–3 2 Pediatric Dental Services B–16 B-5 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 B-14 4 Skilled Nursing Facility Services B–27 7 B-17 5 Home Health Care Services B–29 8 B-19 6 Hospice Care Services B–32 9 B-21 7 Mental Health and Substance Use Disorder Abuse Services B–34 10 Emergency Services and Urgent Care B–37 11 B-23 8 Medical Devices and Supplies B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 General Provisions B–46 15 B-26 9 Utilization Management Requirements B-29 10 Exclusions and Limitations B–52 SAMPLEB-32

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 four (4) months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: SAMPLE Director, District of Columbia Department of Health Care Finance Office of Health Care Ombudsman and Bill of Rights One Judiciary Square 000 0xx Xx. XX, Xxxxx 000 Xxxxx Xxxxxxxxxx, XX 00000 If a Member is dissatisfied with the resolution reached through CareFirst BlueChoiceCareFirst’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 3 Pediatric Vision Services B–21 4 Adult Vision Services B–23 5 Inpatient Hospital Services B–24 6 Skilled Nursing Facility Services B–27 7 Home Health Care Services B–29 B–28 8 Hospice Care Services B–32 B–30 9 Mental Health and Substance Use Disorder Services B–34 B–32 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–35 11 Prescription Drugs B–39 12 Prescription Drugs B–43 13 Care Support Programs B–45 14 B–41 13 General Provisions B–46 B–42 14 Utilization Management B–48 15 Exclusions and Limitations B–52 B–51 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Xxxx of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Commissioner, Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process000 Xxxxx Xx. X.X., 0xx Xxxxx SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–14 3 Pediatric Vision Services B–21 B–19 4 Adult Vision Services B–23 B–21 5 Inpatient Hospital Services B–24 B–22 6 Skilled Nursing Facility Services B–27 B–25 7 Home Health Care Services B–29 B–26 8 Hospice Care Services B–32 B–28 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–30 10 Emergency Services and Urgent Care B–37 B–32 11 Medical Devices and Supplies B–39 B–34 12 Prescription Drugs B–43 B–38 13 Care Support Programs B–45 Patient-Centered Medical Home B–39 14 Complex Chronic or High Risk Acute Disease Management B–40 15 General Provisions B–46 15 B–44 16 Exclusions and Limitations B–52 B–49 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process relating to an Adverse Benefit Determination shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during United States Office of Personnel Management within one (1) year of the internal claims date of receipt of the decision. The complaint may be sent to: MSPP External Review National Healthcare Operations U.S. Office of Personnel Management 0000 X Xxxxxx, XX Facsimile: 000-000-0000 Email: xxxx@xxx.xxx Information concerning external review may be found on the U.S. Office of Personnel Management website: xxxx://xxx.xxx.xxx/healthcare-insurance/multi-state-plan- program/external-review/. The U.S. Office of Personnel Management’s jurisdiction for external review purposes encompasses appeals concerning medical judgments, contractual disputes and rescissions. In instances where an enrollee is appealing an adverse decision in an expedited (urgent) case, the enrollee may file his or her appeal processsimultaneously with CareFirst and the U.S. Office of Personnel Management. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–14 3 Pediatric Vision Services B–21 B–19 4 Adult Vision Services B–23 B–21 5 Inpatient Hospital Services B–24 B–22 6 Skilled Nursing Facility Services B–27 B–25 7 Home Health Care Services B–29 B–26 8 Hospice Care Services B–32 B–28 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–30 10 Emergency Services and Urgent Care B–37 11 Medical Devices and Supplies B–39 12 B–32 11 Prescription Drugs B–43 B–36 12 Patient-Centered Medical Home B–37 13 Care Support Programs B–45 Complex Chronic or High Risk Acute Disease Management B–38 14 General Provisions B–46 B–42 15 Utilization Management B–47 16 Exclusions and Limitations B–52 SAMPLEB–50

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Xxxx of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE Sample The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE Sample [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–15 3 Pediatric Vision Services B–21 B–20 4 Adult Vision Services B–23 B–22 5 Inpatient Hospital Services B–24 B–23 6 Skilled Nursing Facility Services B–27 B–26 7 Home Health Care Services B–29 B–28 8 Hospice Care Services B–32 B–31 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–33 10 Emergency Services and Urgent Care B–37 B–35 11 Medical Devices and Supplies B–39 B–37 12 Prescription Drugs B–41 13 Patient-Centered Medical Home B–42 14 Complex Chronic or High Risk Acute Disease Management B–43 13 Care Support Programs B–45 14 15 General Provisions B–46 15 B–47 16 Exclusions and Limitations B–52 SAMPLESample SECTION 1 OUTPATIENT FACILITY, OFFICE, AND PROFESSIONAL SERVICES

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Xxxx of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–15 3 Pediatric Vision Services B–21 B–20 4 Adult Vision Services B–23 B–22 5 Inpatient Hospital Services B–24 B–23 6 Skilled Nursing Facility Services B–27 B–26 7 Home Health Care Services B–29 B–28 8 Hospice Care Services B–32 B–31 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–33 10 Emergency Services and Urgent Care B–37 B–35 11 Medical Devices and Supplies B–39 B–37 12 Prescription Drugs B–41 13 Patient-Centered Medical Home B–42 14 Complex Chronic or High Risk Acute Disease Management B–43 13 Care Support Programs B–45 14 15 General Provisions B–46 15 B–47 16 Exclusions and Limitations B–52 SAMPLEB–52

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Xxxx of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–14 3 Pediatric Vision Services B–21 B–19 4 Adult Vision Services B–23 B–21 5 Inpatient Hospital Services B–24 B–22 6 Skilled Nursing Facility Services B–27 B–25 7 Home Health Care Services B–29 B–26 8 Hospice Care Services B–32 B–28 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–30 10 Emergency Services and Urgent Care B–37 B–32 11 Medical Devices and Supplies B–39 B–34 12 Prescription Drugs B–43 B–38 13 Care Support Programs B–45 Patient-Centered Medical Home B–39 14 Complex Chronic or High Risk Acute Disease Management B–40 15 General Provisions B–46 15 B–44 16 Exclusions and Limitations B–52 B–49 SAMPLE

EXTERNAL APPEAL PROCEDURE. A Member who is dissatisfied with a decision rendered in a final internal grievance process shall have the opportunity to pursue an appeal before an external independent review organization if filed within 4 months of the final grievance decision. If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding medical necessity, the Member may contact the Director Director, Office of Health Care Ombudsman and Xxxx of Rights, at the following: If a Member is dissatisfied with the resolution reached through CareFirst BlueChoice BlueChoice’s internal grievance system regarding all other grievances, the Member may contact the Commissioner at the following: A Member shall also have the option to contact the District of Columbia Department of Insurance, Securities and Banking to request an investigation or file a complaint with the Department at any time during the internal claims and appeal process. SAMPLE The services described herein are eligible for coverage under the Agreement. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services incurred by a Member, including any extension of benefits for which the Member is eligible. Refer to the Agreement for additional definitions of capitalized terms included in this Description of Covered Services. SAMPLE [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office, and Professional Services B–3 2 Pediatric Dental Services B–16 B–15 3 Pediatric Vision Services B–21 B–20 4 Adult Vision Services B–23 B–22 5 Inpatient Hospital Services B–24 B–23 6 Skilled Nursing Facility Services B–27 B–26 7 Home Health Care Services B–29 B–28 8 Hospice Care Services B–32 B–31 9 Mental Health and Substance Use Disorder Abuse Services B–34 B–33 10 Emergency Services and Urgent Care B–37 B–35 11 Medical Devices and Supplies B–39 B–37 12 Prescription Drugs B–41 13 Patient-Centered Medical Home B–42 14 Complex Chronic or High Risk Acute Disease Management B–43 13 Care Support Programs B–45 14 15 General Provisions B–46 15 B–47 16 Exclusions and Limitations B–52 SAMPLE