Common use of Pharmacotherapy Benefit Limitations Clause in Contracts

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: Kidney Liver Pancreas Intestine Heart Lung multi-visceral (3 or more abdominal Organs) simultaneous multi-Organ transplants – unless investigational pancreas islet cell infusion Meniscal Allograft Autologous Chondrocyte Implantation – knee only Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Cost-Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung multi• Multi-visceral (3 three or more abdominal Organs) simultaneous • Simultaneous multi-Organ transplants – unless investigational pancreas • Pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple Multiple myeloma o leukemia Leukemia o aplastic Aplastic anemia o lymphoma Lymphoma o severe Severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ Germ cell tumor o neuroblastoma Neuroblastoma o Wilms Tumor o myelodysplastic Myelodysplastic Syndrome o myelofibrosis Myelofibrosis o sickle Sickle cell disease o thalassemia Thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy · Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: · Kidney · Liver · Pancreas · Intestine · Heart · Lung · multi-visceral (3 or more abdominal Organs) · simultaneous multi-Organ transplants – unless investigational · pancreas islet cell infusion · Meniscal Allograft · Autologous Chondrocyte Implantation – knee only · Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Cost-Sharing amount. Telemedicine Services Services‌ PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-networkperson. PHP will not impose originating-site restrictions. Coverage may be maybe extended to out-of-network providers in instances where no in- in-network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung multi• Multi-visceral (3 three or more abdominal Organs) simultaneous • Simultaneous multi-Organ transplants – unless investigational pancreas • Pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple Multiple myeloma o leukemia Leukemia o aplastic Aplastic anemia o lymphoma Lymphoma o severe Severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ Germ cell tumor o neuroblastoma Neuroblastoma o Wilms Tumor o myelodysplastic Myelodysplastic Syndrome o myelofibrosis Myelofibrosis o sickle Sickle cell disease o thalassemia Thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: Kidney Liver Pancreas Intestine Heart Lung multi-visceral (3 or more abdominal Organs) simultaneous multi-Organ transplants – unless investigational pancreas islet cell infusion Meniscal Allograft Autologous Chondrocyte Implantation – knee only Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization prior authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.

Pharmacotherapy Benefit Limitations. Prescription Drugs/Medications purchased at an In-network Pharmacy Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Cost-Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person or In-network. PHP will not impose originating-site restrictions. Coverage may be extended to out-of-network providers in instances where no in- network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Presbyterian provides coverage for organ transplants and associated care and will not: Deny that coverage solely on the basis of a covered person's physical or mental disability; Deny to a covered person with a physical or mental disability eligibility or continued eligibility to enroll or to renew coverage under the terms of the health benefit policy or plan solely for the purpose of avoiding the requirements of this section; Penalize or otherwise reduce or limit the reimbursement or provide monetary or nonmonetary incentives to a health care provider to induce that health care provider not to provide an organ transplant or associated care to a covered person with a physical or mental disability; or Reduce or limit coverage benefits to a covered person with a physical or mental disability for the associated care related to organ transplantation as determined in consultation with the physician and patient. Human Solid Organ transplant benefits are Covered for: Kidney Liver Pancreas Intestine Heart Lung multiMulti-visceral (3 three or more abdominal Organs) simultaneous Simultaneous multi-Organ transplants – unless investigational pancreas Pancreas islet cell infusion Meniscal Allograft Autologous Chondrocyte Implantation – knee only Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple Multiple myeloma o leukemia Leukemia o aplastic Aplastic anemia o lymphoma Lymphoma o severe Severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ Germ cell tumor o neuroblastoma Neuroblastoma o Wilms Tumor o myelodysplastic Myelodysplastic Syndrome o myelofibrosis Myelofibrosis o sickle Sickle cell disease o thalassemia Thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. All Organ transplants must be performed at site that we approve and require Prior Authorization. Women’s Healthcare The following Woman’s Healthcare Services, in addition to services listed in the Preventive Care and other Sections of this Agreement are available for our female Members under the Women’s Health and Cancer Rights Act (WHCRA). Inpatient Hospital services require Prior Authorization. Gynecological care includes: Annual exams Care related to pregnancy Miscarriage Therapeutic abortions Elective abortions up to 24 weeks Other gynecological services Prenatal Maternity care benefits include: Prenatal care Pregnancy related diagnostic tests, (including an alpha-fetoprotein IV screening test, generally between 16 and 20 weeks of pregnancy, to screen for certain abnormalities in the fetus) Visits to an Obstetrician Certified Nurse-midwife Licensed Midwife Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider. Prescription nutritional supplements require Prior Authorization. Childbirth in a Hospital or in a licensed birthing center Maternity Care In Accordance with the Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act), the following services are available: Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require notification to appropriately manage care. Your provider will provide notification to the Health Plan of your maternity admission. Please see coverage for emergent/Prior Authorization admissions. In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. High-risk Ambulance services are Covered in accordance with the Ambulance Services Benefits Section. The services of a Licensed Midwife or Certified Nurse Midwife are Covered, for the following: o The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. o The services must be provided in preparation for or in connection with the delivery of a newborn. o For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home.