Common use of MISCELLANOUS Clause in Contracts

MISCELLANOUS. The Group reserves the right to change, modify, or terminate the Plan[, in whole or in part]. Members have no Plan benefits after a Plan termination [or partial Plan termination affecting them], except with respect to covered events giving rise to benefits and occurring prior to the date of Plan termination [or partial Plan termination affecting them] and except as otherwise expressly provided, in writing, by the Group, or as required by federal, state or local law. Members should not rely on any oral description of the Plan, because the written terms in the Group‟s Plan documents always govern.] [This amendment is issued to be attached to the [[In-Network] Evidence of Coverage] [Agreement]. This amendment does not change the terms and conditions of the [[In-Network] Evidence of Coverage] [Agreement], unless specifically stated herein.] CareFirst BlueChoice, Inc. [Signature] [Name] [Title] CareFirst BlueChoice, Inc. [000 Xxxxx Xxxxxx, XX] [Xxxxxxxxxx, XX 20065] [202-479-8000] An independent licensee of the Blue Cross and Blue Shield Association ATTACHMENT [B] DESCRIPTION OF COVERED SERVICES – HEALTH MAINTENANCE ORGANIZATION The services described herein are eligible for coverage under the Evidence of Coverage. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services, Covered Dental Services and Covered Vision Services incurred by a Member, including any extension of benefits for which the Member is eligible. It is important to refer to the Schedule of Benefits to determine the percentage of the Allowed Benefit that CareFirst BlueChoice will pay and any specific limits on the number of services that will be covered. The Schedule of Benefits also lists important information about Deductibles, the Out-of- Pocket Maximum, and other features that affect Member coverage, including specific benefit limitations. Refer to the Evidence of Coverage for additional definitions of capitalized terms included in this Description of Covered Services. CareFirst BlueChoice, Inc. [Signature] [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office and Professional Services [B]–[X] 2 Pediatric Dental Services [B]–[X] 3 Pediatric Vision Services [B]–[X] 4 Inpatient Hospital Services [B]–[X] 5 Skilled Nursing Facility Services [B]–[X] 7 Hospice Care Services [B]–[X] 8 Inpatient and Outpatient Mental Health and Substance Abuse Services [B]–[X] 10 Medical Devices and Supplies [B]–[X] 11 Prescription Drugs [B]-[X] 12 Patient-Centered Medical Home [B]–[X] 13 Complex Chronic or High Risk Acute Disease Management [B]–[X] 14 General Provisions [B]–[X] 15 Exclusions and Limitations [B]–[X] SECTION 1

MISCELLANOUS. The Group reserves the right to change, modify, or terminate the Plan[, in whole or in part]. Members have no Plan benefits after a Plan termination [or partial Plan termination affecting them], except with respect to covered events giving rise to benefits and occurring prior to the date of Plan termination [or partial Plan termination affecting them] and except as otherwise expressly provided, in writing, by the Group, or as required by federal, state or local law. Members should not rely on any oral description of the Plan, because the written terms in the Group‟s Plan documents always govern.] [This amendment is issued to be attached to the [[In-Network] Evidence of Coverage] [Agreement]. This amendment does not change the terms and conditions of the [[In-Network] Evidence of Coverage] [Agreement], unless specifically stated herein.] CareFirst BlueChoice, Inc. [Signature] [Name] [Title] CareFirst BlueChoice, Inc. [000 Xxxxx Xxxxxx, XX] [Xxxxxxxxxx, XX 2006500000] [202000-479000-80000000] An independent licensee of the Blue Cross and Blue Shield Association ATTACHMENT [B] DESCRIPTION OF COVERED SERVICES – HEALTH MAINTENANCE ORGANIZATION The services described herein are eligible for coverage under the Evidence of Coverage. CareFirst BlueChoice will provide the benefits described in the Schedule of Benefits for Medically Necessary Covered Services, Covered Dental Services and Covered Vision Services incurred by a Member, including any extension of benefits for which the Member is eligible. It is important to refer to the Schedule of Benefits to determine the percentage of the Allowed Benefit that CareFirst BlueChoice will pay and any specific limits on the number of services that will be covered. The Schedule of Benefits also lists important information about Deductibles, the Out-of- Pocket Maximum, and other features that affect Member coverage, including specific benefit limitations. Refer to the Evidence of Coverage for additional definitions of capitalized terms included in this Description of Covered Services. CareFirst BlueChoice, Inc. [Signature] [Name] [Title] SECTION TABLE OF CONTENTS PAGE 1 Outpatient Facility, Office and Professional Services [B]–[X] 2 Pediatric Dental Services [B]–[X] 3 Pediatric Vision Services [B]–[X] 4 Inpatient Hospital Services [B]–[X] 5 Skilled Nursing Facility Services [B]–[X] 7 Hospice Care Services [B]–[X] 8 Inpatient and Outpatient Mental Health and Substance Abuse Services [B]–[X] 10 Medical Devices and Supplies [B]–[X] 11 Prescription Drugs [B]-[X] 12 Patient-Centered Medical Home [B]–[X] 13 Complex Chronic or High Risk Acute Disease Management [B]–[X] 14 General Provisions [B]–[X] 15 Exclusions and Limitations [B]–[X] SECTION 1