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.

Phone: (570) 941-7767

The appropriate Blue Cross and Blue Shield Plan contact is:

Address: First Priority Health

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:

_________________________________________________________________________________________

The University of Scranton

Linden and Monroe Ave.

Scranton, PA 18510-4679

Phone: (570) 941-7767

24-0795495

501

The benefits in this summary apply to active employees of The University of Scranton.

The premiums for your benefits under the plan are paid by the employer

2-1-99

The University of Scranton

Human Resources Department

Linden and Monroe Ave.

Scranton, PA 18510-4679

Phone: (570) 941-7767

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

1. To administer the Plan in accordance with its terms.
2. To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies or omissions.
3. To decide disputes which may arise relative to a Plan Participant’s rights.
4. To prescribe procedures for filing a claim for benefits and to review claim denials.
5. To keep and maintain the Plan documents and all other records pertaining to the Plan.
6. To appoint a Claims Administrator to pay claims.
7. To perform all necessary reporting as required by ERISA.
8. To establish and communicate procedures to determine whether a medical child support order is qualified under ERISA Sec. 609.
9. To delegate to any person or entity such Powers, duties and responsibilities as it deems appropriate.

1. with care, skill, prudence and diligence under the given circumstances that a prudent person, acting in a like capacity and familiar with such matters, would use in a similar situation;
2. by diversifying the investments of the Plan so as to minimize the risk of large losses, unless under the circumstances it is clearly prudent not to do so; and
3. in accordance with the Plan documents to the extent that they agree with ERISA.

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

The cost of the Plan is funded as follows:

Newly hired and rehired full-time employees and their eligible dependents will be eligible for the benefits described in this summary plan description on the first of the date of hire.

Persons who become eligible dependents of an enrolled employee after the effective date of the employee’s enrollment will be eligible for these benefits upon notification from employee of such additional dependents.

Each eligible employee must complete an application form.

1. In the event a participant is covered under a Benefit program other than this Plan, which does not contain a provision coordinating its benefits with those of this Plan, such other Plan will be primary Plan and as such shall determine its benefits before benefits are determined under this Plan. Benefits payable under another Plan include the benefits that would be payable, whether or not claim is made therefore.

Such other Plan may include any company-sponsored Plan, including any group Blue Cross/Blue Shield Plan, franchise arrangements, or any company-sponsored Plan to which any employer contributes or makes payroll deductions. Such other Plan will not include blanket student accident coverage.

2. When a participant is covered under another Plan which contains a provision coordinating its benefit with those of this Plan, the following rules will establish order of determining liability of this or any other Plan:
1. The Plan covering the patient as a contract Holder is the primary Plan, which shall determine its benefits before benefits are determined under any other Plan.
2. Except for situations where the parents of a child are separated or divorced:

1. The Plan of the parent whose date of birth (month/day) falls earlier in the calendar year is the primary Plan. If both parents have the same birthday, the Plan which covered the parent longer will be the primary Plan; or
2. If this Plan is coordinating with a Plan which uses the rule based on the gender of the parent, the Plan of the male parent is the primary Plan.

1. In those situations where the parents of the child are separated or divorced;

1. The Plan covering the child as a dependent of the parent with custody will be the primary Plan;
2. If the parent with custody has remarried, the Plan which covers the child as a dependent of the step-parent with custody will be the primary Plan;
3. Where there is a court decree which establishes financial responsibility for the health care expenses of the dependent child, the plan which covers the child as a dependent of the parent with such financial responsibility will be the primary Plan, as long as the Plan of the parent has actual knowledge of the court decree; or
4. If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the Plans covering the child shall follow the order of benefit determination rules outlined in paragraph 2.b.

1. Where the determination cannot be made in Accordance with the above, the Plan which has covered the participant for the longer period of time will be considered the primary Plan, except:
1. The Plan which covers the participant as an active employee (or a dependent of such a person) is the primary Plan over a Plan that covers a participant as laid-off or retired employee (or dependent of such a person); or
2. If either Plan does not have a provision regarding laid-off or retired employees and as a result, the benefits of each Plan are determined after the other, then the

provisions of a 3.a. above shall not apply.

2. Services provided under any governmental Program for which any periodic payment of rate is made by or for the participant shall always be the primary Plan, except where prohibited by law.
3. Individual Non-Group Health Plans of any kind will not be coordinated when the participant pays the entire cost.
4. When this Plan is determined to be the Primary Plan, benefits will be paid without regard to coverage under any other Plan and there are remaining covered services, this Plan will pay its regular benefit up to the amount of such remaining eligible covered services.
5. Facility of Payment – Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other Plan, Blue Cross and Blue Shield will have the right, at their sole discretion, to pay to any organization making such other payments any amounts they determine to be warranted in order to satisfy the intent of this provision and amounts so paid will be considered benefits paid under this Plan and Blue Cross and Blue Shield will be fully discharged from liability.
6. Right of Recovery – Whenever payments have been made by Blue Cross and Blue Shield in excess of the maximum amount of payment necessary to satisfy the intent of this provision, irrespective of to whom paid, Blue Cross and Blue Shield will have the right to recover such payments to the extent of such excess from among one or more of the following, as Blue Cross and Blue Shield will determine:
1. Any persons to or for or with respect to whom such payments were made (including the participants covered under this Plan);
2. Any insurance companies; and
3. Any organization.

1. Plan Responsibilities

Plan represents and warrants that the Summary Plan Description confers on the Plan rights of subrogation and third part recovery. Plan delegates or assigns these subrogation rights and third party recovery rights to Blue Cross of Northeastern Pennsylvania as the Plans agent for purposes of subrogation.

2. BCNEPA’s Subrogation Duties

Blue Cross of Northeastern Pennsylvania shall 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 Pennsylvania shall be subrogated, and succeed to the rights of recovery of a participant for expenses incurred against any person or organization except insurers or policies of health insurance issued to and in the name of participant. In those instances where the subrogation recovery efforts of the participant’s attorney should, in the opinion of Blue Cross of Northeastern Pennsylvania, be compensated, the Plan delegates to Blue Cross of Northeastern Pennsylvania full authority to act on behalf of the Plan to negotiate reasonable attorney fees not to exceed thirty-three and one-third percent (33 1/3%) for personal injury cases, up to forty percent (40%) for medical malpractice cases and twenty percent (20%) for worker’s compensation cases. Any determination by Blue Cross of Northeastern Pennsylvania will respect to attorney fees shall be final and conclusive, unless overturned under a limited arbitrary and capricious standard of review. Blue Cross of Northeastern Pennsylvania shall provide the participant’s attorney with updated lien amounts, as requested, and shall work with the participant’s attorney to recover 100% of the Covered Services paid (unless such amount is compromised as set forth in Section C). Blue Cross of Northeastern Pennsylvania shall credit the plan with the amount recovered, minus, as applicable, a prorata share of the costs and the participant’s attorney fees.

3. Authority to compromise Liens

In those instances where a plan’s subrogation lien should, in the opinion of Blue Cross of Northeastern Pennsylvania, be compromised, the plan delegates to Blue Cross of Northeastern Pennsylvania full authority to act on behalf of the plan to compromise the lien. Any determination by Blue Cross of Northeastern Pennsylvania with respect to subrogation liens shall be final and conclusive, unless overturned under a limited arbitrary and capricious standard of review.

 

 

 

4. Participant’s Duties

The participant shall pay to Blue Cross of Northeastern Pennsylvania all amounts recovered by suit, settlement, or otherwise from any third party or his insurer to the extent of the benefits provided and paid under the plan less any attorney’s fees and expenses. The participant shall take such action, furnish such information and assistance, and execute such papers as Blue Cross of Northeastern Pennsylvania may require to facilitate enforcement of its rights and shall take no action prejudicing the rights and interest of Blue Cross of Northeastern Pennsylvania.

5. Prohibited by Law

Consolidated Omnibus Budget Reconciliation

Employers with twenty (20) or more employees (as defined under COBRA to mean full or part-time and whether or not enrolled for coverage under this Contract) are subject to COBRA regulations. Employers with less than twenty (20) employees are not subject to COBRA regulations and cannot make available continuation coverage under this Contract after the Subscriber ceases to be an Eligible Person.

Upon timely notice from the Group, the Plan will make available continuation coverage, as required by COBRA, for all Employees and their Dependents determined to be qualified beneficiaries, as defined in Section 162 (k) (7) (B) of the Internal Revenue Code as amended from time to time, and Section 607 (3) of the Employee Retirement Income Security Act (ERISA), as amended from time to time. The Group shall retain full responsibility for notifying Employees of their rights to continuation coverage and administering the exercise of continuation rights, as required by COBRA. The Plan shall have no obligation to ensure that any termination instructions received from the Group comply with the requirements of COBRA. For purposes of COBRA, the Plan is not the administrator as defined under ERISA.

Each Employee has a right to continue coverage if:

1. Employment with the Group ends for a reason other than gross misconduct; or
2. Work hours are reduced.

Each Dependent has a right to continue coverage if:

1. The Employee’s employment with the Group ends for a reason other than gross misconduct;
2. The Employee’s work hours are reduced;
3. The Employee dies;
4. In the case of an Employee’s spouse, when such spouse ceases to be an Eligible Dependent as a result of divorce or legal separation;
5. The Employee becomes entitled to Medicare; or
6. In the case of a Dependent child, when such child no longer satisfies the eligibility requirements for coverage as a Dependent under this Contract.

Under the COBRA law, the Employee or an Eligible Dependent has the responsibility to inform the administrator (as defined under ERISA) of a divorce, legal separation, or a child losing dependent status under this Contract within sixty (60) days of the date of the later of the event or the date on which coverage would end under this Contract because of the event. The Group has the responsibility to notify the administrator of the Employee’s death, termination of employment, reduction in hours or Medicare entitlement. Similar rights may apply to certain retirees, spouses, and dependent children if the Group commences a bankruptcy proceeding.

When the administrator is notified that one of these events has happened, the administrator will in turn notify the qualified beneficiary within

fourteen (14) days of the notification that he/she has the right to choose continuation coverage. The qualified beneficiary has at least (60) days from such notification to inform the administrator 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 or her decision to pay the retroactive premium.

In the case of the Employee’s termination of employment or reduction in work hours, the coverage may be continued for up to eighteen (18) months. The eighteen (18) months may also be extended to twenty-nine (29) months if an individual is determined to be disabled (for Social Security disability purposes) and the administrator is notified of the determination within sixty (60) days. The affected individual must also notify the administrator within sixty (60) days of any final determination that the individual is no longer disabled. With respect to all other qualifying events, coverage may be continued for up to thirty-six (36) months. Furthermore, in no event will continuation coverage last beyond thirty-six months from the date of the event that originally made a qualified beneficiary eligible to elect coverage. The end of the maximum coverage period is measured from the date of the qualifying event does not result in a loss of coverage under this Contract until some later date.

However, the law also provides that continuation coverage may be cut short for any of the following five reasons:

1. The Group ceases to provide group health insurance to any Employee;
2. The qualified beneficiary fails to make timely payments of any premium required;
3. The qualified beneficiary is covered under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition that the qualified beneficiary may have;
4. The qualified beneficiary is entitled to benefits under Medicare; or
5. The qualified beneficiary extended coverage for up to twenty-nine (29) months due to a disability and there has been a final determination that the qualified beneficiary is no longer disabled.

This Plan shall at all times comply with the Family and Medical Leave Act of 1993 as promulgated in regulations issued by the Department of Labor.

Leave taken under the Family Medical Leave Act shall be covered under this plan on the same conditions as previously provided, as though the Employee has been continuously employed up to the 12-week leave period.

If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the Employee and his or her covered Dependents if the Employee returns to work in accordance with the terms of the FMLA leave. Coverage will be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started, and will be reinstated to the same extent that it was in force when the coverage terminated. For example, Pre-Existing conditions limitations and other Waiting Periods will not be imposed unless they were in effect for the Employee and/or his or her Dependents when Plan coverage terminated.

If the subscriber ceases to be a participant for this program because of layoff, disability, leave of absence or termination of employment, arrangements may be made to continue both Blue Cross and Blue Shield under the direct payment type of participant Agreements. However, if a participant becomes one of a group having benefits available under a Health insurance Program other than Blue Cross, he or she is not entitled to this conversion privilege.

If the participant dies, the surviving spouse and child may continue coverage under the direct payment type of subscriber Agreements.

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.

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.

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%

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 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

Allergy Tests & Treatments $15 PCP copay 80%

$25 Specialist copay

PCP Referred Self Referred

Lab Tests 100% 80%

Mammography 100% 80%

X-rays 100% 80%

Emergency Medical/Accident $35 copay; waived if admitted

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

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

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

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

2^nd course reduced to 50% 2^nd 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

1. The following words and phrases when used herein shall have, unless the context clearly indicates otherwise, the meaning given to them below:

1. ALCOHOL OR DRUG ABUSE – Any use of alcohol or other drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. For the purposes of this summary, "drugs" shall be defined as addictive drugs

3. CALENDAR YEAR – A one (1) year period which begins on January 1 and ends on December 31.
4. COINSURANCE – The percentage of the Provider’s Reasonable Charge or the Reasonable Equitable Fee for a Self-Referred Covered Services that is the responsibility of the Participant after the Deductible is satisfied, as set forth in the "Covered Services" section.
5. COPAYMENT – The amount a Participant must pay directly to Providers of health care in connection with Covered Services set forth in the "Covered Services" section.
6. COSMETIC PROCEDURES – Medical or surgical procedures which are intended to improve the appearance of any portion of the body and from which no improvement in physiologic function can be expected.
7. CUSTODIAL CARE – Services to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets and

supervision of medication that usually can be self-administered. Custodial care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel. In determining whether a person is receiving custodial care, the factors considered are the level of care and medical supervision required and furnished. The decision should not be based on diagnosis, type of condition, degree of functional limitation or rehabilitation potential.

8. DEDUCTIBLE – The portion of charges for Self-Referred Covered Services that First Priority Health considers to be the Provider’s Reasonable Charge (PRC) or the Reasonable Equitable Fee (REF), that must be incurred by a Participant before First Priority Health will assume any liability for all or part of the remaining Self-Referred Covered Services, as set forth in the "Self-Referred Covered Services" section.
9. DEPENDENT – Any person in a Subscriber’s family who meets all the eligibility requirements as specified by the Plan and has enrolled for coverage.
10. DETOXIFICATION – The process whereby an alcohol-intoxicated or drug-intoxicated or alcohol-dependent or drug-dependent person is assisted, in a facility licensed by the Department of Health, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or other drugs, alcohol, drug or other drug dependency factors or alcohol in combination with drugs as determined by a licensed Physician, while keeping the physiological risk to the patient at a minimum.
11. DRUG FORMULARY – A listing of drugs which are preferred for use by

1. can withstand repeated use; and
2. is primarily and customarily used to serve a medical purpose; and
3. generally is not useful to a person in the absence of an illness or injury; and
4. is appropriate for use in the home.

3. DURABLE MEDICAL EQUIPMENT

1. can withstand repeated use; and
2. is primarily and customarily used to serve a medical purpose; and
3. generally is not useful to a person in the absence of an illness or injury; and
4. is appropriate for use in the home.

3. EMEREGENCY SERVICES –

Professional health care services for a condition which requires immediate medical attention to preserve life or stabilize health; such services are available on an Inpatient or Outpatient basis, twenty-four (24) hours per day, seven (7) days per week.

4. FACILITY OTHER PROVIDER – An institution or entity other than a Hospital which is licensed, where required, to render covered services. Facility Other Providers include:

* Ambulatory Surgical Facility

* Durable Medical Equipment Supplier

* Freestanding Dialysis Facility

* Freestanding Outpatient Facility

* Home Health Care Agency

* Home Infusion Therapy Agency

* Hospice

* Inpatient Non-Hospital Residential Facility

* Orthotics and Prosthetics Supplier

* Outpatient Psychiatric Facility

* Pharmacy

* Psychiatric Hospital

* Rehabilitation Hospital

* Skilled Nursing Facility

* Substance Abuse Treatment Facility

5. FULL-TIME STUDENT – A Participant who is attending a recognized college or university, trade or secondary school as certified by the Plan Administrator.

17. GROUP THERAPY – Counseling of two (2) or more individuals at one (1) time to resolve an identified problem. This type of therapy is lead by a Participating Provider.

1. provides skilled Outpatient services on a visiting basis in the Participant’s home; and
2. is responsible for supervising the delivery of such services under a plan authorized by the Primary Care Physician.

19. HOME INFUSION THERAPY AGENCY – A Facility Other Provider that provides hi-tech services designed to coordinate the effective provision of Physician directed nursing, Pharmacy and related services necessary to conduct a parental/enteral regime safely and effectively in the patient’s home.
20. HOSPICE – a Facility Other Provider, approved by First Priority Health, which is primarily engaged in providing palliative care to terminally ill individuals.
21. HOSPITAL – A Provider that is a short-term, acute care or rehabilitation Hospital which has been approved by the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Hospital Association or by First Priority Health, and which:

1. is a duly licensed institution;
2. is primarily engaged in providing

Inpatient diagnostic and therapeutic

Services for the diagnosis, treatment and care of injured and sick persons by or under the supervision of Physicians;

3. has organized departments of medicine and/or major surgery;
4. provides twenty-four (24) hour nursing service by or under the supervision of registered nurses; and
5. is not, other than incidentally, a:

19. INPATIENT – A Participant who is treated as a registered overnight bed patient in a Hospital or Facility Other Provider.
20. INPATIENT NON-HOSPITAL RESIDENTIAL CARE – The provision of medical, nursing, counseling, or therapeutic services to patients suffering from Alcohol and/or Drug Abuse or dependency in a residential environment, according to individualized treatment plans.
21. INPATIENT NON-HOSPITAL RESIDENTIAL FACILITY – A Facility Other Provider licensed by the Department of Health to render an Alcohol and/or Drug Abuse treatment program designed to provide Inpatient Non-Hospital Residential Care.
22. LIFETIME COVERED SERVICES MAXIMUM – The maximum dollar amount of Cover Services paid by First Priority Health for Self-Referred Covered Services provided under the Agreement during the lifetime of any Participant, as set forth in the "Self-Referred Covered Services" section.
23. LONG-TERM RESIDENTIAL CARE The provision of long-term diagnostic or therapeutic services (i.e., assistance or supervision in managing basic day-to-day activities and responsibilities) to patients suffering from Alcohol and/or Drug Abuse or dependency. This care is provided in a long-term residential environment known as a Transitional Living Facility, on an individual, group and/or family basis, with a program duration greater than sixty (60) days. Long-Term Residential Care is not Inpatient Non-Hospital Residential Care.
24. MAINTENANCE PRESECRIPTION DRUG – Any Prescription Drug, not specifically designated, which is generally used to treat chronic medical conditions and is generally not needed urgently for an immediate acute illness and which the Participant chooses to obtain from a Participating Mail Order Pharmacy.
25. MEDICAL SERVICES - Professional services rendered by a Physician or Professional Other Provider.
26. MEDICARE – The programs of health care for the aged and disabled established by Title XVIII of the Social Security Act of 1965, as amended.
27. ORTHOTICS -- A rigid or semi-rigid appliance used for the purpose of supporting a weak or deformed body part or for restricting or eliminating motion in a diseased or injured part of the body.
28. OUT-OF-AREA CARE FOR AN UNEXPECTED CONDITION – Outpatient medical care that is required, while the Participant is out of the First Priority Health service area, for an unexpected condition that is not life threatening and cannot reasonably

be postponed until the Participant returns to the First Priority Health service are.

29. OUTPATIENT – Services or supplies received by a Participant while not Inpatient.
30. OUT-OF-POCKET COINSURANCE MAXIMUM – The maximum dollar amount of Coinsurance which must be incurred by a Participant for Self-Referred Covered Services in a Calendar Year, as set forth in the "Self-Referred Covered Services" section.
31. PARTIAL HOSPITALIZATION – The provision of medical, nursing, counseling or therapeutic services on a planned and regularly scheduled basis in a Hospital or facility other provider licensed as a mental health or Alcohol and/or Drug Abuse treatment program by the Department of Health, designed for a patient or client who would benefit from more intensive services than are offered in outpatient treatment but who does not require Inpatient care.
32. PHARMACIST – An individual who has been issued a license by the appropriate state licensing agency to engage in the practice of pharmacy, including the preparation and dispensing of Prescription Drugs and the dissemination of drug information to patients and health professionals.
33. PHARMACY – An establishment which has been issued a permit by the appropriate state licensing agency wherein the practice of pharmacy is conducted under the direct supervision and control of a licensed Pharmacist.
34. PHYSICIAN – A person who is a doctor of medicine (M.D.) or a doctor of Osteopathy (D.O.), licensed and legally entitled to practice medicine in all its branches.
35. PRE-CERTIFICATION – The process of providing initial Prior Authorization to a Provider via telephone review by the Provider and First Priority Health with regard to the Medical Necessity of a service, supply or procedure prior to the date of service. Upon initial approval by First Priority Health, a Pre-certification number is issued to the Provider. When Self-Referred Covered Services are being used, this process of determining Medical Necessity is between the Participant and First Priority Health and the Pre-Certification number is issued to the Participant.
36. PRESCRIPTION DRUGS – Any medication which by federal/or state law may not be dispenses without a prescription order issued by a licensed practitioner authorized by law to prescribe such drugs.
37. PRIOR AUTHORIZATION – The process whereby Participants are given initial determination of approval to receive Covered Services from a Provider other than the Primary Care Physician. Section II of this summary identifies when Prior Authorization is required from the Primary Care Physician or from both the Primary Care Physician and First Priority Health. Prior Authorization is issued as either a Written Referral or Pre-certification, in accordance with First Priority Health’s policies and procedures.
38. PRIVATE DUTY NURSING – Total patient care provided by a registered nurse or licensed practical nurse on an individual basis.
39. PROFESSIONAL OTHER PROVIDER – An individual or practitioner other than a Physician who is licensed where required to render Covered Services. Professional Other Providers include, but are not limited to:

* Certified Addiction Counselor

* Nurse Practitioner

* Chiropractor

* Occupational Therapist

* Clinical Psychologist

* Optometrist

* Clinical Nurse Specialist

* Physical Therapist

* Dentist

* Physician Assistant

* Independent Clinical Laboratory

* Podiatrist

* Registered Nurse

* Licensed Practical Nurse

* Social Worker

* Nurse Midwife

* Speech Therapist

40. PROSTETICS – An artificial body part which replaces all or part of a body organ or which replaces all or part of the function of a permanently inoperative or malfunctioning body part.
41. PROVIDER’S REASONABLE CHARGE (PRC) – A dollar amount that First Priority Health determines is reasonable for Self-Referred Covered Services provided to a Participant from a Hospital or Facility Other Provider, as set forth in the "Self-Referred Covered Services".
42. REASONABLE EQUITABLE FEE (REF) – A dollar amount that First Priority Health determined is reasonable for Self-Referred Covered Services provided to a Participant by a Physician or a Professional Other Provider, as set forth in the "Self-

Referred Covered Services".

43. RECONSTRUCTIVE PROCEDURES – Procedures performed on a structure of the body to improve and/or restore bodily function (i.e. congenital or developmental anomalies) or to correct deformity resulting from disease, trauma or a previous therapeutic process.
44. REGIONAL REFERRAL CENTER – First Priority Health’s dedicated unit that provides eligibility verification, triage, referral and utilization management for mental health-chemical recovery services.
45. SELF-REFERRAL FORM – A form that Participants must complete, sign and return to First Priority Health when filing a claim for Self-Referred Covered Services.
46. SELF-REFERRED COVERED SERVICES – The provision of Self-Referred Covered Services to Participants at a reduced level of payment as set forth in the "Self Referred Covered Services".
47. SKILLED INPATIENT CARE – Covered Services that are authorized by the Primary Care Physician as rehabilitative services (not maintenance or Custodial Care), performed in a Skilled Nursing Facility on a daily basis and which can only be performed by, or under the supervision of, licensed professional personnel or professional therapists, such as physical therapists, occupational therapists, and speech pathologists or audiologists. Services which are needed only occasionally, such as once or twice a week, or rehabilitation services which are no longer improving the Participant’s condition and may be carried out by someone other than the skilled therapist, are not considered Skilled Inpatient Care.
48. SKILLED NURSING FACILITY – A Facility Other Provider which is an institution or a distinct part of an institution, other than one which is primarily for the care and treatment of mental disorders, alcoholism and drum addiction, which is certified as a Skilled Nursing Facility under the Medicare Law, or is qualified to receive such approval, if so requested, or is otherwise approved by First Priority Health.
49. SUBSTANCE ABUSE – Any use of drugs and/or alcohol which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal.
50. THERAPY SERVICE – Services or supplies used for the treatment of an illness or injury to promote the recovery of a Participant. Therapy Services are covered to the extent specified in this summary.

1. RADIATION THERAPY – The treatment of disease by x-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.
2. CHEMOTHERAPY – The treatment of malignant disease by chemical or biological antineoplastic agents.
3. DIALYSIS TREATMENT – The treatment of acute renal failure or chronic irreversible renal insufficiency or removal of waste materials from the body to include hemodialysis or peritoneal dialysis.
4. PHYSICAL THERAPY – The treatment by physical means, hydrotherapy, heat or similar modalities, physical agents, bio-mechanical and neuro-psychological principles, and devices to relieve pain, restore maximum function and

prevent disability following disease, injury or loss of body part.

5. RESPIRATORY THERAPY – The introduction of dry or moist gases into the lungs for treatment purposes.
6. OCCUPATIONAL THERAPY – The treatment of a physically disabled person by means of constructive activities designed and adapted to promote the restoration of the person’s ability to satisfactorily accomplish the ordinary tasks of daily living and those required by the person’s particular occupational role.
7. SPEECH THERAPY – The treatment for the correction of speech impairment resulting from disease, surgery, injury, congenital and developmental anomalies or previous therapeutic processes.
8. CONGNITIVE THERAPY – The treatment designed to correct the disorder involving disruption in such mental activities as conscious thought, problem solving, judgment and comprehension related to coping.

1. PRIMARY CARE PHYSICIAN COVERED SERVICES

1. Home visits by the Participant’s Participating Primary Care Physician, if the Participant’s Primary Care Physician deems it Medically Necessary. Participant is responsible for a Copayment for each home visit in the amount shown on the "Covered Services when coordinated through your Primary Care Physician".
2. Well child care from birth.
3. Childhood immunizations. Covered Services are provided for these immunizations, including the immunizing agents, which as determined by the Department of Health, conform with the standards of the Advisory Committee on Immunization Practices of the Center for Disease Control, U.S. Department of Health and Human Services. Covered Services are limited to Participants until age twenty-one (21); however, there is no age restriction for Dependent Children. Covered Services are exempt from any Deductibles of dollar limits.
4. Adult immunizations; but not solely for the purpose of travel or work.
5. Routine physical examinations, once per Calendar Year and additional examinations when Medically Necessary.
6. Routine allergy injections.
7. Routine annual gynecological examinations including a pelvic examination, clinical breast examination and one (1) routine Papanicolaou smear for female Participants per Calendar Year. Participants can utilize their Primary Care Physician for this service or they can choose a participating gynecologist. If the plan participant requires gynecological services, they

are permitted to select a specialist

participating within the plan to obtain maternity or medically necessary gynecological care. This includes medically necessary and appropriate follow-up care and written referrals for diagnostic testing related to maternity and gynecological care, without prior approval from their Primary Care Physician. Such health care services should be within the scope of practice of the selected participating professional provider, who is responsible for keeping your Primary Care Physician informed of all health care services provided. This Covered Service is exempt from any Deductibles or dollar limits.

8. Laboratory and x-ray services, EKGs and other diagnostic services.
9. Casts.
10. Emergency coverage arrangements through the Participant’s Primary Care Physician’s office which are available twenty-four (24) hours a day, seven (7) days a week.
11. Follow-up care after Emergency Services.
12. Obstetrical services. A female Participant may select a Participating Professional Provider for maternity and gynecological services, including Medical Necessary follow up care and Written Referrals for diagnostic testing relating to maternity and gynecological care, without prior approval from the Participant’s Primary Care Physician. Such health care services shall be within the scope of practice of the selected Participating Professional Provider, who is responsible for keeping the Participant’s Primary Care Physician informed of all health care services provided.
13. Therapeutic drugs, medications and injectables, only when deemed a critical part of the therapeutic Covered Service being rendered by the Primary Care Physician during an office visit, and when Medically Necessary. Coverage is limited to the amount of therapeutic drug, medication or injectable administered during the office visit. Coverage does not include infertility injectables, when used for the purpose of ovulation, and contraceptives, when used for the purpose of birth control. First Priority Health has the right to require authorization for certain injectables in order to determine medical necessity.

1. OUTPATIENT COVERED SERVICES

1. Ambulance service:

1. in an emergency, but subject to the notification requirements set forth in Section II.G. of this summary; or
2. in a non-emergency upon Prior Authorization by the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department.

1. Ambulatory surgery (i.e., surgery performed in an acute-care Hospital’s short procedure unit or freestanding surgical facility), upon initial Prior authorization by the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department.
2. Laboratory and x-ray services, EKGs and other diagnostic services.
3. Outpatient surgery (i.e., surgery performed in a Physician’s office or in an acute care Hospital’s Outpatient department).
4. Medical social services and other health services to include:

1. pre- and post-hospital planning;
2. referral to (but not payment for) community health and social welfare agency services;
3. referral to (but not payment for) related family counseling services except as specified in Section II.E.1;
4. referral to and payment for services of appropriate family planning agencies as necessary; and
5. referral to appropriate specialties for payment for fertility services, except injectable and infertility related supplies.

1. Home health and Hospice services, upon Prior Authorization by the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department.
2. Mammography screenings. One (1) mammography screening per Calendar Year is covered for all Participants age forty (40) and over whether or not directed toward a definite condition of disease or injury. Diagnostic mammographies with Prior Authorization by a Primary Care Physician are covered for all Participants.
3. Dialysis Treatment.
4. Oxygen and the initial equipment necessary to utilize oxygen, upon Prior Authorization by the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department, when Medically Necessary. Replacement of the initial oxygen equipment is not covered.
5. Chemotherapy.
6. Cardiac rehabilitation programs associated with Participating Providers. Participants may receive up to thirty-six (36) sessions, for a twelve (12) week period, upon Prior Authorization from the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department.
7. Nutritional counseling at Participating Hospitals for Participants with diabetes mellitus or for pregnancy.
8. Radiation Therapy.
9. Infertility Testing, limited to laboratory, x-ray studies and surgical procedures necessary to confirm a diagnosis of infertility; and artificial insemination.
10. Diabetic supplies – First Priority Health Plus provides the following benefits related to diabetic supplies and outpatient self-management training and education:

1. SPECIALIST PHYSICIAN COVERED SERVICES

1. Allergy Care (except routine injections, which should be administered by Participant’s Primary Care Physician).
2. Anesthesia.
3. Cardiology.
4. Endocrinology.
5. Gynecology and Obstetrics.
6. Internal Medicine.
7. Neurology.
8. Oncology.
9. Ophthalmology.
10. Oral Surgery for (a) any condition which is a result of trauma or disease, or (b) baby bottle syndrome prior to age four (4), once per lifetime.
11. Orthopedics.
12. Orolaryngology.
13. Pathology.
14. Pediatrics.
15. Radiology (except dental x-rays unless related to Covered Services).
16. Surgery.
17. Urology.

1. INPATIENT HOSPITAL & SKILLED NURSING FACILITY COVERED SERVICES

1. Semi-private room and board accommodations.
2. Private accommodations when Medically necessary and upon authorization by Participant’s Primary Care Physician and First Priority Health’s Medical Director. A Participant who occupies a private room without such authorization shall be directly liable to the Participating Hospital or Participating Skilled Nursing Facility for the difference between

payment by First Priority Health to the Participating Hospital or Participating Skilled Nursing Facility of the per-diem or other agreed-upon rate established between First Priority Health and the Participating Hospital or the Participating Skilled Nursing Facility and the private room rate.

3. General nursing care.
4. Use of intensive or special care facilities when Medically Necessary and Appropriate.
5. Diagnostic and therapeutic radiological procedures, except as specifically excluded in Section III.
6. Use of operating room and related facilities.
7. Drugs, medications and biologicals, when Medically Necessary.
8. Laboratory testing and services.
9. Pre- and post-operative care.
10. Special tests when Medically Necessary.
11. Therapy Services.
12. Oxygen.
13. Anesthesia and anesthesia services.
14. Unreplaced blood and blood components and the administration and processing of whole blood, blood plasma and blood derivatives.
15. Intravenous injections and solutions.
16. Dialysis Treatment.
17. Surgical, medical and obstetric services provided by a Participating Hospital.
18. Transplants that are Medically Necessary and not considered to be Experimental of Investigative by First Priority Health for a recipient who is a Participant. Covered Services will be

provided for the removal and transport of the organ from a living donor or cadaver only when the recipient is a First Priority Health Participant and only to the extent covered services are unavailable from any other source.

19. Chemotherapy.

1. ALCOHOL AND/OR DRUG ABUSE TREATMENT COVERED SERVICES

1. Outpatient – Participant is eligible for thirty (30) Outpatient full-service visits or equivalent partial visits per Calendar Year for treatment of Alcohol and/or Drug Abuse or dependency. (A visit is defined as one (1) hour of therapy.) Participant is additionally eligible for up to thirty (30) separate sessions of Outpatient visits or Partial Hospitalization days per Calendar Year. These additional thirty (30) sessions may be exchanged on a two-for-one basis for up to fifteen(15) Non-Hospital Residential Care days, as described in Paragraph 3 below.

1. Physician, psychologist, nurse certified addictions counselor and trained staff services;
2. Rehabilitation therapy and counseling;
3. Family counseling and intervention;
4. Psychiatric, psychological and medical laboratory tests;
5. Drugs, medicines, equipment use and supplies.

1. RRC coordinates the care, and
2. the Participant maintains Full-Time Students status and attends classes.

1. Lodging and dietary services;
2. Physician, psychologist, nurse, certified addictions counselor and trained staff services.
3. Diagnostic x-ray;
4. Psychiatric, psychological and medical laboratory tests;
5. Drugs, medicines, equipment use and supplies.

1. Lodging and dietary services;
2. Physician, psychologist, nurse, certified addictions counselor and trained staff services;
3. Rehabilitation therapy and counseling;
4. Family counseling and intervention;
5. Psychiatric, psychological and medical laboratory tests;
6. Drugs, medicines, equipment use and supplies.

F. MENTAL HEALTH CARE SERVICES

1. Outpatient Mental Health Care Services: Each Participant may receive twenty (20) visits each Calendar Year to a psychiatrist, clinical psychologist or psychiatric social worker in individual, group, family therapy or electroconvulsive therapy (ECT) sessions. A visit is one (1) hour of therapy or an ECT treatment.

7. EMERGENCY CARE

• placing their health or, with respect to a pregnant woman, the health of her unborn child, in serious jeopardy;

• serious impairment to bodily functions; or

• serious dysfunction of any bodily organ or part.

What to do in an emergency

• The plan participant must pay the emergency room copayment to the hospital and obtain a paid-in-full receipt. Mail their receipt and ask their Primary Care Physician to mail their referral to the First Priority health Claims Department within five (5) days of the service. We'll reimburse the plan participant for the difference between their Primary Care Physician and emergency room copayment.

7. OUT-OF-AREA CARE COVERED SERVICES FOR AN UNEXPECTED CONDITION

1. Speech Therapy-Speech Therapy Covered Services are available on a short-term basis. The Covered Service consists of treatment for forty-five (45) visits per Calendar Year, if the Participant’s Primary Care Physician certifies that the treatment will result in a significant improvement of the Participant’s condition within this time period and treatment is approved by First Priority Health’s Medical Director.
2. Physical Therapy – Physical Therapy Covered Services are available on a short-term basis. The Covered Services consists of treatment for forty-five (45) visits per Calendar Year, if the Participant’s Primary Care Physician certifies that the treatment will result in a significant improvement of the Participant’s condition within this time period and treatment is approved by First Priority Health’s Medical Director.
3. Occupational Therapy – Occupational Therapy Covered Services are available on a short-term basis. The covered services consists of treatment for forty-five (45) visits per Calendar Year, if the Participant’s Primary Care Physician certifies that the treatment will result in a significant improvement of the Participant’s condition within this time period and treatment is approved by First Priority Health’s Medical Director.
4. Cognitive Therapy – Cognitive Therapy Covered Services are available on a short-term basis. The Covered Services consists of treatment for forty-five (45) visits per Calendar Year, if the Participant’s Primary Care Physician certifies that the treatment will result in a significant improvement of the Participant’s condition within this time period and treatment is approved by First Priority Health’s Medical Director.

10. DURABLE MEDICAL EQUIPMENT/ PROSTHETICS AND ORTHOTICS

1. hospital beds and related equipment (bed rails, mattresses);
2. equipment to increase mobility (standard wheelchairs);
3. commodes (portable bedside commodes);
4. oxygen and breathing apparatus (oxygen cylinders, positive and intermittent positive pressure breathing machines, suction machines);
5. therapeutic equipment (infusion equipment, IV stands, and equipment);
6. apnea monitors;
7. glucose monitors (insulin dependent diabetics only) and;
8. jobst stocking for burn diagnosis.

10. PRESCRIPTION DRUGS

1. Prescription drugs and medications are covered when prescribed by a licensed physician when Medically Necessary including, but not limited to, the following:

• insulin and insulin syringes for diabetics

• contraceptives when used for the purpose of birth control

• diabetic test agents

1. The Prescription drug mail order service is through Express Scripts

10. SELF-REFERRED COVERED SERVICES

1. Self-Referred Covered Services which require only the Self-Referral Form:

1. Primary Care Physician Covered Services, as outlined in Section II.A.

1. Outpatient surgery, as outlined in Section II.B.4.
2. Medical social services and other health services, as outlined in Section II.B.5.
3. Mammography screenings, as outlined in Section II.B.7.
4. Outpatient Dialysis, as outlined in Section II.B.8.
5. Outpatient Chemotherapy, as outlined in Section II.B.10.
6. Nutritional counseling, as outlined in Section II.B.12.
7. Radiation Therapy, as outlined in Section II.B.13.
8. Infertility Testing and artificial insemination, as outlined in Section II.B.14.
9. Diabetes education services, as outlined in Section II.B.15.
10. Specialist Physician Covered Services, as outlined in Section II.C.

1. Self-Referred Covered Services which require the Self-Referral Form and Pre-Certification:

1. Ambulatory surgery, as outlined in Section II.B.2.
2. Home Health and Hospice services, as outlined in Section II.B.6.
3. Outpatient oxygen, as outlined in Section II.B.9.
4. Cardiac rehabilitation programs, as outlined in Section II.B.11.
5. Inpatient Hospital and Skilled Nursing Facility Covered Services, as outlined in Section II.D., except for transplants as outlined in Section II.D.18.
6. Alcohol and/or Drug Abuse Treatment Covered Services, as outlined in Section II.E.
7. Mental Health Care Services, as outlined in Section
8. Occupation Therapy, Physical Therapy, Speech Therapy and Cognitive Therapy, as outlined in Section II.I.

1. Hospitalization for transplants, as outlined in Section II.D.18. is not eligible for Self-Referred Covered Services.
2. Claims for Self-Referred Covered Services must be received by First Priority Health with one (1) year from the date of service.

1. The following are not covered services under the Agreement:

1. Any service obtained by or on behalf of a Participant without prior authorization by the Participant’s Primary Care Physician and when appropriate, by First Priority Health, except as described in Section II.E., F., G., H., and L. of this summary.
2. Cosmetic procedures for cosmetic purposes, except those performed to correct medically diagnosed congenital defects and birth abnormalities or a condition resulting from an accident or illness.
3. Unless otherwise stated in this summary, all dental services related to the care, filling, removal or replacement of teeth and treatment of diseases of the teeth or gums, including but not limited to apicoectomy (dental root resection), orthodontics, root canal treatment, soft tissue impactions, treatment of temoromandibular joint dysfunction with intraoral prosthetic devices, or any other method to alter the vertical dimension of the bite, alveolectomy and treatment of periodontal disease.
4. Services or supplies which First Priority Health initially determines are Experimental or Investigative in nature or for the Covered Services related to them; First Priority Health’s procedure in determining whether the use of any treatment, procedure, Provider, equipment, drug, device or supply is Experimental or Investigative is set forth in Section V, Other Provisions section of this summary.
5. Care of any illness or injury suffered after the Participant’s Effective Date of coverage as a result of any act of war.
6. Coverage of non-First Priority Health donor in a transplant procedure unless the recipient of the transplant is a Participant. In the event a Participant is the recipient, coverage will be provided under the Agreement for a live non-First Priority Health donor to the extent covered services are unavailable from any other source. The purchase of human organs which are sold rather than donated to transplant recipients are not covered.
7. Charges to the extent payment has been made under Medicare or would have been made if the Participant had applied for Medicare and claimed Medicare Covered Services.
8. Treatment of mental retardation, defects, deficiencies and learning disabilities. This exclusion does not apply to Mental Health Care Services as described in Section II.F. or to medical treatment of retarded Participants in accordance with the covered services provided in Section II.
9. Care for conditions that state or local law requires to be treated in a public facility.
10. The cost of securing the services of professional blood donors.
11. Palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, the treatment of subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails (except surgery for ingrown nails), fallen arches, weak feet, chronic foot strain and symptomatic complaints of the feet.
12. Provision of personal convenience items or service such as barber services, guest meals, radio and television rentals, and other like items and services.
13. Custodial care, domiciliary care or rest cures.
14. Weight reduction programs.
15. Drugs, medications and injectables, including fertility injectables when used for the purpose of ovulation and contraceptives when used for the purpose of birth control, except as provided in Section II.
16. Special medical reports, unless directly related to treatment of a Participant.
17. Private duty or special nursing care.
18. Payment for services which are eligible for payment under the provisions of an automobile insurance contract or pursuant to any federal or state law which mandates identification for such services to persons suffering bodily injury from motor vehicle accidents, where permitted by state law.
19. Chronic Alcohol and/or Drug Abuse treatment, except as provided by Section II.E.
20. Long-Term Residential Care.
21. Therapy or rehabilitation, except as provided by Section II.I.
22. Reversal of voluntary sterilization.
23. Transsexual surgery or related services.
24. Elective abortions, except however, services which are necessary to avert the death of the woman and services to terminate pregnancies caused by rape or incest will be covered. Therapeutic abortions are covered only when Medically Necessary and approved by First Priority Health’s Medical Direct.
25. Immunizations obtained for the purpose of international travel or which are work related.

1. Charges for any illness or bodily injury which occurs in the course of employment if benefits or compensation are available, in whole or in part, under the provisions of workers’ compensation, occupational disease or similar type legislation. This exclusion applies regardless of whether the Participant claims the covered service or compensation.
2. Charges for treatment of obesity, except when surgical treatment of morbid obesity is Medically Necessary.
3. Orthoptics (a technique of eye exercise designed to correct the visual axes of eyes not properly coordinated for binocular vision).
4. Services or supplies received from a dental or medical department established primarily for treatment of employees or Participants and maintained by or on behalf of an employer, a mutual covered service association, labor union, trust or similar person or group.
5. Charges incurred prior to the Participant’s Effective Date or during an Inpatient admission that commenced prior to the Participant’s Effective Date.
6. Charges incurred after the date of termination of the Participant’s coverage, except as provided in this summary.
7. Services or supplies for personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers, physical fitness equipment and air filtering machines.
8. Charges for telephone consultations, charges for failure to keep a scheduled visit or charges for completion of a claim form.
9. Charges for which the Participant has no legal obligation to pay.
10. Charges which are recoverable by or on behalf of the Participant in any action at law or in compromise or settlement of a claim against a party, other than an insurer of the Participant, unless the Participant furnished such information as First Priority Health may require to facilitate enforcement of its rights.
11. Charges for Inpatient admissions and home care services not certified as eligible by the Participant’s Primary Care Physician and First Priority Health’s Utilization Management Department.
12. Spinal Manipulation.
13. Mandated treatment, including court ordered treatment, unless such treatment is Medically Necessary.
14. Corneal surgery to change the shape of the cornea which will correct vision problems such as myopia (nearsightedness), hyperopia (farsightedness) and astigmatism. The correction of astigmatism resulting from trauma or from previously eligible surgery, including, but not limited to, cataract and corneal surgery, is eligible for payment.
15. In Vitro Fertilization; Gamete Intra Fallopian Tube Transfer (a form of In Vivo Fertilization) and Zygote Intra Fallopian Tube Transfer (a form of In Vitro Fertilization) including the drugs, diagnostic monitoring (ultrasound) and other services and supplies related to these procedures.
16. Durable Medical Equipment, Prosthetics and Orthotics, with the exception of oxygen and the initial equipment necessary to utilize oxygen. Replacement of the initial oxygen equipment in not covered.
17. Inpatient care and Partial Hospitalization for mental health care services.
18. Preventive dental care.
19. Paramedics.

At the direction of the Plan, First Priority Health will enroll the Subscriber and his/her spouse and all unmarried and unemployed dependent children under 19 years of age as participants for the coverage described herein.

Each eligible dependent child participant is covered from birth until: (a) the end of the calendar year in which he/she reaches their 19^th birthday, (b) the end of the month in which he/she marries or becomes employed or (c) the end of any period during which he is incapable of self-support because of a disabling abnormality or condition of illness or injury. Eligibility for continuation of such disabled children will be initially determined by First Priority Health.

Unmarried dependent student participants will be covered to age 23 if they are attending on a full time* basis an accredited college, university, technical or specialized school and are pursuing a course of study requiring at least 2 years which will lead to a degree or certificate upon completion.

1. IDENTIFICATION CARD

The identification card issued by First Priority Health to a Participant pursuant to the Agreement is for identification purposes only. Possession of an identification card

confers no right to services or covered services under the Agreement, and misuse of such identification card may be grounds for initial termination of a Participant’s coverage pursuant to Section IV. If the Participant who misuses the card is the Subscriber, coverage may be terminated for the Subscriber as well as any Dependents. To be eligible for services or benefits under the Agreement, the holder of the card must be a Participant on whose behalf all applicable administrative fees under the Agreement have been paid. Any person receiving services or covered services which he or she is not entitled to receive pursuant to the provisions of the Agreement shall be charged for such services or covered services at prevailing rates.

If any Participant permits the use of his or her identification card by any other person, such card may be retained by First Priority Health, and all rights of such Participant and his or her Dependents, if any, pursuant to the Agreement shall be initially terminated immediately, subject to the Grievance Procedure attached in Exhibit C of the Agreement.

If a Subscriber terminates coverage with First Priority Health, it is the Plan’s responsibility to obtain the identification cards of the Subscriber and affiliated Participant and to return the cards to First Priority Health.

2. MEDICAL NECESSITY

Participants will receive covered services under the Agreement only when Medically Necessary. First Priority Health may determine whether any covered service provided was Medically Necessary, and First Priority Health has the option to initially select the appropriate Participating Hospital to render services if hospitalization is necessary. Decisions as to Medical Necessity are subject to review by First Priority Health Medical Director, or his/her Physician designee.

3. EXPERIMENTAL OR INVESTIGATIVE SERVICES

1. If, in making that initial determination, the Medical Director finds that the service, for which a claim for covered services is made, is either: (1) the subject of a written investigational or research protocol used by the treating facility or of a written investigational or research protocol of another facility studying substantially the same Service; or (2) the subject of a written informed consent used by the treating facility which refers to the Service as experimental, investigative, educational or research; or (3) the subject of an ongoing phase I, II or III clinical trial, the Service shall be deemed to be Experimental or Investigative.
2. If, in making that initial determination, the Medical Director finds that neither a protocol, an informed consent nor an ongoing clinical trial, as described above, exist, then the Medical Director may require that demonstrated evidence exists, as reflected in the published Peer Reviewed Medical Literature:

1. that the Services is recognized by a majority of those practicing the appropriate medical specialty as being safe and effective for use in the treatment of the particular condition in question; and
2. that the Service has a definite positive effect on health outcomes;

such evidence must include well-designed investigations that have been reproduced by non-affiliated authoritative sources with measurable results supported by the positive endorsements of national medical bodies or panels regarding scientific efficacy and rationale; and

3. that, over time, the Service leads to improvements in health outcomes, i.e. the beneficial effects of the Service outweigh any harmful effects of the Service; and
4. that the Service is at least as effective in improving health outcomes as established technology or is usable in appropriate clinical contexts in which established technology is not employable; and
5. that improvement in health outcomes is possible in standard conditions of medical practice outside clinical investigatory settings.

1. If, in making the initial determination, the Medical Director finds that a drug, a device, a supply or equipment has not received marketing approval (permission for commercial distribution) by the United States Food

1. HOSPITAL AND FACILITY OTHER PROVIDER RULES

Participant is subject to all the rules and regulations of each Hospital and other facility in which covered services are provided.

2. REFUSAL OF TREATMENT

Participant may, for personal reasons, refuse to accept procedures, medicines or courses of treatment recommended by a Participating Physician. If such Participating Physician (after a second Participating Physician’s opinion, if requested by Participant) believes that no professionally acceptable alternative exists, and if after being so advised, Participant still refuses to follow the recommended treatment procedure, Participant will receive no further treatment for the condition involved. In such case neither the Providers nor First Priority Health will have further responsibility to provide any of the covered services available under the Agreement for treatment of such condition. First Priority Health will provide written notice to Participant of a decision not to render further treatment for a particular condition. The decision is subject to the Grievance Procedure attached in Exhibit C of the Agreement. Treatment of the condition involved will be resumed in the event Participant agrees to follow the recommended treatment or procedure.

 

 

3. NON-ASSIGNMENT OF PAYMENT OF BENEFITS

No person other than a Participant is entitled to receive benefits for Covered Services under this Agreement.

Furthermore, First Priority Health will arrange payments of Covered Services to be made directly to Participating Providers furnishing Covered Services under this Agreement. However, First Priority Health reserves the right to make payments directly to Participants.

The right of a Participant to receive payment is not assignable nor may the right to receive Covered Services be transferred by a Participant.

4. LEGAL ACTION

No action at law or in equity may be maintained against First Priority Health for any expense or bill unless brought within the statute of limitations for such cause of action.

5. PHYSICIAN – PATIENT RELATIONSHIP

Participating Physicians maintain the physician-patient relationship with Participant and are solely responsible to the Participant for all Medical Services which are rendered by Providers.

 

 

 

 

 

 

 

 

 

 

 

6. CONFIDENTIALITY

Information contained in the medical records of Participants and information received from Physicians, surgeons, Hospitals or other health professionals incident to the doctor-patient relationship or hospital-patient relationship shall be kept confidential in accordance with the Agreement.

7. LIMITATION ON SERVICES

Except in cases of emergency as provided under Section II.G. of the Benefit Summary, services are available only from Participating Providers, and First Priority Health shall have no liability or obligation whatsoever on account of any service or covered service sought or received by a Participant from any Provider or other person, entity, institution or organization unless prior arrangements are made by First Priority Health.

8. ALTERNATIVE TREATMENT PLAN