Common use of Referred Services Clause in Contracts

Referred Services. Except as described in the Exclusions and Limitations section of this Rider, the Certificate, any amendments and/or riders are hereby revised to remove the requirement that a Member must obtain a Referral from their PCP prior to accessing Covered Benefits from Participating Providers. Under this provision, a Member may directly access Participating Specialists, ancillary Providers and facilities for Covered Benefits without a PCP Referral, subject to the terms and conditions of the Certificate and any cost-sharing requirements set forth in the Schedule of Benefits. Participating Providers will be responsible for obtaining pre-authorization of services from HMO. Except as described in this Rider, the Covered Benefits section and the Exclusions and Limitations section of the Certificate remain unchanged and the ability of a Member to directly access Participating Providers does not alter any other provisions of the Certificate. Except for Emergency Services and out- of-area Urgent Care services, a Member must access Covered Benefits from Participating Providers and facilities or benefits will not be covered under this Certificate and a Member will be responsible for all expenses incurred unless HMO has pre-authorized the services to a non-participating Provider. The Exclusions and Limitations section of the Certificate is amended to delete the following exclusion: • Unauthorized services, including any service obtained by or on behalf of a Member without a prior written Referral issued by the Member’s PCP or certified by HMO. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation or when it is a direct access benefit. The Exclusions and Limitations section of the Certificate is amended to include the following exclusion: • Unauthorized services obtained by the Member that require pre-authorization by HMO including but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining pre-authorization of Covered Benefits from HMO. The Exclusions and Limitations section of the Certificate is amended to include the following limitations: • Upon pre-authorization, other treatment plans may be subject to case management and a Member may be directed to specific Participating Providers for Covered Benefits including, but not limited to transplants and other treatment plans. • Supplemental plans provided under a separate contract or policy in addition to an HMO health benefit plan, including but not limited to dental plans and behavioral health plans, are not subject to the provisions of this Rider and a Member is required to abide by the terms and conditions of the separate contract or policy. Subsection A.2.a of the Eligibility and Enrollment section of the Certificate is hereby deleted and replaced with the following:

Referred Services. Except as described in the Exclusions and Limitations section of this Rider, the Certificate, any amendments and/or riders are hereby revised to remove the requirement that a Member must obtain a Referral from their PCP prior to accessing Covered Benefits from Participating Providers. Under this provision, a Member may directly access Participating Specialists, ancillary Providers and facilities for Covered Benefits without a PCP Referral, subject to the terms and conditions of the Certificate and any cost-sharing requirements set forth in the Schedule of Benefits. Participating Providers will be responsible for obtaining pre-authorization of services from HMO. Except as described in this Rider, the Covered Benefits section and the Exclusions and Limitations section of the Certificate remain unchanged and the ability of a Member to directly access Participating Providers does not alter any other provisions of the Certificate. Except for Emergency Services and out- of-area Urgent Care services, a Member must access Covered Benefits from Participating Providers and facilities or benefits will not be covered under this Certificate and a Member will be responsible for all expenses incurred unless HMO has pre-authorized the services to a non-participating Provider. The Exclusions and Limitations section of the Certificate is amended to delete the following exclusion: • Unauthorized services, including any service obtained by or on behalf of a Member without a prior written Referral issued by the Member’s PCP or certified by HMO. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation or when it is a direct access benefit. The Exclusions and Limitations section of the Certificate is amended to include the following exclusion: • Unauthorized services obtained by the Member that require pre-authorization by HMO including but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining pre-authorization of Covered Benefits from HMO. The Exclusions and Limitations section of the Certificate is amended to include the following limitations: • Upon pre-authorization, other treatment plans may be subject to case management and a Member may be directed to specific Participating Providers for Covered Benefits including, but not limited to transplants and other treatment plans. • Supplemental plans provided under a separate contract or policy in addition to an HMO health benefit plan, including but not limited to dental plans and behavioral health plans, are not subject to the provisions of this Rider and a Member is required to abide by the terms and conditions of the separate contract or policy. Subsection A.2.a of the Eligibility and Enrollment section of the Certificate is hereby deleted and replaced with the following:Benefit Maximums

Referred Services. Except as described in the Exclusions and Limitations section of this Rider, the Certificate, any amendments and/or riders are hereby revised to remove the requirement that a Member must obtain a Referral from their PCP prior to accessing Covered Benefits from Participating Providers. Under this provision, a Member may directly access Participating Specialists, ancillary Providers and facilities for Covered Benefits without a PCP Referral, subject to the terms and conditions of the Certificate and any cost-sharing requirements set forth in the Schedule of Benefits. Participating Providers will be responsible for obtaining pre-authorization of services from HMO. Except as described in this Rider, the Covered Benefits section and the Exclusions and Limitations section of the Certificate remain unchanged and the ability of a Member to directly access Participating Providers does not alter any other provisions of the Certificate. Except for Emergency Services and out- of-area Urgent Care services, a Member must access Covered Benefits from Participating Providers and facilities or benefits will not be covered under this Certificate and a Member will be responsible for all expenses incurred unless HMO has pre-authorized the services to a non-participating Provider. The Exclusions and Limitations section of the Certificate is amended to delete the following exclusion: • Unauthorized services, including any service obtained by or on behalf of a Member without a prior written Referral issued by the Member’s PCP or certified by HMO. This exclusion does not apply in a Medical Emergency or Emergency, in an Urgent Care situation situation, or when it is a direct access benefit. The Exclusions and Limitations section of the Certificate is amended to include the following exclusion: • Unauthorized services obtained by the Member that require pre-authorization by HMO including but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining pre-authorization of Covered Benefits from HMO. The Exclusions and Limitations section of the Certificate is amended to include the following limitations: • Upon pre-authorization, other treatment plans may be subject to case management and a Member may be directed to specific Participating Providers for Covered Benefits including, but not limited to transplants and other treatment plans. • Supplemental plans provided under a separate contract or policy in addition to an HMO health benefit plan, including but not limited to dental plans and behavioral health plans, are not subject to the provisions of this Rider and a Member is required to abide by the terms and conditions of the separate contract or policy. Subsection A.2.a of the Eligibility and Enrollment section of the Certificate is hereby deleted and replaced with the following:.

Referred Services. Except as described in the Exclusions and Limitations section of this Rider, the Certificate, any amendments and/or riders are hereby revised to remove the requirement that a Member must obtain a Referral from their PCP prior to accessing Covered Benefits from Participating Providers. Under this provision, a Member may directly access Participating Specialists, ancillary Providers and facilities for Covered Benefits without a PCP Referral, subject to the terms and conditions of the Certificate and any cost-sharing requirements set forth in the Schedule of Benefits. Participating Providers will be responsible for obtaining pre-authorization of services from HMO. Except as described in this Rider, the Covered Benefits section and the Exclusions and Limitations section of the Certificate remain unchanged and the ability of a Member to directly access Participating Providers does not alter any other provisions of the Certificate. Except for Emergency Services and out- of-area Urgent Care services, a Member must access Covered Benefits from Participating Providers. Services rendered by non-Participating Providers and facilities or benefits will not be covered under this Certificate in non-emergent and a Member will be responsible for all expenses incurred non-urgent situations unless HMO has pre-authorized the services use of such non-Participating Provider. The Infertility Services Benefit provision of the Covered Benefits section of the Certificate is amended to include the following provision: • Infertility Program – A Member or their Participating Physician may contact the Infertility case management unit to apply for eligibility. A Member who is eligible for the program may be subject to case management, have access to a non-participating Providerselect network of Participating Providers and will be required to utilize Participating Providers from this select network to receive Covered Benefits. The Exclusions and Limitations section of the Certificate is amended to delete the following exclusion: • Unauthorized services, including any service obtained by or on behalf of a Member without a prior written Referral issued by the Member’s PCP or certified by HMO. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation or when it is a direct access benefit. The Exclusions and Limitations section of the Certificate is amended to include the following exclusion: • Unauthorized services obtained by the Member that require pre-authorization by HMO including but not limited to Hospital admissions and outpatient surgery. Participating Providers are responsible for obtaining pre-authorization of Covered Benefits from HMO. The Exclusions and Limitations section of the Certificate is amended to include the following limitations: • Upon pre-authorization, other treatment plans may be subject to case management and a Member may be directed to specific Participating Providers for Covered Benefits including, but not limited to transplants and other treatment plans. • Supplemental plans provided under a separate contract or policy in addition to an HMO health benefit plan, including but not limited to dental plans and behavioral health plans, are not subject to the provisions of this Rider and a Member is required to abide by the terms and conditions of the separate contract or policy. Subsection A.2.a of the Eligibility The Continuation and Enrollment Conversion section of the Certificate is amended to include the following provision: Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. Certificate is hereby amended: The Covered Benefits, Additional Benefits, Inherited Metabolic Diseases section is hereby deleted and replaced with the following:  Inherited Metabolic Diseases Benefit. Coverage is provided for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be Medically Necessary by the Member’s Physician. The benefits shall be provided to the same extent as for any medical condition under the Certificate. All other terms and conditions of the Certificate shall remain in full force and effect except as amended herein. Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. (HMO) Certificate is hereby amended as follows: