Common use of Member Reimbursement Clause in Contracts

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000‐ 923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  ⮚ Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion ⮚ Rehabilitation and Therapy u Prior Auth Required Exclusion This benefit includes one or more exclusions as specified in the Exclusions section.  Prior Auth Required • Rehabilitation and Therapy Services requires Prior Authorization.  • Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  • Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   🖐 • Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to us a Provider for reimbursementany sums owed to the Provider by Presbyterian. The DMR Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement form together with and attach the itemized cash register receipt must contain and the prescription drug detail (pharmacy pamphlet) along with the following information: o · Patient’s name and ID number o Name and quantity · Patient’s Date of Birth · Name of the drug o · Quantity dispensed · NDC (National Drug Code · Fill Date purchased o · Name of Prescriber · Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o · Reason for the purchase (nature of emergency) o · Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY number 711. Please follow the mailing instructions on the Direct Member Reimbursement form. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies, and Members to address pharmacy benefit questions. Please contact them at 711 (000) 000-0000 or toll-free at 0-000-000-0000 and follow the voice prompts and select Pharmacy.. A registered professional nurse or visit physician shall be immediately available by phone 24 hours a day, seven days a week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free phone number to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate phone access 24 hours a day, seven days a week to their PCP or the Pharmacy page of our website at xxx.xxx.xxxprovider’s authorized on-call back-up provider.  Reconstructive Surgery Exclusion This benefit includes one When these providers are unavailable, a registered nurse or more exclusions as specified in physician on the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery utilization management staff must be prescribed available to respond to inquiries concerning emergency or Urgent Care. In the event medically necessary covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer specialist similar to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer type of specialist to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in whom a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation referral is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andrequested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000‐ 923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  ⮚ Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  ⮚ Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  • Rehabilitation and Therapy Services requires Prior Authorization.  • Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  • Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   🖐 • Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000‐ 923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; network however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of o Payment SC Call P 505‐923‐5678 1‐800‐356‐2219 PC 505‐923‐6980 1‐800‐923‐6980 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit xxx.xxx.xxx.  Reconstruct ve Surgery the Pharmacy page of our website at xxx.xxx.xxx.  Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered provided if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andR

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-In- network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can may pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to us a Provider for reimbursementany sums owed to the Provider by Presbyterian. The DMR Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement form together with and attach the itemized cash register receipt must contain and the prescription drug detail (pharmacy pamphlet) along with the following information: o · Patient’s name and ID number o Name and quantity · Patient’s Date of Birth · Name of the drug o · Quantity dispensed · NDC (National Drug Code · Fill Date purchased o · Name of Prescriber · Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o · Reason for the purchase (nature of emergency) o · Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY number at 711 711. Please follow the mailing instructions on the Direct Member Reimbursement form. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies, and Members to address pharmacy benefit questions. Please contact (000) 000-0000 or toll-free at 0-000-000-0000 and follow the voice prompts and select Pharmacy. A registered professional nurse or visit physician shall be immediately available by phone 24 hours a day, seven days a week to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free phone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate phone access 24 hours a day, seven days a week to their PCP or the Pharmacy page of our website at xxx.xxx.xxxprovider’s authorized on-call back-up provider.  Reconstructive Surgery Exclusion This benefit includes one When these providers are unavailable, a registered nurse or more exclusions as specified in physician on the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery utilization management staff must be prescribed available to respond to inquiries concerning emergency or urgent care. In the event medically necessary covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a Member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer specialist similar to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer type of specialist to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in whom a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation referral is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andrequested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and may request Presbyterian Insurance Company, Inc., reimburse you. A Pharmacy Specialist will review and process your request for reimbursement based on the negotiated rate between Presbyterian Insurance Company, Inc., and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with Form and attach the itemized cash register receipt must contain and the prescription drug detail (pharmacy pamphlet) along with the following information: o • Patient’s name and ID number o • Patient’s Date of Birth • Name and quantity of the drug o • Quantity dispensed • NDC (National Drug Code) • Fill Date purchased o • Name of Prescriber • Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o • Reason for the purchase (nature of emergency) o • Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY number 711. Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies and members to address pharmacy benefit questions. them at 711 (000) 000-0000 or toll-free at 0-0- 000-000-0000 (select option 6 when calling either number). A registered professional nurse or visit physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a 5 day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, 7 days a week, to their PCP the Pharmacy page of our website at xxx.xxx.xxxphysician’s authorized on-call back-up provider.  Reconstructive Surgery Exclusion This benefit includes one When these providers are unavailable, a registered nurse or more exclusions as specified in physician on the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery utilization management staff must be prescribed available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer specialist similar to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer type of specialist to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in whom a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation referral is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andrequested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000505) 000‐ 923-0000 5678 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 (000) 000-0000 or toll-free at 0-(000-) 000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andSignificant

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at the point of service you can may pay for the prescription and may request Presbyterian Insurance Company, Inc., reimburse you. A Pharmacy Specialist will review and process your request for reimbursement based on the negotiated rate between Presbyterian Insurance Company, Inc., and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with Form and attach the itemized cash register receipt must contain and the prescription drug detail (pharmacy pamphlet) along with the following information: o • Patient’s name and ID number o • Patient’s Date of Birth • Name and quantity of the drug o • Quantity dispensed • NDC (National Drug Code) • Fill Date purchased o • Name of Prescriber • Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o • Reason for the purchase (nature of emergency) o • Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. , Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call our TTY number 711. Please follow the mailing instructions on the Member Reimbursement Form. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies and members to address pharmacy benefit questions. Please contact them at 711 (000) 000-0000 or toll-free at 0-000-000-0000 (select option 6 when calling either number). A registered professional nurse or visit physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their PCP the Pharmacy page of our website at xxx.xxx.xxxphysician’s authorized on-call back-up provider.  Reconstructive Surgery Exclusion This benefit includes one When these providers are unavailable, a registered nurse or more exclusions as specified in physician on the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery utilization management staff must be prescribed available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare professional at the usual, customary, and reasonable rate or at an agreed-upon rate. Before Presbyterian may deny such a referral to a non- participating physician or healthcare professional, the request must be reviewed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer specialist similar to the Women’s Health Care Section.  Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  Rehabilitation and Therapy Services requires Prior Authorization.  Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer type of specialist to your Summary of Benefits and Coverage for your Cost Sharing amount.  Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in whom a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation referral is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andrequested.

Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursementForm. . Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The DMR form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: o Patient’s name and ID number o Patient’s Date of Birth o Name and quantity of the drug o Quantity dispensed o NDC (National Drug Code) o Fill Date purchased o Name of Prescriber o Name and phone number of Practitioner/Provider o Name and phone number of the dispensing pharmacy o Reason for the purchase (nature of emergency) Call PCSC 000-000-0000 0-000-000-0000 o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member (copy of the check, credit card statement or a receipt showing that payment in full was received) DirectMember Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx.  Exclusion Prior Auth Required Exclusion Prior Auth Required Refer to Refer to Prior Auth Required ➢ Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section.  Excl sion ➢ Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section.  • Rehabilitation and Therapy Services requires Prior Authorization.  • Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.  • Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount.   Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for o Imp rtant Information physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: o Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in Refer to advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. Prior Auth Required o The treatment plans that define expected Significant Improvement must be established at the initial visit. The treatment plan requires Prior Authorization. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. o Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence therapist. of a licensed physical or occupational Refer to o Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. o Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. Coverage is subject to the following limitations: Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost efer to Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day- R Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not accumulated benefit usage. included with Outpatient services when calculating the total  Skilled Nursing Facility Care Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Refer to Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.  Smoking Cessation Counseling/Program Exclusion This benefit has one or more exclusions as specified in the Exclusions section.  Coverage is provided for Diagnostic Services, Smoking Cessation Counseling andImportant