Individuals Rights to Hire Independent in Home Custodial and Skilled Employee by iix21392

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									FIRST PRIORITY HEALTH PLUS
   The University of Scranton
        Member Handbook



          Your Benefits
               And
         How to Use Them
Use this space for information you‟ll need when asking about your coverage.


The company office or person to contact about coverage is:


Address: The University of Scranton, Human Resources Dept.
           Linden & Monroe Avenue
           Scranton, Pa 18510-4679


Phone:     (570) 941-7767


The appropriate Blue Cross and Blue Shield Plan contact is:


Address:   First Priority Health
           70 North Main Street
            Wilkes Barre, Pa 18711

Customer Service Phone: 1-800-822-8753

Website: www.bcnepa.com
Prescription Drugs: 1-877-603-8399


The Subscriber Number shown on my Identification Card is:

_________________________________________________________________________________________


The Group Number shown on my Identification Card is:

_________________________________________________________________________________________


The “Effective Date” when my coverage begins is:

_________________________________________________________________________________________




                                                      2
                                    TABLE OF CONTENTS



Responsibilities for Plan Administration . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Benefit Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Primary Care Physician Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . 23

Specialist Physician Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Inpatient Hospital and Skilled Nursing Covered Services . . . . . . . . . . . . . . . . . 27

Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Out of Area Covered Services for Unexpected Conditions . . . . . . . . . . . . . . . . . 31

Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Self Referred Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Participant Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37




                                                  3
                                                                                          Plan Administrator
 This booklet describes, in general, the main            The University of Scranton
 features of the Plan. Complete terms and                Linden and Monroe Ave.
 conditions are set forth in the Agreement between       Scranton, PA 18510-4679
 Blue Cross, Blue Shield and your employer. The          Phone: (570) 941-7767
 Plan is self-funded health plan and the
 administration is provided through Blue Cross of                           Employer Identification Number
 Northeastern Pennsylvania and Pennsylvania Blue
 Shield, 70 North Main Street, Wilkes-Barre, PA                                                  24-0795495
 18711
                                                                                                Plan Number
 The funding is derived from the funds of the
 Employer and contributions made by employees,                                                            501
 if applicable. The plan is not insured.
                                                                                                  Participants
 This booklet has been prepared to meet the
 summary Plan description requirements of the            The benefits in this summary apply to active
 Employee Retirement Income Security Act of              employees of The University of Scranton.
 1974. The benefits provided under the Plan are
 subject to the terms and conditions of the group                                               Contributions
 insurance contract issued by Blue Cross of
 Northeastern Pennsylvania and Pennsylvania Blue         The premiums for your benefits under the plan are
 Shield, 70 North Main Street, Wilkes-Barre, PA          paid by the employer
 18711.
                                                                                          Plan Effective Date
Name of Plan
                                                                                                        2-1-99
 The University of Scranton.
                                                                                            Named Fiduciary
Employer and Plan Sponsor
                                                         The University of Scranton
 The University of Scranton                              Human Resources Department
 Linden and Monroe Ave.                                  Linden and Monroe Ave.
 Scranton, PA 18510-4679                                 Scranton, PA 18510-4679
 Phone: (570) 941-7767                                   Phone: (570) 941-7767

                                                                                                Plan Records

                                                         The records for the plan are reported on a calendar
                                                         year basis beginning each January 1 and ending
                                                         December 31.




                                                     4
Plan/Type Administration                                                  Duties Of The Plan Administrator

 The program described in this booklet is an               (1) To administer the Plan in accordance with
 employee welfare plan providing Hospital,                     its terms.
 Medical-Surgical and Major Medical benefits
 administered by Blue Cross of Northeastern                (2) To interpret the Plan, including the right to
 Pennsylvania and Pennsylvania Blue Shield.                    remedy possible ambiguities, inconsistencies
                                                               or omissions.
 The benefits provided under this Plan and all
 statements in this booklet are subject to the terms       (3) To decide disputes which may arise relative
 and conditions of the Agreement between Blue                  to a Plan Participant‟s rights.
 Cross, Blue Shield and The University of
 Scranton.                                                 (4) To prescribe procedures for filing a claim
                                                               for benefits and to review claim denials.
Responsibilities for Plan Administration
                                                           (5) To keep and maintain the Plan documents
 Plan Administrator – The plan is to be                        and all other records pertaining to the Plan.
 administered by the Plan Administrator, also
 called the Plan Sponsor. It is to be administered         (6) To appoint a Claims Administrator to pay
 by the Plan Administrator in accordance with the              claims.
 provisions of ERISA. An individual may be
 appointed by The University of Scranton to be             (7) To perform all necessary reporting as
 Plan Administrator and serve at the convenience               required by ERISA.
 of the Employer. If the Plan Administrator
 resigns, dies or is otherwise removed from the            (8) To establish and communicate procedures to
 position, The University of Scranton shall appoint            determine whether a medical child support
 a new Plan Administrator as soon as reasonably                order is qualified under ERISA Sec. 609.
 possible.
                                                           (9) To delegate to any person or entity such
 The Plan Administrator shall administer this                  Powers, duties and responsibilities as it
 Plan in accordance with its terms and establish               deems appropriate.
 its policies, interpretations, practices, and
 procedures. It is the express intent of this Plan                        Plan Administrator Compensation
 that the Plan Administrator shall have maximum
 legal discretionary authority to construe and             The Plan Administrator serves without
 interpret the terms and provisions of the Plan, to        compensation; however, all expenses for plan
 make determinations regarding issues which                administration, including compensation for
 relate to eligibility for benefits, to decide             hired services, will be paid by the Plan.
 disputes which may arise relative to a Plan
 Participant‟s rights, and to decide questions of
 Plan interpretation and those of fact relating to                                                 Fiduciary
 the Plan. The decisions of the Plan
 Administrator will be final and binding on all            A fiduciary exercises discretionary authority or
 interested parties.                                       control over management of the Plan or the
                                                           disposition of its assets, renders investment advice
 Services of legal process may be made upon the            to the Plan or has discretionary authority or
 Plan Administrator.                                       responsibility in the administration of the Plan.




                                                       5
Fiduciary Duties                                             For Dependent Coverage: funding is derived
                                                             from the funds of the Employer and contributions
 A fiduciary must carry out his or her duties and            made by the covered Employees.
 responsibilities for the purpose of providing
 benefits to the Employees and their Dependent(s),           The level of any Employee contributions will be
 and defraying reasonable expenses of                        set by the Plan Administrator. These Employee
 administering the Plan. These are duties which              contributions will be used in funding the cost of
 must be carried out:                                        the Plan as soon as practicable after they have
                                                             been received from the Employee or withheld
 (1) with care, skill, prudence and diligence under          from the Employee‟s pay through payroll
     the given circumstances that a prudent                  deduction.
     person, acting in a like capacity and familiar
     with such matters, would use in a similar               Benefits are paid directly from the Plan through
     situation;                                              the Claims Administrator.

 (2) by diversifying the investments of the Plan so                                              Effective Date
     as to minimize the risk of large losses, unless
     under the circumstances it is clearly prudent          Newly hired and rehired full-time employees and
     not to do so; and                                      their eligible dependents will be eligible for the
                                                            benefits described in this summary plan description
 (3) in accordance with the Plan documents to the           on the first of the date of hire.
     extent that they agree with ERISA.
                                                            Persons who become eligible dependents of an
The Named Fiduciary                                         enrolled employee after the effective date of the
                                                            employee‟s enrollment will be eligible for these
 A “named fiduciary” is the one named in the Plan.          benefits upon notification from employee of such
 A named fiduciary can appoint others to carry out          additional dependents.
 fiduciary responsibilities (other than as a trustee)
 under the Plan. These other persons become                 Each eligible employee must complete an
 fiduciaries themselves and are responsible for             application form.
 their acts under the Plan. To the extent that the
 named fiduciary allocates its responsibility to
 other persons, the named fiduciary shall not be
 liable for any act or omission of such person
 unless either:

 (1) the names fiduciary has violated its stated
     duties under ERISA in appointing the
     fiduciary, establishing the procedures to
     appoint the fiduciary or continuing either the
     appointment or the procedures; or

 (2) the named fiduciary breached its fiduciary
     responsibility under Section 405(1) of ERISA.

Claims Administrator Is Not A Fiduciary

The cost of the Plan is funded as follows:
 For Employee Coverage: funding is derived
 solely from the funds of the Employer.


                                                        6
Statement of ERISA Rights                                    Under ERISA, there are steps you can take to
                                                             enforce the above rights. For instance, if you
 The following statement of rights under ERISA is            request materials from the Plan and do not
 provided as required by regulation issued by the            receive them within 30 days, you may file suit
 Department of Labor and is in the form suggested            in a federal court. In such a case, the court may
 by the Department.                                          require the Plan Administrator to provide the
                                                             materials and pay you up to $100 a day until
 As a participant in your group insurance Plan, you          you receive the materials, unless the materials
 are entitled to certain rights and protections under        were not sent because of reasons beyond the
 the Employee Retirement Income Security Act of              control of the Administrator. If you have a
 1974 (ERISA). ERISA provides all Plan                       claim for benefits which is denied or ignored, in
 participants shall be entitled to:                          whole or part, you may file suite in a state or
                                                             federal court. If it should happen that Plan
 Examine, without charge at the Plan                         fiduciaries misuse the Plan‟s money or if you
 Administrator‟s office and at other specified               are discriminated against for asserting your
 locations, such as work sites and union halls, all          rights, you may seek assistance from the U.S.
 Plan documents including insurance contracts,               Department of Labor, or you may file suit in a
 collective bargaining arrangements and copies of            Federal court. The court will decide who should
 all documents filed by the Plan with the U.S.               pay court costs and legal fees. If you are
 Department of Labor, such as detailed annual                successful, the court may order the person you
 reports and Plan descriptions.                              have sued to pay these costs and fees.

 Obtain copies of all documents and other Plan               If you lose, the court may order you to pay these
 information upon written request to the Plan                costs and fees (for example, if it finds your
 Administrator. The Administrator may make a                 claim in frivolous). If you have any questions
 reasonable charge for the copies.                           about this statement or about your rights under
                                                             ERISA, you should contact the nearest area
 Receive a summary of the Plan‟s annual financial            office of the Pension and Welfare Benefits
 report. The Plan Administrator is required by law           Administration, U.S. Department of Labor listed
 to furnish each participant with a copy of this             in the telephone directory or the Division of
 summary annual report.                                      Welfare Benefits Administration, U.S.
                                                             Department of Labor, 200 Constitution Ave.,
 In addition to creating rights for Plan participants,       N.W., Washington, DC 20210.
 ERISA imposes duties upon the people who are
 responsible for the operation of the Employee                                          Agent For Service of
 Benefit Plan. The people who operate your Plan,                                    Legal Process on the Plan
 called “fiduciaries” of the Plan, have a duty to do
 so prudently and in the interest of you and other           The University of Scranton
 Plan participants and beneficiaries. No one,                Linden and Monroe Ave.
 including your employer, your union or any other            Scranton, PA 18510-4679
 person, may fire you or otherwise discriminate              Phone: (570) 941-7767
 against you in anyway to prevent you from
 obtaining a welfare benefit or exercising your
 rights under ERISA. If your claim for a welfare
 benefits is denied in whole or part, you must
 receive a written explanation of the reason for
 denial. You have the right to have the Plan
 review and reconsider your claim.




                                                         7
                                                          payment for benefits under this Plan will be
Loss of Benefits                                          coordinated with other group health Plans.

 Upon 60 days written notice, the Plan                    1. In the event a participant is covered under a
 Administrator may terminate this contract or,               Benefit program other than this Plan, which
 subject to Blue Cross and Blue Shield approval,             does not contain a provision coordinating its
 may modify, amend or change the benefit                     benefits with those of this Plan, such other
 provisions, terms, and conditions of the                    Plan will be primary Plan and as such shall
 contract. No consent of any participant, or any             determine its benefits before benefits are
 other person referred to on the contract, shall be          determined under this Plan. Benefits
 required to terminate, modify, amend or change              payable under another Plan include the
 the contract.                                               benefits that would be payable, whether or
                                                             not claim is made therefore.
 Plans maintained as a result of collective
 bargaining agreements are, of course, subject to         Such other Plan may include any company-
 change negotiated in the collective bargaining           sponsored Plan, including any group Blue
 process.                                                 Cross/Blue Shield Plan, franchise arrangements,
                                                          or any company-sponsored Plan to which any
 If you are laid off, resign, or retire, all health       employer contributes or makes payroll
 care benefits described herein for you and for           deductions. Such other Plan will not include
 your dependents will cease at the end of the             blanket student accident coverage.
 month in which the event occurs.
                                                          2. When a participant is covered under another
 If the coverage described in this booklet is                Plan which contains a provision
 terminated because it is being replaced by                  coordinating its benefit with those of this
 another carrier, all benefits will cease on the             Plan, the following rules will establish order
 date when such other coverage becomes                       of determining liability of this or any other
 effective.                                                  Plan:

Portability                                                  a. The Plan covering the patient as a
                                                                contract Holder is the primary Plan,
 Under the Health Insurance Portability and                     which shall determine its benefits before
 Accountability Act of 1996 (HIPAA), if you                     benefits are determined under any other
 terminate employment and obtain health                         Plan.
 insurance coverage elsewhere which has a pre-
 existing condition exclusion, you may be                    b. Except for situations where the parents
 entitled to receive credit toward the                          of a child are separated or divorced:
 exclusionary period, provided you have not had
 a bread in coverage of more than 63 days. At                    i. The Plan of the parent whose date of
 the time you terminate coverage with us,                           birth (month/day) falls earlier in the
 BCNEPA will provide you with a certificate of                      calendar year is the primary Plan. If
 coverage showing the period of time during                         both parents have the same birthday,
 which you were covered under this program.                         the Plan which covered the parent
 This new insurer will reduce its exclusionary                      longer will be the primary Plan; or
 period, if any, in accordance with that
 information.                                                    ii. If this Plan is coordinating with a
                                                                     Plan which uses the rule based on the
Coordination of Benefits                                             gender of the parent, the Plan of the
                                                                     male parent is the primary Plan.
 In order to avoid duplication of payment for
 covered services received by the participant,
                                                      8
   c. In those situations where the parents of                   provisions of a 3.a. above shall not
      the child are separated or divorced;                       apply.

       i. The Plan covering the child as a                4. Services provided under any governmental
          dependent of the parent with custody               Program for which any periodic payment of
          will be the primary Plan;                          rate is made by or for the participant shall
                                                             always be the primary Plan, except where
       ii. If the parent with custody has                    prohibited by law.
           remarried, the Plan which covers the
           child as a dependent of the step-              5. Individual Non-Group Health Plans of any
           parent with custody will be the                   kind will not be coordinated when the
           primary Plan;                                     participant pays the entire cost.

       iii. Where there is a court decree which           6. When this Plan is determined to be the
            establishes financial responsibility             Primary Plan, benefits will be paid without
            for the health care expenses of the              regard to coverage under any other Plan and
            dependent child, the plan which                  there are remaining covered services, this
            covers the child as a dependent of               Plan will pay its regular benefit up to the
            the parent with such financial                   amount of such remaining eligible covered
            responsibility will be the primary               services.
            Plan, as long as the Plan of the
            parent has actual knowledge of the            7. Facility of Payment – Whenever payments
            court decree; or                                 which should have been made under this
                                                             Plan in accordance with this provision have
       iv. If the specific terms of a court decree           been made under any other Plan, Blue Cross
           state that the parents shall share joint          and Blue Shield will have the right, at their
           custody, without stating that one of              sole discretion, to pay to any organization
           the parents is responsible for the                making such other payments any amounts
           health care expenses of the child, the            they determine to be warranted in order to
           Plans covering the child shall follow             satisfy the intent of this provision and
           the order of benefit determination                amounts so paid will be considered benefits
           rules outlined in paragraph 2.b.                  paid under this Plan and Blue Cross and
                                                             Blue Shield will be fully discharged from
3. Where the determination cannot be made in                 liability.
   Accordance with the above, the Plan which
   has covered the participant for the longer             8. Right of Recovery – Whenever payments
   period of time will be considered the                     have been made by Blue Cross and Blue
   primary Plan, except:                                     Shield in excess of the maximum amount of
                                                             payment necessary to satisfy the intent of
   a. The Plan which covers the participant as               this provision, irrespective of to whom paid,
      an active employee (or a dependent of                  Blue Cross and Blue Shield will have the
      such a person) is the primary Plan over a              right to recover such payments to the extent
      Plan that covers a participant as laid-off             of such excess from among one or more of
      or retired employee (or dependent of                   the following, as Blue Cross and Blue Shield
      such a person); or                                     will determine:

   b. If either Plan does not have a provision                   a. Any persons to or for or with respect
      regarding laid-off or retired employees                       to whom such payments were made
      and as a result, the benefits of each Plan                    (including the participants covered
      are determined after the other, then the                      under this Plan);


                                                      9
         b. Any insurance companies; and                    Pennsylvania shall be subrogated, and succeed
                                                            to the rights of recovery of a participant for
         c. Any organization.                               expenses incurred against any person or
                                                            organization except insurers or policies of
 Blue Cross and Blue Shield may use such                    health insurance issued to and in the name of
 reasonable efforts as deemed suitable to                   participant. In those instances where the
 determine the existence of other Plans but will            subrogation recovery efforts of the
 be under no obligation to do so. Blue Cross and            participant‟s attorney should, in the opinion of
 Blue Shield shall not be required to determine             Blue Cross of Northeastern Pennsylvania, be
 the existence of any contract or amount of                 compensated, the Plan delegates to Blue Cross
 benefits under any Plan except this Plan and the           of Northeastern Pennsylvania full authority to
 payment of benefits under this Plan shall be               act on behalf of the Plan to negotiate
 affected by the benefits under any and all other           reasonable attorney fees not to exceed thirty-
 Plans only to the extent that Blue Cross and               three and one-third percent (33 1/3%) for
 Blue Shield are furnished with information                 personal injury cases, up to forty percent
 relative to such other Plan by the group or                (40%) for medical malpractice cases and
 participant or any other organization or person.           twenty percent (20%) for worker‟s
                                                            compensation cases. Any determination by
 When the benefits are reduced under the                    Blue Cross of Northeastern Pennsylvania will
 primary Plan because a participant does not                respect to attorney fees shall be final and
 comply with the Plan provisions, the amount of             conclusive, unless overturned under a limited
 such reduction will not be considered covered              arbitrary and capricious standard of review.
 services. Examples of such provisions are those            Blue Cross of Northeastern Pennsylvania shall
 related to second surgical opinions, prior                 provide the participant‟s attorney with updated
 certification of admissions and services and               lien amounts, as requested, and shall work
 preferred provider arrangements.                           with the participant‟s attorney to recover
                                                            100% of the Covered Services paid (unless
 This Coordination of Benefits provision does               such amount is compromised as set forth in
 not apply to individual, non-group or group                Section C). Blue Cross of Northeastern
 conversion policies.                                       Pennsylvania shall credit the plan with the
                                                            amount recovered, minus, as applicable, a
Subrogation                                                 prorata share of the costs and the participant‟s
                                                            attorney fees.
A. Plan Responsibilities
                                                         C. Authority to compromise Liens
   Plan represents and warrants that the
   Summary Plan Description confers on the                  In those instances where a plan‟s subrogation
   Plan rights of subrogation and third part                lien should, in the opinion of Blue Cross of
   recovery. Plan delegates or assigns these                Northeastern Pennsylvania, be compromised,
   subrogation rights and third party recovery              the plan delegates to Blue Cross of
   rights to Blue Cross of Northeastern                     Northeastern Pennsylvania full authority to act
   Pennsylvania as the Plans agent for purposes             on behalf of the plan to compromise the lien.
   of subrogation.                                          Any determination by Blue Cross of
                                                            Northeastern Pennsylvania with respect to
B. BCNEPA‟s Subrogation Duties                              subrogation liens shall be final and conclusive,
                                                            unless overturned under a limited arbitrary
   Blue Cross of Northeastern Pennsylvania shall            and capricious standard of review.
   undertake reasonable steps to identify claims
   in which the Plan has a subrogation interest
   and shall manage subrogation cases on behalf
   of the Plan. Blue Cross of Northeastern
                                                    10
D. Participant‟s Duties                                     COBRA, the Plan is not the administrator as
                                                            defined under ERISA.
   The participant shall pay to Blue Cross of
   Northeastern Pennsylvania all amounts                    Each Employee has a right to continue coverage
   recovered by suit, settlement, or otherwise              if:
   from any third party or his insurer to the
   extent of the benefits provided and paid under           1. Employment with the Group ends for a reason
   the plan less any attorney‟s fees and expenses.             other than gross misconduct; or
   The participant shall take such action, furnish
   such information and assistance, and execute             2. Work hours are reduced.
   such papers as Blue Cross of Northeastern
   Pennsylvania may require to facilitate                   Each Dependent has a right to continue coverage
   enforcement of its rights and shall take no              if:
   action prejudicing the rights and interest of
   Blue Cross of Northeastern Pennsylvania.                 1. The Employee‟s employment with the Group
                                                               ends for a reason other than gross misconduct;
E. Prohibited by Law
                                                            2. The Employee‟s work hours are reduced;
   These provisions shall not apply where                   3. The Employee dies;
   subrogation is specifically prohibited by law.
                                                            4. In the case of an Employee‟s spouse, when
Consolidated Omnibus Budget Reconciliation                     such spouse ceases to be an Eligible
Act of 1985 (COBRA)                                            Dependent as a result of divorce or legal
                                                               separation;
Employers with twenty (20) or more employees
(as defined under COBRA to mean full or part-               5. The Employee becomes entitled to Medicare;
time and whether or not enrolled for coverage                  or
under this Contract) are subject to COBRA
regulations. Employers with less than twenty (20)           6. In the case of a Dependent child, when such
employees are not subject to COBRA regulations                 child no longer satisfies the eligibility
and cannot make available continuation coverage                requirements for coverage as a Dependent
under this Contract after the Subscriber ceases to             under this Contract.
be an Eligible Person.
                                                            Under the COBRA law, the Employee or an
Upon timely notice from the Group, the Plan will            Eligible Dependent has the responsibility to
make available continuation coverage, as required           inform the administrator (as defined under
by COBRA, for all Employees and their                       ERISA) of a divorce, legal separation, or a child
Dependents determined to be qualified                       losing dependent status under this Contract within
beneficiaries, as defined in Section 162 (k) (7) (B)        sixty (60) days of the date of the later of the event
of the Internal Revenue Code as amended from                or the date on which coverage would end under
time to time, and Section 607 (3) of the Employee           this Contract because of the event. The Group has
Retirement Income Security Act (ERISA), as                  the responsibility to notify the administrator of the
amended from time to time. The Group shall                  Employee‟s death, termination of employment,
retain full responsibility for notifying Employees          reduction in hours or Medicare entitlement.
of their rights to continuation coverage and                Similar rights may apply to certain retirees,
administering the exercise of continuation rights,          spouses, and dependent children if the Group
as required by COBRA. The Plan shall have no                commences a bankruptcy proceeding.
obligation to ensure that any termination
instructions received from the Group comply with            When the administrator is notified that one of
the requirements of COBRA. For purposes of                  these events has happened, the administrator will
                                                            in turn notify the qualified beneficiary within

                                                       11
                                                            5. The qualified beneficiary extended coverage
fourteen (14) days of the notification that he/she             for up to twenty-nine (29) months due to a
has the right to choose continuation coverage.                 disability and there has been a final
The qualified beneficiary has at least (60) days               determination that the qualified beneficiary is
from such notification to inform the administrator             no longer disabled.
of his or her decision to elect continued coverage.
The qualified beneficiary will then have forty-five
(45) days after notifying the administrator of his            Continuation During Family and Medical Leave
or her decision to pay the retroactive premium.
                                                            This Plan shall at all times comply with the
In the case of the Employee‟s termination of                Family and Medical Leave Act of 1993 as
employment or reduction in work hours, the                  promulgated in regulations issued by the
coverage may be continued for up to eighteen (18)           Department of Labor.
months. The eighteen (18) months may also be
extended to twenty-nine (29) months if an                   Leave taken under the Family Medical Leave Act
individual is determined to be disabled (for Social         shall be covered under this plan on the same
Security disability purposes) and the administrator         conditions as previously provided, as though the
is notified of the determination within sixty (60)          Employee has been continuously employed up to
days. The affected individual must also notify the          the 12-week leave period.
administrator within sixty (60) days of any final
determination that the individual is no longer              If Plan coverage terminates during the FMLA
disabled. With respect to all other qualifying              leave, coverage will be reinstated for the
events, coverage may be continued for up to                 Employee and his or her covered Dependents if
thirty-six (36) months. Furthermore, in no event            the Employee returns to work in accordance with
will continuation coverage last beyond thirty-six           the terms of the FMLA leave. Coverage will be
months from the date of the event that originally           reinstated only if the person(s) had coverage
made a qualified beneficiary eligible to elect              under this Plan when the FMLA leave started, and
coverage. The end of the maximum coverage                   will be reinstated to the same extent that it was in
period is measured from the date of the qualifying          force when the coverage terminated. For
event does not result in a loss of coverage under           example, Pre-Existing conditions limitations and
this Contract until some later date.                        other Waiting Periods will not be imposed unless
                                                            they were in effect for the Employee and/or his or
However, the law also provides that continuation            her Dependents when Plan coverage terminated.
coverage may be cut short for any of the
following five reasons:                                                                              Conversion

1. The Group ceases to provide group health                 If the subscriber ceases to be a participant for this
   insurance to any Employee;                               program because of layoff, disability, leave of
                                                            absence or termination of employment,
2. The qualified beneficiary fails to make timely           arrangements may be made to continue both Blue
   payments of any premium required;                        Cross and Blue Shield under the direct payment
                                                            type of participant Agreements. However, if a
3. The qualified beneficiary is covered under               participant becomes one of a group having
   another group health plan that does not                  benefits available under a Health insurance
   contain any exclusion or limitation with                 Program other than Blue Cross, he or she is not
   respect to any pre-existing condition that the           entitled to this conversion privilege.
   qualified beneficiary may have;
                                                            If the participant dies, the surviving spouse and
4. The qualified beneficiary is entitled to benefits        child may continue coverage under the direct
   under Medicare; or                                       payment type of subscriber Agreements.


                                                       12
Children who reach the maximum age limit
specified in the program also have the privilege of
converting to the direct payment type of
subscriber Agreements.

Misrepresentations

If a false statement is intentionally made by the
subscriber in obtaining coverage or benefits under
this Agreement, or if the subscriber cooperates
with a provider of service in the making of a false
statement with the knowledge that such statement
is false, this Agreement will be terminated
immediately. Restitution will be sought by Blue
Cross for any amounts paid to the subscriber
because of any false statement or
misrepresentation.




                                                      13
Covered Services
                                  PCP Referred                  Self Referred
Deductible                        None                          $200/$600
Annual Out-of-Pocket Maximum      None                          $1,000/$3,000
Lifetime Maximum                  Unlimited                     $1,000,000
Precertification Penalty          None                          $300 penalty for late
                                                                Precertification
                                                                NO PRECERTIFICATION
                                                                ON FILE: NO PAYMENT
Coinsurance                       100% coverage                 80% coverage
Choice of Hospital                Hospital associated           Accredited facilities
                                  With FPH                      nationwide
Inpatient Hospital Services       100%                          80%
                                  Precertification Required     $300 penalty if late
                                                                Precertification
Outpatient Hospital Surgery       100%                          80%
                                  Precertification Required     $300 penalty if late
                                                                Precertification
Anesthesia                        100%                          80%
Surgeon/Assistant Surgeon         100%                          80%
Pre-Admission Testing             100%                          80%
PHYSICIAN SERVICES
Choice of Physician               Physicians participating      Any licensed accredited
                                  With First Priority Health    physician
PCP/Specialist                    $15 PCP copay                 80%
Office Visits                     $25 Specialist copay
Pediatric Immunizations           $15 copay if office visit     80%
                                                                Not subject to deductible
Routine GYN Exams                 $25 copay                     80%
MATERNITY SERVICES
Maternity Care                    $25 copay for first visit;    80%
                                  Then 100%
Invitro & Invivo Fertilization                          Not covered
Pediatric Visits (In Hospital)    100%                          80%
Sterilization (Vasectomy/Tubal)                         Not covered
TESTS
Allergy Tests & Treatments        $15 PCP copay                 80%
                                  $25 Specialist copay
                                    14
                                               PCP Referred                     Self Referred
Lab Tests                                      100%                             80%
Mammography                                    100%                             80%
X-rays                                         100%                             80%
EMERGENCY SERVICES
Emergency Medical/Accident                              $35 copay; waived if admitted
THERAPY SERVICES
Dialysis, Chemotherapy, Radiation Therapy      100%                             80%
Cardiac Rehabilitation                         100%                            80%
                                                      36 sessions/12 week period
                                                        Precertification required
Occupational Therapy                           100%                            80%
                                            45 visits per year Precertification required
Physical Therapy                                100%                            80%
                                            45 visits per year Precertification required
Respiration Therapy                            100%                            80%
                                                         Precertification required
Cognitive Therapy                               100%                            80%
                                            45 visits per year Precertification required
Speech Therapy                                  100%                            80%
                                            45 visits per year Precertification required
OTHER SERVICES
Durable Medical                                 100%                       80%
Equipment Orthotics & Prosthetics           $2,500 annual maximum Precertification required
Home Health Care                            100%                                80%
                                            Precertification required           $300 penalty if late
                                                                                Precertification
Hospice                                     100%                                80%
                                            Precertification required           180 day lifetime maximum
                                                                                $300 penalty if late
                                                                                Precertification
Ambulance                                   100%                                80%
Oral Surgery                                100%                                80%
                                            Precertification required           $300 penalty if late
                                                                                Precertification
Impacted Wisdom Teeth                                                   Not covered
Spinal Manipulation                                                     Not covered

Skilled Nursing Facility                       100%                            80% (90 days per year)
                                                               Precertification required

                                                   15
                                          PCP Referred                  Self Referred
Transplants                               100%                          No self-referred coverage
                                          PAC required
PHARMACY
Prescription Drugs                        $10 copay at community        No self-coverage
                                          Pharmacy (90 day supply)      (emergency Rx covered
                                          $20 mail order copay           under base HMO policy)
                                          (for 90 day supply)
                                          Mandatory generic
MENTAL HEALTH/SUBSTANCE ABUSE SERVICES
Inpatient Mental Health          100%                        80%
                                    35 days/calendar year, precertification required
Outpatient Mental Health                  $10 copay                     50%
                                                  20 visits/year, precertification required
Inpatient Substance Abuse                 100% first course           80% first course
                                          2nd course reduced to 50% 2nd course reduced to 50%
                                              90 day lifetime maximum, precertification required
Outpatient Substance Abuse                100%                            80%
                                          30 visits/calendar year Additional 30 or equivalent partial
                                          may be exchanged on a 2:1 basis for up to 15 non-hospital
                                          residential days, precertification required
Detoxification                            100%                        80%
                                             7 days per admission, 4 admissions per lifetime




                                            16
Section I. Definitions                                       with Covered Services set forth in the
                                                             “Covered Services” section.
 A. The following words and phrases when
    used herein shall have, unless the context            6. COSMETIC PROCEDURES –
    clearly indicates otherwise, the meaning                 Medical or surgical procedures which
    given to them below:                                     are intended to improve the appearance
                                                             of any portion of the body and from
     1. ALCOHOL OR DRUG ABUSE –                              which no improvement in physiologic
        Any use of alcohol or other drugs                    function can be expected.
        which produces a pattern of
        pathological use causing impairment               7. CUSTODIAL CARE – Services to assist
        in social or occupational functioning                an individual in the activities of daily
        or which produces physiological                      living, such as assistance in walking,
        dependency evidenced by physical                     getting in and out of bed, bathing,
        tolerance or withdrawal. For the                     dressing, feeding, and using the toilet,
        purposes of this summary, “drugs”                    preparation of special diets and
        shall be defined as addictive drugs                  supervision of medication that usually
        and drugs of abuse listed as scheduled               can be self-administered. Custodial
        drugs in The Controlled Substance,                   care essentially is personal care that
        Drug, Device and Cosmetic Act (35                    does not require the continuing
        P.S.§780-101 et seq.).                               attention of trained medical or
                                                             paramedical personnel. In determining
     2.    ALTERNATIVE TREATMENT                             whether a person is receiving custodial
          PLAN – A voluntary program                         care, the factors considered are the
          whereby the Participant is offered                 level of care and medical supervision
          cost-effective treatment alternatives in           required and furnished. The decision
          lieu of the stated covered services in             should not be based on diagnosis, type
          the Agreement, without compromising                of condition, degree of functional
          the quality of care. First Priority                limitation or rehabilitation potential.
          Health‟s Care Management
          Department, in cooperation with the             8. DEDUCTIBLE – The portion of
          Primary Care Physician, organizes and              charges for Self-Referred Covered
          coordinates managed care through                   Services that First Priority Health
          multidisciplinary resources.                       considers to be the Provider‟s
                                                             Reasonable Charge (PRC) or the
     3. CALENDAR YEAR – A one (1) year                       Reasonable Equitable Fee (REF), that
        period which begins on January 1 and                 must be incurred by a Participant
        ends on December 31.                                 before First Priority Health will
                                                             assume any liability for all or part of
     4. COINSURANCE – The percentage of                      the remaining Self-Referred Covered
        the Provider‟s Reasonable Charge or                  Services, as set forth in the “Self-
        the Reasonable Equitable Fee for a                   Referred Covered Services” section.
        Self-Referred Covered Services that is
        the responsibility of the Participant             9. DEPENDENT – Any person in a
        after the Deductible is satisfied, as set            Subscriber‟s family who meets all the
        forth in the “Covered Services”                      eligibility requirements as specified by
        section.                                             the Plan and has enrolled for coverage.

     5. COPAYMENT – The amount a                          10. DETOXIFICATION – The process
        Participant must pay directly to                      whereby an alcohol-intoxicated or
        Providers of health care in connection                drug-intoxicated or alcohol-dependent
                                                              or drug-dependent person is assisted,
                                                     17
   in a facility licensed by the                     14. FACILITY OTHER PROVIDER – An
   Department of Health, through the                     institution or entity other than a
   period of time necessary to eliminate,                Hospital which is licensed, where
   by metabolic or other means, the                      required, to render covered services.
   intoxicating alcohol or other drugs,                  Facility Other Providers include:
   alcohol, drug or other drug
   dependency factors or alcohol in                     * Ambulatory Surgical Facility
   combination with drugs as determined
   by a licensed Physician, while keeping               * Durable Medical Equipment
   the physiological risk to the patient at a             Supplier
   minimum.                                             * Freestanding Dialysis Facility
11. DRUG FORMULARY – A listing of                       * Freestanding Outpatient Facility
    drugs which are preferred for use by
    First Priority Health, which is subject             * Home Health Care Agency
    to periodic review and modification by              * Home Infusion Therapy Agency
    a committee of Physicians and
                                                        * Hospice
    Pharmacists.
                                                        * Inpatient Non-Hospital Residential
   a. can withstand repeated use; and
                                                         Facility
   b. is primarily and customarily used
                                                        * Orthotics and Prosthetics Supplier
      to serve a medical purpose; and
                                                        * Outpatient Psychiatric Facility
   c. generally is not useful to a person
      in the absence of an illness or                   * Pharmacy
      injury; and
                                                        * Psychiatric Hospital
   d. is appropriate for use in the home.
                                                        * Rehabilitation Hospital
12. DURABLE MEDICAL EQUIPMENT
                                                        * Skilled Nursing Facility
   Equipment which:
                                                        * Substance Abuse Treatment Facility
   a. can withstand repeated use; and
                                                     15. FULL-TIME STUDENT – A
   b. is primarily and customarily used                  Participant who is attending a
      to serve a medical purpose; and                    recognized college or university, trade
                                                         or secondary school as certified by the
   c. generally is not useful to a person
                                                         Plan Administrator.
      in the absence of an illness or
      injury; and                                    16. GENERIC EQUIVALENT DRUG -
   d. is appropriate for use in the home.                Any drug Product that is considered to
                                                         be therapeutically equivalent to other
13. EMEREGENCY SERVICES –                                pharmaceutical equivalent products by
    Professional health care services for a              the Food and Drug Administration, has
    condition which requires immediate                   received an “A Code” in the FDA
    medical attention to preserve life or                “Approved Drug Products with
    stabilize health; such services are                  Therapeutic Equivalence Evaluations,”
    available on an Inpatient or Outpatient              and is in compliance with applicable
    basis, twenty-four (24) hours per day,               state generic substitution laws and
    seven (7) days per week.                             regulations.


                                                18
17. GROUP THERAPY – Counseling of                         by or under the supervision of
    two (2) or more individuals at one (1)                Physicians;
    time to resolve an identified problem.
    This type of therapy is lead by a                  c. has organized departments of
    Participating Provider.                               medicine and/or major surgery;
                                                       d. provides twenty-four (24) hour
18. HOME HEALTH CARE AGENCY -
                                                          nursing service by or under the
    A Facility Other Provider which has
                                                          supervision of registered nurses;
    been approved by the Joint
                                                          and
    Commission on the Accreditation of
    Healthcare Organizations or First                  e. is not, other than incidentally, a:
    Priority Health which:
                                                           * Skilled Nursing Facility
   a. provides skilled Outpatient
      services on a visiting basis in the                  * Nursing Home
      Participant‟s home; and                              * Custodial Care Home
   b. is responsible for supervising the                   * Health Resort
      delivery of such services under a
      plan authorized by the Primary                       * Spa or Sanitarium
      Care Physician.
                                                           * place for rest
19. HOME INFUSION THERAPY
    AGENCY – A Facility Other Provider                     * place for the aged
    that provides hi-tech services designed                * place for the treatment of mental
    to coordinate the effective provision of                 illness
    Physician directed nursing, Pharmacy
    and related services necessary to                      * place for the provision of
    conduct a parental/enteral regime                        Hospice care, or
    safely and effectively in the patient‟s
    home.                                                  * personal care home

20. HOSPICE – a Facility Other Provider,            22. INPATIENT – A Participant who is
    approved by First Priority Health,                  treated as a registered overnight bed
    which is primarily engaged in                       patient in a Hospital or Facility Other
    providing palliative care to terminally             Provider.
    ill individuals.                                23. INPATIENT NON-HOSPITAL
21. HOSPITAL – A Provider that is a                     RESIDENTIAL CARE – The
    short-term, acute care or rehabilitation            provision of medical, nursing,
    Hospital which has been approved by                 counseling, or therapeutic services to
    the Joint Commission on the                         patients suffering from Alcohol and/or
    Accreditation of Healthcare                         Drug Abuse or dependency in a
    Organizations, the American                         residential environment, according to
    Osteopathic Hospital Association or by              individualized treatment plans.
    First Priority Health, and which:               24. INPATIENT NON-HOSPITAL
   a. is a duly licensed institution;                   RESIDENTIAL FACILITY – A
                                                        Facility Other Provider licensed by the
   b. is primarily engaged in providing                 Department of Health to render an
      Inpatient diagnostic and therapeutic              Alcohol and/or Drug Abuse treatment
      Services for the diagnosis, treatment             program designed to provide Inpatient
      and care of injured and sick persons              Non-Hospital Residential Care.
                                               19
25. LIFETIME COVERED SERVICES                        31. OUT-OF-AREA CARE FOR AN
    MAXIMUM – The maximum dollar                         UNEXPECTED CONDITION –
    amount of Cover Services paid by First               Outpatient medical care that is
    Priority Health for Self-Referred                    required, while the Participant is out of
    Covered Services provided under the                  the First Priority Health service area,
    Agreement during the lifetime of any                 for an unexpected condition that is not
    Participant, as set forth in the “Self-              life threatening and cannot reasonably
    Referred Covered Services” section.                  be postponed until the Participant
                                                         returns to the First Priority Health
26. LONG-TERM RESIDENTIAL CARE                           service are.
    The provision of long-term diagnostic
    or therapeutic services (i.e., assistance        32. OUTPATIENT – Services or supplies
    or supervision in managing basic day-                received by a Participant while not
    to-day activities and responsibilities)              Inpatient.
    to patients suffering from Alcohol
    and/or Drug Abuse or dependency.                 33. OUT-OF-POCKET COINSURANCE
    This care is provided in a long-term                 MAXIMUM – The maximum dollar
    residential environment known as a                   amount of Coinsurance which must be
    Transitional Living Facility, on an                  incurred by a Participant for Self-
    individual, group and/or family basis,               Referred Covered Services in a
    with a program duration greater than                 Calendar Year, as set forth in the
    sixty (60) days. Long-Term                           “Self-Referred Covered Services”
    Residential Care is not Inpatient Non-               section.
    Hospital Residential Care.
                                                     34. PARTIAL HOSPITALIZATION –
27. MAINTENANCE PRESECRIPTION                            The provision of medical, nursing,
    DRUG – Any Prescription Drug, not                    counseling or therapeutic services on a
    specifically designated, which is                    planned and regularly scheduled basis
    generally used to treat chronic medical              in a Hospital or facility other provider
    conditions and is generally not needed               licensed as a mental health or Alcohol
    urgently for an immediate acute illness              and/or Drug Abuse treatment program
    and which the Participant chooses to                 by the Department of Health, designed
    obtain from a Participating Mail Order               for a patient or client who would
    Pharmacy.                                            benefit from more intensive services
                                                         than are offered in outpatient treatment
28. MEDICAL SERVICES - Professional                      but who does not require Inpatient
    services rendered by a Physician or                  care.
    Professional Other Provider.
                                                     35. PHARMACIST – An individual who
29. MEDICARE – The programs of health                    has been issued a license by the
    care for the aged and disabled                       appropriate state licensing agency to
    established by Title XVIII of the                    engage in the practice of pharmacy,
    Social Security Act of 1965, as                      including the preparation and
    amended.                                             dispensing of Prescription Drugs and
                                                         the dissemination of drug information
30. ORTHOTICS -- A rigid or semi-rigid                   to patients and health professionals.
    appliance used for the purpose of
    supporting a weak or deformed body               36. PHARMACY – An establishment
    part or for restricting or eliminating               which has been issued a permit by the
    motion in a diseased or injured part of              appropriate state licensing agency
    the body.                                            wherein the practice of pharmacy is
                                                20
   conducted under the direct supervision              nurse or licensed practical nurse on an
   and control of a licensed Pharmacist.               individual basis.

37. PHYSICIAN – A person who is a                   42. PROFESSIONAL OTHER
    doctor of medicine (M.D.) or a doctor               PROVIDER – An individual or
    of Osteopathy (D.O.), licensed and                  practitioner other than a Physician who
    legally entitled to practice medicine in            is licensed where required to render
    all its branches.                                   Covered Services. Professional Other
                                                        Providers include, but are not limited
38. PRE-CERTIFICATION – The process                     to:
    of providing initial Prior Authorization            * Certified Addiction Counselor
    to a Provider via telephone review by
    the Provider and First Priority Health             * Nurse Practitioner
    with regard to the Medical Necessity               * Chiropractor
    of a service, supply or procedure prior
    to the date of service. Upon initial               * Occupational Therapist
    approval by First Priority Health, a
    Pre-certification number is issued to              * Clinical Psychologist
    the Provider. When Self-Referred                   * Optometrist
    Covered Services are being used, this
    process of determining Medical                     * Clinical Nurse Specialist
    Necessity is between the Participant
    and First Priority Health and the Pre-             * Physical Therapist
    Certification number is issued to the              * Dentist
    Participant.
                                                       * Physician Assistant
39. PRESCRIPTION DRUGS – Any
    medication which by federal/or state               * Independent Clinical Laboratory
    law may not be dispenses without a
                                                       * Podiatrist
    prescription order issued by a licensed
    practitioner authorized by law to                  * Registered Nurse
    prescribe such drugs.
                                                       * Licensed Practical Nurse
40. PRIOR AUTHORIZATION – The
    process whereby Participants are given             * Social Worker
    initial determination of approval to               * Nurse Midwife
    receive Covered Services from a
    Provider other than the Primary Care               * Speech Therapist
    Physician. Section II of this summary
    identifies when Prior Authorization is          43. PROSTETICS – An artificial body
    required from the Primary Care                      part which replaces all or part of a
    Physician or from both the Primary                  body organ or which replaces all or
    Care Physician and First Priority                   part of the function of a permanently
    Health. Prior Authorization is issued               inoperative or malfunctioning body
    as either a Written Referral or Pre-                part.
    certification, in accordance with First
    Priority Health‟s policies and                  44. PROVIDER‟S REASONABLE
    procedures.                                         CHARGE (PRC) – A dollar amount
                                                        that First Priority Health determines is
41. PRIVATE DUTY NURSING – Total                        reasonable for Self-Referred Covered
    patient care provided by a registered               Services provided to a Participant from
                                                        a Hospital or Facility Other Provider,
                                               21
   as set forth in the “Self-Referred                 therapists, and speech pathologists or
   Covered Services”.                                 audiologists. Services which are
                                                      needed only occasionally, such as once
45. REASONABLE EQUITABLE FEE                          or twice a week, or rehabilitation
    (REF) – A dollar amount that First                services which are no longer
    Priority Health determined is                     improving the Participant‟s condition
    reasonable for Self-Referred Covered              and may be carried out by someone
    Services provided to a Participant by a           other than the skilled therapist, are not
    Physician or a Professional Other                 considered Skilled Inpatient Care.
    Provider, as set forth in the “Self-
    Referred Covered Services”.                    51. SKILLED NURSING FACILITY – A
                                                       Facility Other Provider which is an
46. RECONSTRUCTIVE PROCEDURES                          institution or a distinct part of an
    – Procedures performed on a structure              institution, other than one which is
    of the body to improve and/or restore              primarily for the care and treatment of
    bodily function (i.e. congenital or                mental disorders, alcoholism and drum
    developmental anomalies) or to correct             addiction, which is certified as a
    deformity resulting from disease,                  Skilled Nursing Facility under the
    trauma or a previous therapeutic                   Medicare Law, or is qualified to
    process.                                           receive such approval, if so requested,
                                                       or is otherwise approved by First
47. REGIONAL REFERRAL CENTER –                         Priority Health.
    First Priority Health‟s dedicated unit
    that provides eligibility verification,        52. SUBSTANCE ABUSE – Any use of
    triage, referral and utilization                   drugs and/or alcohol which produces a
    management for mental health-                      pattern of pathological use causing
    chemical recovery services.                        impairment in social or occupational
                                                       functioning or which produces
48. SELF-REFERRAL FORM – A form                        physiological dependency evidenced
    that Participants must complete, sign              by physical tolerance or withdrawal.
    and return to First Priority Health
    when filing a claim for Self-Referred          53. THERAPY SERVICE – Services or
    Covered Services.                                  supplies used for the treatment of an
                                                       illness or injury to promote the
49. SELF-REFERRED COVERED                              recovery of a Participant. Therapy
    SERVICES – The provision of Self-                  Services are covered to the extent
    Referred Covered Services to                       specified in this summary.
    Participants at a reduced level of
    payment as set forth in the “Self                 a. RADIATION THERAPY – The
    Referred Covered Services”.                          treatment of disease by x-ray,
                                                         gamma ray, accelerated particles,
50. SKILLED INPATIENT CARE –                             mesons, neutrons, radium or
    Covered Services that are authorized                 radioactive isotopes.
    by the Primary Care Physician as
    rehabilitative services (not                      b. CHEMOTHERAPY – The
    maintenance or Custodial Care),                      treatment of malignant disease by
    performed in a Skilled Nursing Facility              chemical or biological
    on a daily basis and which can only be               antineoplastic agents.
    performed by, or under the supervision            c. DIALYSIS TREATMENT – The
    of, licensed professional personnel or               treatment of acute renal failure or
    professional therapists, such as                     chronic irreversible renal
    physical therapists, occupational                    insufficiency or removal of waste
                                              22
       materials from the body to include                  Hospital Residential Facility rendering
       hemodialysis or peritoneal dialysis.                inpatient Non-Hospital Residential
                                                           Care. Specific Transitional Living
   d. PHYSICAL THERAPY – The                               Facilities include half-way houses,
      treatment by physical means,                         group homes or supervised apartment
      hydrotherapy, heat or similar                        settings.
      modalities, physical agents, bio-
      mechanical and neuro-                             55. WRITTEN REFERRAL – Prior
      psychological principles, and                         initial Authorization documented in
      devices to relieve pain, restore                      writing, on a form provided by First
      maximum function and                                  Priority Health, authorizing a
      prevent disability following                          Participant to receive Covered
      disease, injury or loss of body part.                 Services from a Provider other than
   e. RESPIRATORY THERAPY –                                 the Primary Care Physician.
      The introduction of dry or moist             Section II. Covered Services
      gases into the lungs for treatment
      purposes.                                       A. PRIMARY CARE PHYSICIAN
   f. OCCUPATIONAL THERAPY –                             COVERED SERVICES
      The treatment of a physically                       Except in an emergency as described
      disabled person by means of                         in Section II.G. of this summary, the
      constructive activities designed and                following services will be provided to
      adapted to promote the restoration                  Participants when Medically
      of the person‟s ability to                          Necessary and at or through the
      satisfactorily accomplish the                       Participant‟s Primary Care Physician‟s
      ordinary tasks of daily living and                  office of record, or at other
      those required by the person‟s                      Participating Providers upon initial
      particular occupational role.                       Prior Authorization by the
   g. SPEECH THERAPY – The                                Participant‟s Primary Care Physician.
      treatment for the correction of                     Payment will be made for Covered
      speech impairment resulting from                    Services provided by a Non-
      disease, surgery, injury, congenital                Participating Provider if Medically
      and developmental anomalies or                      Necessary and upon initial Prior
      previous therapeutic processes.                     Authorization by the Participant‟s
                                                          Primary Care Physician and First
   h. CONGNITIVE THERAPY – The                            Priority Health‟s Medical Director.
      treatment designed to correct the                   Covered Services from the Primary
      disorder involving disruption in                    Care Physician include:
      such mental activities as conscious
      thought, problem solving,                           The referral to or designation of a
      judgment and comprehension                          specialist shall be pursuant to a
      related to coping.                                  treatment plan approved by First
                                                          Priority Health, in conjunction with the
54. TRANSITIONAL LIVING                                   Primary Care Physician, the
    FACILITY – A facility that renders                    Participant and, as appropriate, the
    Long-Term Residential Care. This                      Specialist Physician. When possible,
    type of facility can be licensed, when                the Specialist Physician must be a
    appropriate, by the Department of                     Participating Professional Provider.
    Health. However, a facility providing                 Covered Services from the Primary
    Long-Term Residential Care is not to                  Care Physician include:
    be considered an Inpatient Non-
                                              23
1. Office visits during office hours and           examination and one (1) routine
   during non-office hours when                    Papanicolaou smear for female
   Medically Necessary. Participant is             Participants per Calendar Year.
   responsible for a Copayment for                 Participants can utilize their
   each such visit in the amount shown             Primary Care Physician for this
   on the “Covered Services when                   service or they can choose a
   coordinated through your Primary                participating gynecologist. If the
   Care Physician”.                                plan participant requires
                                                   gynecological services, they
2. Home visits by the Participant‟s                are permitted to select a specialist
   Participating Primary Care                      participating within the plan to obtain
   Physician, if the Participant‟s                 maternity or medically necessary
   Primary Care Physician deems it                 gynecological care. This includes
   Medically Necessary. Participant is             medically necessary and appropriate
   responsible for a Copayment for                 follow-up care and written referrals
   each home visit in the amount                   for diagnostic testing related to
   shown on the “Covered Services                  maternity and gynecological care,
   when coordinated through your                   without prior approval from their
   Primary Care Physician”.                        Primary Care Physician. Such health
3. Well child care from birth.                     care services should be within the
                                                   scope of practice of the selected
4. Childhood immunizations. Covered                participating professional provider,
   Services are provided for these                 who is responsible for keeping your
   immunizations, including the                    Primary Care Physician informed of
   immunizing agents, which as                     all health care services provided.
   determined by the Department of                 This Covered Service is exempt from
   Health, conform with the standards              any Deductibles or dollar limits.
   of the Advisory Committee on
   Immunization Practices of the                9. Laboratory and x-ray services, EKGs
   Center for Disease Control, U.S.                and other diagnostic services.
   Department of Health and Human               10. Casts.
   Services. Covered Services are
   limited to Participants until age            11. Emergency coverage arrangements
   twenty-one (21); however, there is               through the Participant‟s Primary
   no age restriction for Dependent                 Care Physician‟s office which are
   Children. Covered Services are                   available twenty-four (24) hours a
   exempt from any Deductibles of                   day, seven (7) days a week.
   dollar limits.
                                                12. Follow-up care after Emergency
5. Adult immunizations; but not solely              Services.
   for the purpose of travel or work.
                                                13. Obstetrical services. A female
6. Routine physical examinations,                   Participant may select a Participating
   once per Calendar Year and                       Professional Provider for maternity
   additional examinations when                     and gynecological services, including
   Medically Necessary.                             Medical Necessary follow up care and
                                                    Written Referrals for diagnostic
7. Routine allergy injections.                      testing relating to maternity and
8. Routine annual gynecological                     gynecological care, without prior
   examinations including a pelvic                  approval from the Participant‟s
   examination, clinical breast                     Primary Care Physician. Such health
                                                    care services shall be within the scope
                                           24
   of practice of the selected                    B. OUTPATIENT COVERED SERVICES
   Participating Professional Provider,
   who is responsible for keeping the             Except in an emergency as described in
   Participant‟s Primary Care Physician           Section II.G. of this Summary, the following
   informed of all health care services           services will be provided to Participants when
   provided.                                      Medically Necessary and at or through the
                                                  Participant‟s Primary Care Physician‟s office
14. Therapeutic drugs, medications and            of record, or at other Participating Providers
    injectables, only when deemed a               upon Prior Authorization by the Participant‟s
    critical part of the therapeutic              Primary Care Physician. Payment will be
    Covered Service being rendered by             made for Covered Services provided by a
    the Primary Care Physician during an          Non-Participating Provider if Medically
    office visit, and when Medically              Necessary and upon initial Prior Authorization
    Necessary. Coverage is limited to the         by the Participant‟s Primary Care Physician
    amount of therapeutic drug,                   and First Priority Health‟s Medical Director.
    medication or injectable administered         Outpatient services include:
    during the office visit. Coverage does
    not include infertility injectables,             1. Ambulance service:
    when used for the purpose of
    ovulation, and contraceptives, when                  a. in an emergency, but subject to
    used for the purpose of birth control.                  the notification requirements set
    First Priority Health has the right to                  forth in Section II.G. of this
    require authorization for certain                       summary; or
    injectables in order to determine                    b. in a non-emergency upon Prior
    medical necessity.                                      Authorization by the
   Copayment – If a Participant has an                      Participant‟s Primary Care
   office visit with their Primary Care                     Physician and First Priority
   Physician, the Participant is                            Health‟s Utilization Management
   responsible for the appropriate                          Department.
   Copayment in the amount shown for                 2. Ambulatory surgery (i.e., surgery
   Primary Care Physician Office Visits                 performed in an acute-care
   on the “Covered Services when                        Hospital‟s short procedure unit or
   coordinated through your Primary                     freestanding surgical facility), upon
   Care Physician”.                                     initial Prior authorization by the
   Participants may utilize their Primary               Participant‟s Primary Care Physician
   Care Physician for Obstetrical                       and First Priority Health‟s Utilization
   Services. Participants are responsible               Management Department.
   for the appropriate Copayment in the              3. Laboratory and x-ray services, EKGs
   amount shown for Obstetrical                         and other diagnostic services.
   Services – Primary Care Physician
   Office Visit on the “Covered Services             4. Outpatient surgery (i.e., surgery
   when coordinated through your                        performed in a Physician‟s office or
   Primary Care Physician”. A                           in an acute care Hospital‟s
   Copayment is charged for the first                   Outpatient department).
   obstetrical office visit. No charge is
   made for second and subsequent                    5. Medical social services and other
   obstetrical office visits.                           health services to include:

                                                         a. pre- and post-hospital planning;


                                             25
   b. referral to (but not payment for)                    Authorization from the Participant‟s
      community health and social                          Primary Care Physician and First
      welfare agency services;                             Priority Health‟s Utilization
                                                           Management Department.
   c. referral to (but not payment for)
      related family counseling                        12. Nutritional counseling at Participating
      services except as specified in                      Hospitals for Participants with diabetes
      Section II.E.1;                                      mellitus or for pregnancy.
   d. referral to and payment for
      services of appropriate family                   13. Radiation Therapy.
      planning agencies as necessary;                  14. Infertility Testing, limited to
      and                                                  laboratory, x-ray studies and surgical
   e. referral to appropriate specialties                  procedures necessary to confirm a
      for payment for fertility services,                  diagnosis of infertility; and artificial
      except injectable and infertility                    insemination.
      related supplies.                                15. Diabetic supplies – First Priority
6. Home health and Hospice services,                       Health Plus provides the following
   upon Prior Authorization by the                         benefits related to diabetic supplies
   Participant‟s Primary Care Physician                    and outpatient self-management
   and First Priority Health‟s Utilization                 training and education:
   Management Department.                                  * The cost of diabetic equipment and
7. Mammography screenings. One (1)                           supplies, including blood glucose
   mammography screening per                                 monitors, monitor supplies, insulin,
   Calendar Year is covered for all                          injection aids, syringes, insulin
   Participants age forty (40) and over                      infusion devices, pharmacological
   whether or not directed toward a                          agents for controlling blood sugar
   definite condition of disease or                          and orthotics.
   injury. Diagnostic mammographies                        * Outpatient self-management training
   with Prior Authorization by a                             and education, including information
   Primary Care Physician are covered                        on proper diets, under the
   for all Participants.                                     supervision of a licensed health care
8. Dialysis Treatment.                                       professional with expertise in
                                                             diabetes.
9. Oxygen and the initial equipment
   necessary to utilize oxygen, upon                       * Coverage for outpatient self-
   Prior Authorization by the                                management training and education
   Participant‟s Primary Care Physician                      benefits, including information on
   and First Priority Health‟s Utilization                   proper diets, will be provided when
   Management Department, when                               performed in a hospital setting by a
   Medically Necessary. Replacement                          participating facility.
   of the initial oxygen equipment is not         C. SPECIALIST PHYSICIAN COVERED
   covered.                                          SERVICES
10. Chemotherapy.                                   Except in an emergency as described in
11. Cardiac rehabilitation programs                 Section II.G., covered services will be
    associated with Participating                   provided to a Participant by a Participating
    Providers. Participants may receive             Specialist Physician or at a Participating
    up to thirty-six (36) sessions, for a           Hospital Outpatient department if, Medically
    twelve (12) week period, upon Prior             Necessary and upon Prior Authorization by
                                             26
Participant‟s Primary Care Physician.                     17. Urology.
Standing Referrals – If the Plan Participant
meets our established criteria of having a life              Copayment – If a Participant has an
threatening, degenerative or disabling disease,              office visit with a Participating
they may receive upon request, a standing                    Specialist, the Participant is responsible
referral to a specialist with clinical expertise             for the appropriate Copayment in the
in treating the disease; or utilize the                      amount shown for Specialist Physician
specialist to provide and coordinate all care                Office Visits on the “Covered Services
needs related to their condition. The referral               when coordinated through your Primary
to or designation of a specialist will be for a              Care Physician”.
treatment plan approved by First Priority
Health. Payment will be made for Covered                     Emergency – In an emergency as
Services provided by a Non-Participating                     described in Section II.G., the services
Provider if Medically Necessary upon Prior                   listed above will be covered without
Authorization by the Participant‟s Primary                   Prior Authorization, subject to all
Care Physician and First Priority Health‟s                   conditions and requirements set forth in
Medical Director. Specialist Physician                       Section II.G.
services include, but are not limited to:
                                                        D. INPATIENT HOSPITAL & SKILLED
1. Allergy Care (except routine injections,                NURSING FACILITY COVERED
   which should be administered by                         SERVICES
   Participant‟s Primary Care Physician).
                                                          A Participant who is hospitalized by a
2. Anesthesia.                                            Participating Physician, if Medically
3. Cardiology.                                            Necessary and upon Prior Authorization
                                                          from Participant‟s Primary Care Physician
4. Endocrinology.                                         and First Priority Health‟s Utilization
                                                          Management Department, is entitled to the
5. Gynecology and Obstetrics.                             following Covered Services only at
6. Internal Medicine.                                     Participating Hospitals and Participating
                                                          Skilled Nursing Facilities. Payment will be
7. Neurology.                                             made for Covered Services provided by a
                                                          Non-Participating Provider if Medically
8. Oncology.                                              Necessary and upon Prior Authorization by
9. Ophthalmology.                                         the Participant‟s Primary Care Physician and
                                                          First Priority Health'‟ Medical Director.
10. Oral Surgery for (a) any condition which              Covered Services in Skilled Nursing
    is a result of trauma or disease, or (b)              Facilities are limited to those which are
    baby bottle syndrome prior to age four                Medically Necessary and which constitute
    (4), once per lifetime.                               Skilled Inpatient Care. Inpatient Hospital
                                                          and Skilled Nursing Facility Covered
11. Orthopedics.                                          Services include:
12. Orolaryngology.
                                                          1. Semi-private room and board
13. Pathology.                                               accommodations.
14. Pediatrics.                                           2. Private accommodations when
15. Radiology (except dental x-rays unless                   Medically necessary and upon
    related to Covered Services).                            authorization by Participant‟s Primary
                                                             Care Physician and First Priority
16. Surgery.                                                 Health‟s Medical Director. A
                                                             Participant who occupies a private room
                                                   27
   without such authorization shall be                     Experimental of Investigative by First
   directly liable to the Participating                    Priority Health for a recipient who is a
   Hospital or Participating Skilled Nursing               Participant. Covered Services will be
   Facility for the difference between                     provided for the removal and transport
   payment by First Priority Health to the                 of the organ from a living donor or
   Participating Hospital or Participating                 cadaver only when the recipient is a First
   Skilled Nursing Facility of the per-diem                Priority Health Participant and only to
   or other agreed-upon rate established                   the extent covered services are
   between First Priority Health and the                   unavailable from any other source.
   Participating Hospital or the
   Participating Skilled Nursing Facility               19. Chemotherapy.
   and the private room rate.
                                                           Copayment – Participant is responsible
3. General nursing care.                                   for a Copayment in the amount shown
                                                           for Inpatient Services on the “Covered
4. Use of intensive or special care facilities             Services when coordinated through your
   when Medically Necessary and                            Primary Care Physician”.
   Appropriate.
                                                           Emergency – In an emergency as
5. Diagnostic and therapeutic radiological                 described in Section II.G. the services
   procedures, except as specifically                      listed above will be covered without
   excluded in Section III.                                prior authorization subject to all the
                                                           conditions and requirements set forth in
6. Use of operating room and related                       Section II.G.
   facilities.
                                                      E. ALCOHOL AND/OR DRUG ABUSE
7. Drugs, medications and biologicals,
                                                         TREATMENT COVERED SERVICES
   when Medically Necessary.

8. Laboratory testing and services.                     Except in an emergency as described in
                                                        Section II.G., the following Covered
9. Pre- and post-operative care.                        Services are provided only when Medically
                                                        Necessary and when the First Priority
10. Special tests when Medically Necessary.             Health Regional Referral Center (RRC) is
                                                        notified and coordinates the Participant‟s
11. Therapy Services.                                   care before the Covered Services are
                                                        rendered. Alcohol and/or Drug Abuse
12. Oxygen.                                             Covered Services include:
13. Anesthesia and anesthesia services.                 1. Outpatient – Participant is eligible for
                                                           thirty (30) Outpatient full-service visits
14. Unreplaced blood and blood components
                                                           or equivalent partial visits per Calendar
    and the administration and processing of
                                                           Year for treatment of Alcohol and/or
    whole blood, blood plasma and blood
                                                           Drug Abuse or dependency. (A visit is
    derivatives.
                                                           defined as one (1) hour of therapy.)
15. Intravenous injections and solutions.                  Participant is additionally eligible for up
                                                           to thirty (30) separate sessions of
16. Dialysis Treatment.                                    Outpatient visits or Partial
                                                           Hospitalization days per Calendar Year.
17. Surgical, medical and obstetric services               These additional thirty (30) sessions may
    provided by a Participating Hospital.                  be exchanged on a two-for-one basis for
18. Transplants that are Medically                         up to fifteen(15) Non-Hospital
    Necessary and not considered to be
                                                 28
   Residential Care days, as described in                admission is limited to seven (7) days of
   Paragraph 3 below.                                    treatment or an equivalent amount.

   Treatment for Alcohol and/or Drug                     The following services shall be covered
   Abuse or dependency shall be provided                 under Inpatient Detoxification treatment:
   according to an individualized treatment
   plan, subject to a lifetime limit of one-             1. Lodging and dietary services;
   hundred-twenty (120) visits.
                                                         2. Physician, psychologist, nurse,
   Covered Services involve diagnosis,                      certified addictions counselor and
   Detoxification, medical treatment and                    trained staff services.
   medical referral services by the RRC for
   Alcohol and/or Drug Abuse. Covered                    3. Diagnostic x-ray;
   Services also include:
                                                         4. Psychiatric, psychological and
   1. Physician, psychologist, nurse certified              medical laboratory tests;
       addictions counselor and trained staff
       services;                                         5. Drugs, medicines, equipment use and
                                                            supplies.
   2. Rehabilitation therapy and counseling;

   3. Family counseling and intervention;             3. Inpatient Non-Hospital Residential Care
                                                         – Participant is eligible for thirty (30)
   4. Psychiatric, psychological and medical             days per Calendar Year for Inpatient
       laboratory tests;                                 Non-Hospital Residential Care in an
                                                         Inpatient Residential Facility, subject to
   5. Drugs, medicines, equipment use and                a ninety (90) day lifetime limit.
       supplies.                                         Inpatient Non-Hospitals Residential
                                                         Care Covered Services include:
   Participant out-of-area students may
   receive Outpatient Alcohol and/or Drug                1. Lodging and dietary services;
   Abuse treatment out of the First Priority
   Health service area if:                               2. Physician, psychologist, nurse,
                                                            certified addictions counselor and
   a. RRC coordinates the care, and                         trained staff services;
   b. the Participant maintains Full-Time
      Students status and attends classes.               3. Rehabilitation therapy and
                                                            counseling;
   If Inpatient treatment is required, the
   Participant must return to the First                  4. Family counseling and intervention;
   Priority Health service area to utilize
   coverage.                                             5. Psychiatric, psychological and
                                                            medical laboratory tests;
2. Inpatient Detoxification – Participant is
    eligible for Inpatient Detoxification                6. Drugs, medicines, equipment use and
    Covered Services in either a                            supplies.
    Participating Hospital or an Inpatient
    Non-Hospital Residential Facility. This                  Copayment – Participant is
    Inpatient Detoxification Covered                         responsible for the appropriate
    Services is subject to a lifetime                        Copayment in the amount shown for
    maximum of four (4) admissions per                       Inpatient Alcohol and/or Drug Abuse
    Participant. Reimbursement per                           treatment on the “Covered Services

                                                 29
         when coordinated through your                    medical condition that manifests itself by
         Primary Care Physician”.                         acute symptoms of sufficient severity or
                                                          severe pain, such that a prudent layperson,
F. MENTAL HEALTH CARE SERVICES                            who possesses an average knowledge of
                                                          health and medicine, could reasonably
  Except in an emergency as described in                  expect the absence of immediate medical
  Section II.G., the following Covered                    attention to result in:
  Services will be provided to Participants
  only when Medically Necessary and when                     placing their health or, with respect to a
  First Priority Health‟s Regional Referral                   pregnant woman, the health of her
  Center (RRC) is notified and coordinates the                unborn child, in serious jeopardy;
  Participant‟s care before the Covered
  Services are rendered.                                     serious impairment to bodily functions;
                                                              or
  1. Outpatient Mental Health Care Services:
     Each Participant may receive twenty                     serious dysfunction of any bodily organ
     (20) visits each Calendar Year to a                      or part.
     psychiatrist, clinical psychologist or
     psychiatric social worker in individual,             Emergency services are available on an
     group, family therapy or                             inpatient basis, twenty-four (24) hours per
     electroconvulsive therapy (ECT)                      day, seven (7) days per week.
     sessions. A visit is one (1) hour of
     therapy or an ECT treatment.                         First Priority Health will reimburse the plan
                                                          participant or their health care provider for
     Participant out-of-area students may                 the reasonable cost of emergency medical
     receive Outpatient Mental Health                     and hospital services (less appropriate
     treatment out of the First Priority Health           Copayments) performed within or outside
     service area if a) the Primary Care                  our service area by participating or non-
     Physician and RRC coordinate the care,               participating providers without prior
     and b) the Participant maintains Full-               authorization. When processing a claim for
     Time Student status and attends classes.             emergency services, First Priority Health
     If the Participant has Inpatient mental              Plus will take into consideration the
     health care coverage under the                       presenting symptoms as an emergency by a
     Agreement‟s Mental Health Care                       prudent lay person, and the services
     Services Rider and Inpatient treatment is            provided.
     required, the Participant must return to
     the First Priority Health service area to         What to do in an emergency
     utilize coverage under the Agreement.
                                                          If a situation arises where the plan
     Copayment – Participant is responsible               participant feels emergency services are
     for the appropriate Copayment for each               required, they should seek treatment
     visit in the amount shown for Outpatient             immediately, because even the slightest
     Mental Health Visits on the “Covered                 delay may be harmful to their health. If the
     Services when coordinated through your               health care provider determines that
     Primary Care Physician”.                             emergency services are necessary, he or she
                                                          will initiate necessary intervention to
G. EMERGENCY CARE                                         evaluate and, if necessary, stabilize the
                                                          condition. The emergency care provider is
  Emergency services are defined as any                   not required to obtain prior authorization for
  health care service provided to a plan                  emergency services from First Priority
  participant after the sudden onset of a                 Health and the plan participant will only
                                                          Be responsible for the outpatient emergency
                                                  30
Room copayment identified in the “Covered             H. OUT-OF-AREA CARE COVERED
Services” section of this summary.                       SERVICES FOR AN UNEXPECTED
If a plan participant is referred to the                 CONDITION
emergency room by their Primary Care
Physician, they will only be responsible for            For Non-Emergency Services outside the
the Primary Care Physician copayment.* If               First Priority Health service area,
a plan participant is admitted to the hospital          Participants can receive Out-of-Area Care
from the emergency room, the emergency                  for an Unexpected Condition a) if they are
room copayment is waived.                               traveling in the service are of an HMO that
                                                        participates in the Away From Home Care
Conditions that require immediate medical               Program and b) if they contact the HMO
treatment as emergencies include, but are               Blue USA Away From Home Care
not limited to:                                         Coordinator for the coordination of care for
                                                        the unexpected condition. Out-of-area non-
* Uncontrolled or excessive bleeding.                   Emergency Services which are not
                                                        coordinated by an Away From Home Care
* Acute pain requiring immediate attention,             Coordinator are not covered. Emergencies
  such as but not limited to, suspected                 as described in Section II.G. need not be
  heart attack or severe shortness of                   coordinated through this program.
  breath.
                                                      I. REHABILITATION COVERED
* Serious burns.                                         SERVICES
* Poisoning.                                            1. Speech Therapy-Speech Therapy
                                                           Covered Services are available on a
* Convulsions.                                             short-term basis. The Covered Service
                                                           consists of treatment for forty-five (45)
* Loss of consciousness.                                   visits per Calendar Year, if the
                                                           Participant‟s Primary Care Physician
Once the plan participant‟s condition is
                                                           certifies that the treatment will result in a
stabilized, their care could be transferred
                                                           significant improvement of the
from a non-participating provider to one
                                                           Participant‟s condition within this time
within the network.
                                                           period and treatment is approved by First
                                                           Priority Health‟s Medical Director.
        The plan participant must pay the
         emergency room copayment to                    2. Physical Therapy – Physical Therapy
         the hospital and obtain a paid-in-                Covered Services are available on a
         full receipt. Mail their receipt                  short-term basis. The Covered Services
         and ask their Primary Care                        consists of treatment for forty-five (45)
         Physician to mail their referral to               visits per Calendar Year, if the
         the First Priority health Claims
                                                           Participant‟s Primary Care Physician
         Department within five (5) days                   certifies that the treatment will result in a
         of the service. We'll reimburse                   significant improvement of the
         the plan participant for the                      Participant‟s condition within this time
         difference between their Primary                  period and treatment is approved by First
         Care Physician and emergency
                                                           Priority Health‟s Medical Director.
         room copayment.
                                                       3. Occupational Therapy – Occupational
                                                           Therapy Covered Services are available
                                                           on a short-term basis. The covered
                                                           services consists of treatment for forty-

                                                 31
      five (45) visits per Calendar Year, if the             d. oxygen and breathing apparatus (oxygen
      Participant‟s Primary Care Physician                      cylinders, positive and intermittent
      certifies that the treatment will result in a             positive pressure breathing machines,
      significant improvement of the                            suction machines);
      Participant‟s condition within this time               e. therapeutic equipment (infusion
      period and treatment is approved by First                 equipment, IV stands, and equipment);
      Priority Health‟s Medical Director.
                                                             f. apnea monitors;
  4. Cognitive Therapy – Cognitive Therapy                   g. glucose monitors (insulin dependent
     Covered Services are available on a                        diabetics only) and;
     short-term basis. The Covered Services
     consists of treatment for forty-five (45)               h. jobst stocking for burn diagnosis.
     visits per Calendar Year, if the
     Participant‟s Primary Care Physician                  K. PRESCRIPTION DRUGS
     certifies that the treatment will result in a
     significant improvement of the                          1. Prescription drugs and medications are
     Participant‟s condition within this time                   covered when prescribed by a licensed
     period and treatment is approved by First                  physician when Medically Necessary
     Priority Health‟s Medical Director.                        including, but not limited to, the
                                                                following:
J. DURABLE MEDICAL EQUIPMENT/
   PROSTHETICS AND ORTHOTICS                                    -   insulin and insulin syringes for
                                                                    diabetics
  Durable Medical Equipment, the initial                        -   contraceptives when used for the
  provision of Prosthetics and the initial                          purpose of birth control
  provision of Orthotics and the initial
  provision of hearing aids, as listed below, if                -   diabetic test agents
  Medically Necessary and approved by the
  Participant‟s Primary Care Physician and                   First Priority Health has the right to require
  First Priority Health‟s Utilization                        prior authorization by First Priority Health
  Management Department are covered.                         for Prescription Drugs in order to determine
  Instructions and appropriate services                      medical necessity. A Participating
  required for Participant to properly use the               Physician will advise the Participant when
  item such as attachment or insertion are also              prior authorization is required prior to
  covered. Replacements are not covered,                     prescribing the drug. If the Participant
  except as certified medically necessary for                utilizing a Non-Participating Physician, the
  children.                                                  First Priority Participating Pharmacy will
                                                             advise the Participant when prior
  Covered Durable Medical Equipment,                         authorization is required prior to dispensing
  Prosthetics and Orthotics includes but is not              the drug. As soon as the authorization is
  limited, to the following:                                 obtained by the Participant, coverage for the
                                                             drug will be available. Should a Participant
  a. hospital beds and related equipment (bed                elect not to obtain authorization from First
     rails, mattresses);                                     Priority Health prior to receiving the
  b. equipment to increase mobility (standard                Prescription Drug and is subsequently
     wheelchairs);                                           determined that the Prescription Drug was
                                                             not Medically Necessary, no benefits will be
  c. commodes (portable bedside                              provided by First Priority Health.
     commodes);
                                                             Each prescription is limited to a maximum
                                                             34-day supply, with up to five (5) refills
                                                      32
  when authorized by a licensed physician,             Self-Referral Form. Copies one (1) and
  Prescriptions must be filled at a First              two (2) of the Self-Referral Form should
  Priority Health Participating Pharmacy.              be sent by the Participant to First Priority
  There is a $10 generic pharmaceutical                Health within fourteen (14) calendar days,
  Copayment. Copayments are payable                    but no later than 180 calendar days from
  directly to the Participating Pharmacy for           the date of service. Failure to submit the
  each prescription.                                   completed and signed Self-Referral Form
                                                       to First Priority Health within 180
  2. The Prescription drug mail order                  calendar days from the date of service,
     service is through Express Scripts                will result in the denial of payment. Copy
     Mail Services Inc. The mail order                 three (3) is to be given to the Participant‟s
     program provides significant cost                 self-referred Provider on the date of
     savings when obtaining prescription               service. Copy four (4) is for the
     medications.                                      Participant‟s records. For Self-Referred
                                                       Covered Services described in Section
     Each Maintenance Prescription Drug is             II.L.2., the Self-Referral Form applies to
     limited to a ninety day (90) supply               the number of days authorized by First
     based on the prescriber‟s directions for          Priority Health in one Pre-Certification.
     use and/or maximum daily dosages as               Subsequent visits and/or Pre-Certifications
     indicated in the drug information                 require additional Self-Referral Forms.
     literature and further subject to the
     supply limits authorized by the                   First Priority Health will inform the
     prescriber on the prescription order.             Participant‟s Primary Care Physician of
     Prescriptions are refillable for a period         the Self-Referred Covered Services
     not in excess of one (1) year from the            received by the Participant, to assist the
     date written and further subject to refill        Participant‟s Primary Care Physician with
     limitations as set forth in federal               the coordination of the Participant‟s future
     and/or state law or by the prescriber.            care.
     The Maintenance Prescription Drug
                                                       1. Self-Referred Covered Services which
     copay is $20 generic pharmaceutical
                                                          require only the Self-Referral Form:
     copayment.

L. SELF-REFERRED COVERED                                  a. Primary Care Physician Covered
   SERVICES                                                  Services, as outlined in Section
                                                             II.A.
  Participants may receive coverage at the
  reduced level of payment, as described in               b. Outpatient laboratory and x-ray
  the “Self-Referred Covered Services”,                      services, EKG‟s and other
  without initial prior authorization by the                 diagnostic services, as outlined in
  Participant'‟ Primary Care Physician, only                 Section II.B.3.
  if the Participant follows the self-referral
  procedures as described in this Section;                c. Outpatient surgery, as outlined in
                                                             Section II.B.4.
  The services are listed in Section II.L.1. or
                                                          d. Medical social services and other
  Section II.L.2; and First Priority Health
                                                             health services, as outlined in
  determines that the services are Medically
                                                             Section II.B.5.
  Necessary.
                                                          e. Mammography screenings, as
  Before a Participant receives Self-Referred                outlined in Section II.B.7.
  Covered Services, the Participant must
  complete and sign First Priority Health‟s
                                                  33
   f. Outpatient Dialysis, as outlined in             Participant‟s responsibility to include
      Section II.B.8.                                 First Priority Health‟s Pre-Certification
                                                      number on the Self-Referral Form before
   g. Outpatient Chemotherapy, as                     the Participant submits the Self-Referral
      outlined in Section II.B.10.                    Form to First Priority Health and the
   h. Nutritional counseling, as outlined             Provider, in accordance with this
      in Section II.B.12.                             summary.

   i. Radiation Therapy, as outlined in               Should the Participant fail to obtain
      Section II.B.13.                                initial Pre-Certification, when required,
                                                      the Participant shall be liable for
   j. Infertility Testing and artificial              payment of a penalty equal to the first
      insemination, as outlined in                    $300 of charges for Covered Services.
      Section II.B.14.                                Such penalty shall not be applied toward
   k. Diabetes education services, as                 the Participant‟s Out-of-Pocket
      outlined in Section II.B.15.                    Coinsurance Maximum.

   l. Specialist Physician Covered                    The following are Self-Referred Covered
      Services, as outlined in Section                Services which require the Self-Referral
      II.C.                                           Form and initial Pre-Certification:

2. Self-Referred Covered Services                     a. Ambulatory surgery, as outlined in
   which require the Self-Referral Form                  Section II.B.2.
   and Pre-Certification:
                                                      b. Home Health and Hospice services,
   Prior to receiving the Self-Referred                  as outlined in Section II.B.6.
   Covered Services identified in this
   Section, in addition to completing                 c. Outpatient oxygen, as outlined in
   the Self-Referral Form in accordance                  Section II.B.9.
   with this summary, Participant must
   receive initial Pre-Certification from             d. Cardiac rehabilitation programs, as
   First Priority Health‟s Utilization                   outlined in Section II.B.11.
   Management Department. To
   receive Pre-Certification, the                     e. Inpatient Hospital and Skilled
   Participant must phone First Priority                 Nursing Facility Covered Services,
   Health‟s Utilization Management                       as outlined in Section II.D., except
   Department and provide evidence                       for transplants as outlined in Section
   that the Self-Referred Covered                        II.D.18.
   Services are Medically Necessary.
   Although a Physician or Physician'‟                f. Alcohol and/or Drug Abuse
   office staff may phone First Priority                 Treatment Covered Services, as
   Health for Pre-Certification on the                   outlined in Section II.E.
   Participant‟s behalf, it is the                    g. Mental Health Care Services, as
   Participant‟s responsibility to ensure that           outlined in Section
   initially Pre-Certification occurs prior to
   the date of service. When First Priority           h. Occupation Therapy, Physical
   Health has determined that the Self-                  Therapy, Speech Therapy and
   Referred Covered Services are                         Cognitive Therapy, as outlined in
   Medically Necessary, First Priority                   Section II.I.
   Health will issue a Pre-Certification
   number to the Participant. It is the

                                                 34
   3. Hospitalization for transplants, as                     procedure, Provider, equipment,
      outlined in Section II.D.18. is not                     drug, device or supply is
      eligible for Self-Referred Covered                      Experimental or Investigative is set
      Services.                                               forth in Section V, Other Provisions
   4. Claims for Self-Referred Covered                        section of this summary.
      Services must be received by First
      Priority Health with one (1) year from            5. Care of any illness or injury suffered
      the date of service.                                 after the Participant‟s Effective Date
                                                           of coverage as a result of any act of
Section III. Exclusions                                    war.
                                                        6. Coverage of non-First Priority Health
   A. The following are not covered services               donor in a transplant procedure unless
      under the Agreement:                                 the recipient of the transplant is a
                                                           Participant. In the event a Participant
       1. Any service obtained by or on behalf             is the recipient, coverage will be
          of a Participant without prior                   provided under the Agreement for a
          authorization by the Participant‟s               live non-First Priority Health donor to
          Primary Care Physician and when                  the extent covered services are
          appropriate, by First Priority Health,           unavailable from any other source.
          except as described in Section II.E.,            The purchase of human organs which
          F., G., H., and L. of this summary.              are sold rather than donated to
                                                           transplant recipients are not covered.
       2. Cosmetic procedures for cosmetic
          purposes, except those performed to           7. Charges to the extent payment has
          correct medically diagnosed                      been made under Medicare or would
          congenital defects and birth                     have been made if the Participant had
          abnormalities or a condition resulting           applied for Medicare and claimed
          from an accident or illness.                     Medicare Covered Services.

       3. Unless otherwise stated in this               8. Treatment of mental retardation,
          summary, all dental services related             defects, deficiencies and learning
          to the care, filling, removal or                 disabilities. This exclusion does not
          replacement of teeth and treatment of            apply to Mental Health Care Services
          diseases of the teeth or gums,                   as described in Section II.F. or to
          including but not limited to                     medical treatment of retarded
          apicoectomy (dental root resection),             Participants in accordance with the
          orthodontics, root canal treatment,              covered services provided in Section
          soft tissue impactions, treatment of             II.
          temoromandibular joint dysfunction
          with intraoral prosthetic devices, or         9. Care for conditions that state or local
          any other method to alter the vertical           law requires to be treated in a public
          dimension of the bite, alveolectomy              facility.
          and treatment of periodontal disease.
                                                        10.   The cost of securing the services of
       4. Services or supplies which First                    professional blood donors.
          Priority Health initially determines
          are Experimental or Investigative in          11.   Palliative or cosmetic foot care
          nature or for the Covered Services                  including flat foot conditions,
          related to them; First Priority                     supportive devices for the foot, the
          Health‟s procedure in determining                   treatment of subluxations of the foot,
          whether the use of any treatment,                   care of corns, bunions (except capsular
                                                              or bone surgery), calluses, toenails
                                                   35
   (except surgery for ingrown nails),                  abortions are covered only when
   fallen arches, weak feet, chronic foot               Medically Necessary and approved by
   strain and symptomatic complaints of                 First Priority Health‟s Medical Direct.
   the feet.
                                                     25. Immunizations obtained for the purpose
12. Provision of personal convenience                    of international travel or which are work
    items or service such as barber                      related.
    services, guest meals, radio and
    television rentals, and other like items         26.Costs related to any court appearance,
    and services.                                       proceeding or hearing.

13. Custodial care, domiciliary care or rest         27. Charges for any illness or bodily injury
    cures.                                               which occurs in the course of
                                                         employment if benefits or compensation
14. Weight reduction programs.                           are available, in whole or in part, under
                                                         the provisions of workers‟
15. Drugs, medications and injectables,
                                                         compensation, occupational disease or
    including fertility injectables when used
                                                         similar type legislation. This exclusion
    for the purpose of ovulation and
                                                         applies regardless of whether the
    contraceptives when used for the
                                                         Participant claims the covered service or
    purpose of birth control, except as
                                                         compensation.
    provided in Section II.
16. Special medical reports, unless directly         28. Charges for treatment of obesity, except
    related to treatment of a Participant.               when surgical treatment of morbid
                                                         obesity is Medically Necessary.
17. Private duty or special nursing care.
                                                     29. Orthoptics (a technique of eye exercise
18. Payment for services which are eligible              designed to correct the visual axes of
    for payment under the provisions of an               eyes not properly coordinated for
    automobile insurance contract or                     binocular vision).
    pursuant to any federal or state law
    which mandates identification for such           30. Services or supplies received from a
    services to persons suffering bodily                 dental or medical department established
    injury from motor vehicle accidents,                 primarily for treatment of employees or
    where permitted by state law.                        Participants and maintained by or on
                                                         behalf of an employer, a mutual covered
19. Chronic Alcohol and/or Drug Abuse
                                                         service association, labor union, trust or
    treatment, except as provided by Section
                                                         similar person or group.
    II.E.
20. Long-Term Residential Care.                      31. Charges incurred prior to the
                                                         Participant‟s Effective Date or during an
21. Therapy or rehabilitation, except as                 Inpatient admission that commenced
    provided by Section II.I.                            prior to the Participant‟s Effective Date.
22. Reversal of voluntary sterilization.
                                                     32. Charges incurred after the date of
23. Transsexual surgery or related services.             termination of the Participant‟s
                                                         coverage, except as provided in this
24. Elective abortions, except however,                  summary.
    services which are necessary to avert the
    death of the woman and services to               33. Services or supplies for personal hygiene
    terminate pregnancies caused by rape or              and convenience items such as, but not
    incest will be covered. Therapeutic
                                                36
   limited to, air conditioners, humidifiers,                    other services and supplies related to
   physical fitness equipment and air                            these procedures.
   filtering machines.
                                                             42. Durable Medical Equipment, Prosthetics
34. Charges for telephone consultations,                         and Orthotics, with the exception of
    charges for failure to keep a scheduled                      oxygen and the initial equipment
    visit or charges for completion of a                         necessary to utilize oxygen.
    claim form.                                                  Replacement of the initial oxygen
                                                                 equipment in not covered.
35. Charges for which the Participant has no
    legal obligation to pay.                                 43. Inpatient care and Partial Hospitalization
                                                                 for mental health care services.
36. Charges which are recoverable by or on
    behalf of the Participant in any action at               44. Preventive dental care.
    law or in compromise or settlement of a
    claim against a party, other than an                     45. Paramedics.
    insurer of the Participant, unless the
    Participant furnished such information as
    First Priority Health may require to                                 Section IV. Participant Eligibility
    facilitate enforcement of its rights.
                                                      At the direction of the Plan, First Priority Health
37. Charges for Inpatient admissions and              will enroll the Subscriber and his/her spouse and all
    home care services not certified as               unmarried and unemployed dependent children
    eligible by the Participant‟s Primary             under 19 years of age as participants for the
    Care Physician and First Priority                 coverage described herein.
    Health‟s Utilization Management                   Each eligible dependent child participant is covered
    Department.                                       from birth until: (a) the end of the calendar year in
                                                      which he/she reaches their 19th birthday, (b) the end
38. Spinal Manipulation.                              of the month in which he/she marries or becomes
                                                      employed or (c) the end of any period during which
39. Mandated treatment, including court               he is incapable of self-support because of a
    ordered treatment, unless such treatment          disabling abnormality or condition of illness or
    is Medically Necessary.                           injury. Eligibility for continuation of such disabled
                                                      children will be initially determined by First
40. Corneal surgery to change the shape of            Priority Health.
    the cornea which will correct vision
    problems such as myopia                           Unmarried dependent student participants will be
    (nearsightedness), hyperopia                      covered to age 23 if they are attending on a full
    (farsightedness) and astigmatism. The             time* basis an accredited college, university,
    correction of astigmatism resulting from          technical or specialized school and are pursuing a
    trauma or from previously eligible                course of study requiring at least 2 years which will
    surgery, including, but not limited to,           lead to a degree or certificate upon completion.
    cataract and corneal surgery, is eligible
    for payment.                                         * The term „full-time” does not include
                                                           those students attending night school or
41. In Vitro Fertilization; Gamete Intra                   summer school only, or those attending
    Fallopian Tube Transfer (a form of In                  school on a part-time basis. The initial
    Vivo Fertilization) and Zygote Intra                   determination of eligibility will be made
    Fallopian Tube Transfer (a form of In                  by First Priority Health.
    Vitro Fertilization) including the drugs,
    diagnostic monitoring (ultrasound) and
                                                 37
                                                         provided was Medically Necessary, and
Section V. Other Provisions                              First Priority Health has the option to
                                                         initially select the appropriate
A. IDENTIFICATION CARD                                   Participating Hospital to render services if
                                                         hospitalization is necessary. Decisions as
   The identification card issued by First               to Medical Necessity are subject to review
   Priority Health to a Participant pursuant to          by First Priority Health Medical Director,
   the Agreement is for identification purposes          or his/her Physician designee.
   only. Possession of an identification card
   confers no right to services or covered             C. EXPERIMENTAL OR INVESTIGATIVE
   services under the Agreement, and misuse               SERVICES
   of such identification card may be grounds
   for initial termination of a Participant‟s            The Medical Director of First Priority
   coverage pursuant to Section IV. If the               Health shall have initial authority to
   Participant who misuses the card is the               determine whether the use of any
   Subscriber, coverage may be terminated                treatment, procedure, Provider, equipment,
   for the Subscriber as well as any                     drug, device or supply (each of which is
   Dependents. To be eligible for services or            herein after called a “Service”) is
   benefits under the Agreement, the holder              Experimental or Investigative.
   of the card must be a Participant on whose
   behalf all applicable administrative fees             a. If, in making that initial determination,
   under the Agreement have been paid. Any                  the Medical Director finds that the
   person receiving services or covered                     service, for which a claim for covered
   services which he or she is not entitled to              services is made, is either: (1) the
   receive pursuant to the provisions of the                subject of a written investigational or
   Agreement shall be charged for such                      research protocol used by the treating
   services or covered services at prevailing               facility or of a written investigational
   rates.                                                   or research protocol of another facility
                                                            studying substantially the same
   If any Participant permits the use of his or             Service; or (2) the subject of a written
   her identification card by any other person,             informed consent used by the treating
   such card may be retained by First Priority              facility which refers to the Service as
   Health, and all rights of such Participant               experimental, investigative,
   and his or her Dependents, if any, pursuant              educational or research; or (3) the
   to the Agreement shall be initially                      subject of an ongoing phase I, II or III
   terminated immediately, subject to the                   clinical trial, the Service shall be
   Grievance Procedure attached in Exhibit C                deemed to be Experimental or
   of the Agreement.                                        Investigative.

   If a Subscriber terminates coverage with              b. If, in making that initial determination,
   First Priority Health, it is the Plan‟s                  the Medical Director finds that neither
   responsibility to obtain the identification              a protocol, an informed consent nor an
   cards of the Subscriber and affiliated                   ongoing clinical trial, as described
   Participant and to return the cards to First             above, exist, then the Medical Director
   Priority Health.                                         may require that demonstrated
                                                            evidence exists, as reflected in the
B. MEDICAL NECESSITY                                        published Peer Reviewed Medical
                                                            Literature:
   Participants will receive covered services
   under the Agreement only when Medically                  (1) that the Services is recognized by a
   Necessary. First Priority Health may                         majority of those practicing the
   determine whether any covered service                        appropriate medical specialty as
                                                  38
   being safe and effective for use in             c. If, in making the initial determination,
   the treatment of the particular                    the Medical Director finds that a drug,
   condition in question; and                         a device, a supply or equipment has
                                                      not received marketing approval
(2) that the Service has a definite                   (permission for commercial
    positive effect on health outcomes;               distribution) by the United States Food
    such evidence must include well-                   and Drug Administration: (1) at the
    designed investigations that have                 time the services is rendered; (2) for
    been reproduced by non-affiliated                 the purpose for which it is rendered;
    authoritative sources with                        and (3) for the manner in which it is
    measurable results supported by                   rendered, the drug, device, supply or
    the positive endorsements of                      equipment shall be deemed to be
    national medical bodies or panels                 Experimental or Investigative.
    regarding scientific efficacy and
    rationale; and                               D. HOSPITAL AND FACILITY OTHER
                                                    PROVIDER RULES
(3) that, over time, the Service leads to
    improvements in health outcomes,               Participant is subject to all the rules and
    i.e. the beneficial effects of the             regulations of each Hospital and other
    Service outweigh any harmful                   facility in which covered services are
    effects of the Service; and                    provided.

(4) that the Service is at least as              E. REFUSAL OF TREATMENT
    effective in improving health                  Participant may, for personal reasons, refuse
    outcomes as established                        to accept procedures, medicines or courses of
    technology or is usable in                     treatment recommended by a Participating
    appropriate clinical contexts in               Physician. If such Participating Physician
    which established technology is                (after a second Participating Physician‟s
    not employable; and                            opinion, if requested by Participant) believes
                                                   that no professionally acceptable alternative
(5) that improvement in health                     exists, and if after being so advised,
    outcomes is possible in standard               Participant still refuses to follow the
    conditions of medical practice                 recommended treatment procedure,
    outside clinical investigatory                 Participant will receive no further treatment
    settings.                                      for the condition involved. In such case
                                                   neither the Providers nor First Priority Health
   PEER REVIEWED MEDICAL                           will have further responsibility to provide
   LITERATURE means two (2) or                     any of the covered services available under
   more U.S. scientific publications               the Agreement for treatment of such
   which require that manuscripts be               condition. First Priority Health will provide
   submitted to acknowledged experts               written notice to Participant of a decision not
   inside or outside the editorial office          to render further treatment for a particular
   for their considered opinions or                condition. The decision is subject to the
   recommendations regarding                       Grievance Procedure attached in Exhibit C of
   publication of the manuscript.                  the Agreement. Treatment of the condition
   Additionally, in order to qualify as            involved will be resumed in the event
   Peer Reviewed Medical Literature,               Participant agrees to follow the
   the manuscript must actually have               recommended treatment or procedure.
   been reviewed by acknowledged
   experts before publication.


                                            39
F. NON-ASSIGNMENT OF PAYMENT OF
   BENEFITS
  No person other than a Participant is entitled
  to receive benefits for Covered Services              I. CONFIDENTIALITY
  under this Agreement.
                                                          Information contained in the medical
  Furthermore, First Priority Health will                 records of Participants and information
  arrange payments of Covered Services to be              received from Physicians, surgeons,
  made directly to Participating Providers                Hospitals or other health professionals
  furnishing Covered Services under this                  incident to the doctor-patient relationship or
  Agreement. However, First Priority Health               hospital-patient relationship shall be kept
  reserves the right to make payments directly            confidential in accordance with the
  to Participants.                                        Agreement.

  The right of a Participant to receive payment         J. LIMITATION ON SERVICES
  is not assignable nor may the right to receive
  Covered Services be transferred by a                    Except in cases of emergency as provided
  Participant.                                            under Section II.G. of the Benefit Summary,
                                                          services are available only from
G. LEGAL ACTION                                           Participating Providers, and First Priority
                                                          Health shall have no liability or obligation
  No action at law or in equity may be                    whatsoever on account of any service or
  maintained against First Priority Health for            covered service sought or received by a
  any expense or bill unless brought within the           Participant from any Provider or other
  statute of limitations for such cause of                person, entity, institution or organization
  action.                                                 unless prior arrangements are made by First
                                                          Priority Health.
H. PHYSICIAN – PATIENT RELATIONSHIP
                                                        K. ALTERNATIVE TREATMENT PLAN
  Participating Physicians maintain the
  physician-patient relationship with                     Notwithstanding anything in the Agreement
  Participant and are solely responsible to the           to the contrary, First Priority Health may,
  Participant for all Medical Services which              upon consideration of the Plan, elect to
  are rendered by Providers.                              provide covered services pursuant to an
                                                          approved Alternative Treatment Plan for
                                                          services that would otherwise not be
                                                          covered. All decisions regarding the
                                                          implementation of alternative care or
                                                          alternative treatment to be provided to a
                                                          Participant shall remain the responsibility of
                                                          the Primary Care Physician and/or the
                                                          Attending Physician and the Participant.




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