The ShutterbugLWO SG 01-2016 SYC The Shutterbug/4009062 SUMMARY OF YOUR COSTS This is a summary of Your costs for Covered Services. Your costs are subject to the all of the following:

The Shutterbug

LifeWise Assure Silver EPO 30004009062

LWO SG 01-2014 Rev. 01-2016 LifeWise Assure Silver EPO 3000

HOW TO CONTACT USPlease call or write Our Customer Service staff for help with the following: Questions about the benefits of Your Plan; Questions about Your Claims; Questions or complaints about care or Services You receive; and Change of address or other personal information.

Customer Service - 1-800-596-3440

Mailing Address Local and toll-free phone numbers:

Bend

LifeWise Health Plan of OregonP O Box 7709Bend, OR 97708-7709

1-800-596-3440

TDD number for the hearing impaired1-800-842-5357

Portland

LifeWise Health Plan of Oregon2020 SW Fourth Avenue, Suite 1000Portland, OR 97201

(503) 295-6707

1-800-926-6707

TDD number for the hearing impaired1-800-842-5357

You'll find answers to most of Your questions about Your Plan in this benefit booklet. You can also explore Our Web site at www.lifewiseor.com anytime You want to: Learn more about how to use Your Plan; Locate a health care provider near You; Gain knowledge about diseases, illnesses, medications, treatment, nutrition, fitness and many other health

topics. You can also call Our Customer Service staff at the numbers listed above. We are happy to answer Your

questions and appreciate any comments You want to share.

Group Name: The Shutterbug

Effective Date: January 1, 2016

Group Number: 4009062

Plan: LifeWise Assure Silver EPO 3000

Certificate Form Number: LWO SG 01-2016


INTRODUCTIONThis Benefit Booklet is for Members enrolled in this Plan. This Benefit Booklet describes the benefits and other terms of this Plan. It replaces any other Benefit Booklet You may have received.

We know that healthcare Plans can be hard to understand and use. We hope this Benefit Booklet helps You understand how to get the most from Your benefits.

The benefits and provisions described in this Plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with Us. This benefit booklet is a part of the contract on file at the employer’s office.

This plan will comply with state and federal laws. If clarifications are made by regulators, this plan will comply even if they are not stated or are in conflict with a statement made in this benefit booklet.

Translation Services

If you need an interpreter to help with oral translation services, please call us. The Customer Service Area will be able to guide you through the service.

HOW TO USE THIS BENEFIT BOOKLETEvery section in this Benefit Booklet has important information. You may find that the sections below are especially useful. How to Contact Us – Our website, phone numbers, mailing addresses and other contact information are inside

the front cover Summary of Your Costs – Lists your costs for covered services Important Plan Information – Describes deductibles, Copays, Coinsurance, out-of-pocket maximums and

Allowed Amounts How Providers Affect Your Costs – How using an in-network provider affects Your benefits Prior Authorization and Emergency Admission Notifications – Describes Our Prior Authorization and

Emergency Admission Notifications provision Utilization Review – Describes Our Utilization Review provision Personal Health Support Programs – Describes Our Personal Health Support Programs provision Continuity of Care – Describes how to continue care at the in-network level of benefits when a provider is no

longer in the network Covered Services – A detailed description of what is covered Employee Wellness – Describes a program to help improve wellness Exclusions – Describes Services that are not covered Other Coverage – Describes how benefits are paid when You have other coverage or what You must do when

a third party is responsible for an injury or Illness Sending Us a Claim –Instructions on how to send in a Claim Grievance and Appeals – What to do if You want to share ideas, ask questions, file a complaint, or submit an

appeal Eligibility and Enrollment – Describes who can be covered Termination of Coverage – Describes when coverage ends Continuation Coverage – Describes how You can continue coverage after Your group Plan ends Other Plan Information – Lists general information about how this Plan is administered and required state and

federal notices Definitions – Meanings of words and terms used


TABLE OF CONTENTSSUMMARY OF YOUR COSTS.....................................................................................................................1

IMPORTANT PLAN INFORMATION ...........................................................................................................7

Calendar Year Deductible ......................................................................................................................7

Out-of-Pocket Maximum.........................................................................................................................7

Allowed Amount .....................................................................................................................................7

HOW PROVIDERS AFFECT YOUR COSTS...............................................................................................8

Network Providers ..................................................................................................................................8

PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION...........................................9

UTILIZATION REVIEW ..............................................................................................................................11

Personal Health Support Programs......................................................................................................11

Continuity of Care.................................................................................................................................11

COVERED SERVICES...............................................................................................................................12

Common Medical Services...................................................................................................................13

Prescription Drugs................................................................................................................................15

Other Covered Services .......................................................................................................................24

Employee Wellness..............................................................................................................................27

EXCLUSIONS.............................................................................................................................................28

OTHER COVERAGE..................................................................................................................................31

Coordination Of Benefits ......................................................................................................................31

Third Party Liability ...............................................................................................................................33

SENDING US A CLAIM..............................................................................................................................35

GRIEVANCE AND APPEALS....................................................................................................................36

ELIGIBILITY AND ENROLLMENT ............................................................................................................39

When Coverage Begins .......................................................................................................................40

Enrollment Provisions for Late and Special Enrollees..........................................................................40

TERMINATION OF COVERAGE ...............................................................................................................43

CONTINUATION OF COVERAGE.............................................................................................................43

OTHER PLAN INFORMATION ..................................................................................................................45

DEFINITIONS .............................................................................................................................................47

1 LifeWise Assure Silver EPO 3000LifeWise Health Plan of Oregon

LWO SG 01-2016 SYC The Shutterbug/4009062

SUMMARY OF YOUR COSTSThis is a summary of Your costs for Covered Services. Your costs are subject to the all of the following: The allowed amount. This is the most this Plan allows for a Covered Service. The Copay. This is an amount You pay at the time you get Services. The deductible. This is the amount You pay before Our cost share of the allowed amount is applied.

Deductibles are waived for some Services. The amount of the deductible for this Plan is:

In-network Providers

Individual deductible: $3,000 per Member

Family deductible: $6,000 per Family

Prescription Drug Calendar Year Deductible: $1,500 per Member

$3,000 per Family

The out-of-pocket maximum. This is the most You pay each Year for Services from in-network providers.

Individual out-of-pocket maximum: $6,850 per Member

Family out-of-pocket maximum: $13,700 per Family

Prior authorization. Some Services must be authorized by Us in writing and before You get them. See the Prior Authorization and Emergency Admission Notification section for details.

The conditions, time limits and maximum limits described in this contract. Some Services have special rules. See Covered Services for these details.

YOUR COSTS(of the allowed amount)COVERED SERVICES

IN-NETWORK PROVIDERS

OUT-OF-NETWORK PROVIDERS

COMMON MEDICAL SERVICES

Office and Clinic Visit Your designated Primary Care Provider 0%, deductible waived for

the first 2 visits during the Year. For visits in excess of the first 2 visit limit per Year, $25 Copay.

Not covered

Office visit with Your OB/GYN (even if not Your selected Primary Care Provider)

$25 copay Not covered

Specialist visits and other Primary Care Provider visits/Additional visits/Includes non-hospital urgent care centers.


Facility chargesYou may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

25% Not covered



COVERED SERVICESYOUR COSTS

(of the allowed amount)




Preventive CareLimited to how often You can get them based on Your age and if You are male or female. Routine exams, well baby care and immunizations $0, deductible waived Not covered Women’s pelvic exams, pap smear, clinical breast

exams and mammograms$0, deductible waived Not covered

Pregnant women’s Services, diabetic supplies, electric breast pumps and supplies

$0, deductible waived Not covered

Men’s prostate screening, including PSA $0, deductible waived Not covered Colon cancer screening, outpatient lab and

radiology for preventive screening and tests$0, deductible waived Not covered

Flu shots, flu mist, immunizations for shingles, pneumonia and Pertussis at a pharmacy


Contraceptive management, elective sterilization, tubal ligation and vasectomy


Nicotine dependency programs and health education for conditions other than diabetes


Fall prevention age 65 and older $0, deductible waived Not covered Diabetes health education $0, deductible waived Not covered Nutritional therapy $0, deductible waived Not covered

Pediatric Care Vision care, limited to members up to age 19 Routine exams limited to one per Year $45 copay Not covered Frames, limited to one pair every two Years 0%, deductible waived Not covered Lenses (standard and non-correction) limited to

one pair every two Years0%, deductible waived Not covered

Contact lenses in lieu of glasses, limited to one pair every two Years

0%, deductible waived Not covered

Hearing Aids and hardware, limited to Members under the age of 19 or Dependents age 19 up to age 26. Limited to one hearing aid per impaired ear every three years.


Diagnostic X-ray, Lab and ImagingX-ray and lab, including MRI, MRA, PET and CT Scans

25% Not covered

Prescription Drugs– Retail PharmacyLimited up to a 90-day supply. Some contraceptives may be allowed up to a 12-month supply. You pay one Copay for each 30-day supply. Preventive drugs, limited to prescribed drugs

required by health care reform, and insulin during pregnancy









Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices


Formulary generic drugs $25 copay, waive Prescription Drug deductible

Not covered

Formulary preferred brand name drugs Prescription Drug deductible, 25%

Not covered

Formulary non-preferred brand name drugs Prescription Drug deductible, 25%

Not covered

Prescriptions – Mail Order PharmacyLimited up to a 90-day supply. Some contraceptives may be allowed up to a 12-month supply. You pay one Copay for each 90-day supply. Preventive drugs, limited to prescribed drugs

required by health care reform and insulin during pregnancy


Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices


Formulary generic drugs $75 copay, waive Prescription Drug deductible

Not covered

Formulary preferred brand name drugs Prescription Drug deductible, 25%

Not covered

Formulary non-preferred brand name drugs Prescription Drug deductible, 25%

Not covered

Prescriptions – Specialty PharmacyLimited up to a 30-day supply for formulary, generic and brand name drugs

Prescription Drug deductible, 25%

Not covered

Outpatient Surgery ServicesHospitals, ambulatory surgery center, doctor’s office and the professional Services

25% Not covered

Emergency RoomIncludes emergency room and Hospital Urgent Care facilities.The Copay is waived if You are admitted as an Inpatient through the emergency room.

$250 copay, applies to the out-of-pocket Maximum, then benefits are subject to deductible and coinsurance.

Emergency room Physician 25%

Emergency Ambulance ServicesEmergency air and ground ambulance Services 25%








Urgent Care Centers, affiliated with Your PCPIncludes facility and professional ServicesYou may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

0%, deductible waived for the first 2 visits during the Year. For visits in excess of the first 2 visit limit per Year, $25 Copay.

Not covered

Urgent Care Centers, non-affiliated with Your PCPIncludes facility and professional ServicesYou may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.


Urgent Care Centers, facility basedYou may have additional costs for things such as x-rays, lab and therapeutic injections. See those Covered Services for details.

See Emergency Room

Hospital Services 25% Not covered

Mental Health, Behavioral Health and Substance Abuse Office visits See Office and Clinic

VisitsNot covered

Outpatient facility Services 25% Not covered Inpatient Hospital, partial hospitalization, residential

facilities25% Not covered

Maternity and Newborn CarePrenatal, postnatal care, delivery and Inpatient care.

25% Not covered

Home Health Care 25% Not covered

Hospice CareRespite care is limited to 5 consecutive days up to a lifetime maximum of 30 days.

25% Not covered

Rehabilitation TherapyLimited to a combined 30 Outpatient visits and a combined 30 Inpatient visits/days per Year. An additional 30 visits will be allowed for stroke and spinal cord/head injury. Limits do not apply to Mental Health Services. Outpatient office Services 25% Not covered Inpatient facility Services 25% Not covered Outpatient facility Services 25% Not covered

Habilitation TherapyLimited to physical therapy, occupational therapy and speech therapy up to a combined 30 Outpatient visits and a combined 30 inpatient days per Year. An additional 30 visits per condition may be allowed for stroke and spinal cord/head injury. Limits do not apply to Mental Health Services.








Outpatient office Services 25% Not covered Inpatient facility Services 25% Not covered Outpatient facility Services 25% Not covered

Cardiac RehabilitationLimited to 36 sessions per Year.

25% Not covered

Skilled Nursing FacilityLimited to 60 days per Year.

25% Not covered

Home Medical Equipment (HME), Supplies, Devices, Prosthetics and OrthoticsFoot Orthotics for conditions other than diabetes are limited to 1 pair or 2 units per Year.

25% Not covered

YOUR COSTS(of the allowed amount)COVERED SERVICES



OTHER COVERED SERVICES (Alphabetical Order)

Allergy Testing and Treatment Covered based on the type of Services You get

Not covered

Alternative CareAcupuncture, Chiropractic and Naturopathy Services, combined limit of $1,500 visits per Year.

See Office and Clinic Visits

Not covered

Biofeedback Covered based on the type of Services You get

Not covered

Chemotherapy and Radiation Therapy

Chemotherapy includes infusion and injectable drugs

25% Not covered

Prescribed oral chemotherapy drugs 25%, deductible waived Not covered

Clinical Trials Covered based on the type of Services You get

Not covered

Community Wellness and Safety ProgramsLimited to $250 per Year.


Craniofacial Anomalies Covered based on the type of Services You get

Not covered

Dental Accidents – Outpatient Visits Covered based on the type of Services You get

Not covered

Dental Anesthesia - OutpatientLimited to the following: Members under age 7 with a disability Members with a medical condition and it is not safe

25% Not covered







OTHER COVERED SERVICES (Alphabetical Order)to do the treatment outside a Hospital or ambulatory surgical center.

Dialysis ServicesDialysis Services for End-Stage Renal Disease (ESRD)

25% Not covered

Foot CareRoutine care that is Medically Necessary for treatment of diabetes

25% Not covered

Infusion Therapy (Outpatient) 25% Not covered

Mastectomy and Breast Reconstruction Covered based on the type of Services You get

Not covered

Routine Vision Exam/CareLimited to Members age 19 and older Exams, limited to one exam per Year $25 copay, does not

accrue to out-of-pocket maximum.

Not covered

Frames and lenses, contact lenses, limited to $150 per Year


Sleep Studies - Outpatient 25% Not covered

Telehealth Virtual Care Services See Office and Clinic Visits

Not covered

Telemedicine Services Office visits See Office and Clinic

VisitsNot covered

Facility costs 25% Not covered

Therapeutic Injections 25% Not covered

Transplants Donor Covered Services 25% Not covered Office Visits See Office and Clinic

VisitsNot covered

Inpatient facility, Outpatient care and related Services

25% Not covered

Two round trip tickets, plus two weeks of accommodations for travel and lodging expenses per transplant

0% 0%


LWO SG 01-2014 Rev. 01-2016 The Shutterbug/ 4009062

IMPORTANT PLAN INFORMATIONThis Plan is an Exclusive Provider Plan (EPO). You have benefits for Covered Services from providers within the LifeWise EPO network. Our Plan provides You the flexibility to receive Covered Services from one of the many providers included in Our network without referrals. However, You will receive a lower cost share when You designate a Primary Care Provider (PCP). Please see How Providers Affect Your Costs for more information. You also have access to Emergency Services, throughout the United States and wherever You may travel.

This section includes important information about this Plan, such as Your deductibles, out-of-pocket maximum and the allowed amount.

CALENDAR YEAR DEDUCTIBLEA deductible is the amount You pay for Covered Services for each Year before this Plan provides benefits.

Individual Deductible

This Plan includes an individual deductible when You see in-network providers. After You pay this amount, this Plan will begin paying for Your Covered Services.

Family Deductible

This Plan limits the total deductible that must be met by all family Members on this Plan. Any amount that We count toward a Member’s individual deductible also counts toward the family deductible. When the family deductible is met, all individual deductibles are also met. This is true even if some Members did not meet their individual deductible.

The individual and family deductibles, if any, are subject to the following: Deductibles accrue during a Year, January 1

through December 31 There is no carry over provision. Amounts credited

to Your deductible during the current Year will not count toward the next Year’s deductible.

Amounts credited to the deductible will not be more than the allowed amount

Copays are not applied to the deductible Amounts credited toward the deductible do not

accrue to benefits with a dollar maximum Amounts credited toward the deductible accrue to

benefits with visit limits

Prescription Drug DeductibleIndividual Prescription Drug Deductible

Your Plan includes an Individual Prescription Drug Deductible as stated on the Summary of Your Costs.

Individual Prescription Drug Deductible means the amount You must pay for Covered Services in a Calendar Year before the Plan provides Prescription Drug benefits to You.Family Prescription Drug Deductible

Your Plan includes a Family Prescription Drug Deductible as stated on the Summary of Your Costs. Family Prescription Drug Deductible means the aggregate amount a family must pay for Covered Services in a Calendar Year before the Plan provides Prescription Drug benefits to Your family.

OUT-OF-POCKET MAXIMUMIndividual Out-of-Pocket Maximum

This Plan includes an individual out-of-pocket maximum for Covered Services when You use in-network providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much You pay each Year. The deductibles, Coinsurance and Copays You pay count toward this limit. After You meet the out-of-pocket maximum, benefits for Covered Services are paid at 100% of the allowed amount for the rest of that Year.

Family Out-of-Pocket MaximumThis Plan includes a family out-of-pocket maximum for Covered Services when You use in-network providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much Your family pays each Year. The deductibles, Coinsurance and Copays You pay count toward this limit. After Your family out-of-pocket maximum has been met, benefits for Covered Services are provided at 100% of the allowed amount for the rest of that Year.

Expenses that do not apply to the individual or family out-of-pocket maximum include: Charges above the allowed amount Services above the any benefit maximum limit or

durational limit Services not covered by this Plan Covered Services or benefits that do not apply to

the out-of-pocket maximum. These are shown on the Summary of Your Costs.

Covered Services provided by out-of-network providers

Services that are not prior authorized

ALLOWED AMOUNTThis Plan provides benefits based on the allowed amount for Covered Services. The allowed amount is described below:



NON-EMERGENCY SERVICESIn-Network Providers

The allowed amount is the fee that LifeWise has negotiated with its in-network providers for Covered Services.

EMERGENCY SERVICESConsistent with the requirements of the Affordable Care Act (federal health care reform) the allowed amount will be the greater of the following: The median amount in-network providers have

agreed to accept for the same Services The amount Medicare would allow for the same

Services The amount calculated by the same method the

Plan uses to determine payment to out-of-network providers

In addition to Your deductible, Copay and Coinsurance, You will be responsible for charges received from out-of-network providers above the allowed amount.

If You have questions about this information, please call Us at the number listed on Your LifeWise ID card.

HOW PROVIDERS AFFECT YOUR COSTSThroughout this section You will find information on how to control Your out-of-pocket cost and how the providers You see for Covered Services can affect Your Plan benefits.

NETWORK PROVIDERSYou Can Benefit By Designating A Primary Care Provider

We believe wellness and overall health is enhanced by working closely with one provider. Although this Plan does not require the use or selection of a primary care provider (PCP) or a referral for specialty care, We encourage You to designate a PCP at the time You enroll in this Plan and notify Us of Your selection. Selecting a PCP gives You a partner to help You manage Your care.

How Do I Pay The Lowest Copay

When You use Your designated PCP You will have a lower cost share than seeing other PCPs or Specialists in Our network. In-network OB/GYN providers are always covered at the lower cost share, no matter if You have selected a PCP or not.

Here is an example: When You select a PCP and visit Your PCP for a cut that needs stitches: You will pay the lower Copay amount for the office visit After You

pay Your Copay amount for the visit, You will also have to pay Your deductible and/or Coinsurance amount for the stitching procedure. However, in this example, if You do not select a PCP, Your office visit Copay will be the higher Copay, which means Your overall cost share will be more for the visit.

Please see the Summary of Your Costs for more information.

Who May I Select As My Designated PCP

A designated PCP must be an in-network provider and choices include the following providers: General practice Family practice Internal medicine Pediatrics Geriatric medicine Nurse practitioners Obstetrics and Gynecology (OB/GYN) Physician assistants Naturopaths

How To Designate A PCP

You can designate any PCP in Our network as Your designated PCP. The PCP decides if they have the ability to accept You or Your family Members as patients. Each enrolled family Member may select a different PCP. To find a PCP, You can choose a provider from Our online Provider Directory, located on Our website at lifewiseor.com, or contact Our Customer Service for assistance. Customer Service can be reached by calling the phone number listed on Your LifeWise ID card. Once You choose a PCP, You will need to tell Us who You and Your family chose. We will update Our records with Your selections. Please note, if the provider You or Your family Members choose is not accepting new patients, You will need to designate a different PCP.

What If Your PCP Is Not Available If You need to see Your PCP and Your PCP is not

available, You may see a PCP within the same clinic and You will only be responsible for the lower cost share, or

If Your PCP is a sole practitioner, You may see a PCP that Your provider has asked to cover in their absence and You will only be responsible for the lower cost share.

What If I Want To Change My PCP

You have the option to change Your PCP. Change requests received by the 15th of each month take effect on the first of the next month. Requests received after the 15th of each month take effect on



the 1st of the following month. Example: If We received a request on April 10th, Your change will take effect on May 1st; if we receive Your request on April 20th, Your change will take effect on June 1st.

In-Network Providers

Your Plan uses the Oregon EPO Network of providers, also called “In-Network Providers”. In-network providers are networks of Hospitals, Physicians and other providers that We contract with to provide medical Services at a negotiated fee. We have in-network providers in all categories of Services, such as laboratory and x-ray Specialists and medical specialties such as obstetrics. The network includes providers in Alaska and Washington. Please remember, Covered Services must be provided by an in-network provider to be eligible for benefits.

Contracted Providers Who Offer Unique Services

We have contracted with some health care systems to provide unique Services that are not available from Our in-network providers. We contract with these health care systems to provide covered Medical Services at negotiated fees. These unique Services will be processed at the in-network benefit level and You will not be balance billed for any charge over the allowed amount. Please see the Prior Authorization and Emergency Admissions Notification section of Your Benefit Booklet to request Services from these providers.

Out-of Network Providers

Out-of-network providers are providers that do not have a contract with LifeWise. Except for medical emergencies, Your medical bills will not be covered if You get Services from and out-of-network provider. Please see the Prior Authorization and Emergency Admissions Notification section of Your Benefit Booklet for Covered Services from an out-of-network provider.

How to Select a LifeWise In-Network Provider

A list of Our in-network providers is available in Our provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help You select a provider that is right for You or Members of Your family. We update this directory regularly, but it is subject to change. We suggest that You call Us for current information and to verify that Your provider, their office location or provider group is included in the LifeWise network before You get Services.

The LifeWise Provider Directory is available any time on Our website at lifewiseor.com. You may also request a copy of this directory by calling Customer Service at the number located in the front of this

Benefit Booklet or on Your LifeWise ID card.

The availability of these providers may vary by location. For more information on care outside the Service Area, contact Customer Service.

PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATIONYour coverage for some Services depends on whether the Service is approved by Us before You receive it. This process is called Prior Authorization.

A planned Service is reviewed to make sure it is Medically Necessary and eligible for coverage under this Plan. We will let You know in writing if the Service is authorized. We will also let You know if the Service is not authorized and the reasons why. If You disagree with the decision, You can request an appeal.

See the Grievances and Appeals section or call us.

There are three situations where Prior Authorization is required: Before You receive certain medical Services or

prescription drugs Before You schedule a planned admission to

certain inpatient facilities When You want to see an out-of-network provider

for non-emergency ServicesHow to Ask for Prior AuthorizationThis Plan has a specific list of Services that must have Prior Authorization with any provider. Before You receive Services, We suggest that You review the list of Services requiring Prior Authorization. You can get a detailed list of medical Services requiring Prior Authorization by calling Customer Service at the number on the back of Your ID card or on Our website at lifewiseor.com.Services From In-Network Providers: It is Your in-network provider’s responsibility to get Prior Authorization for planned Services and before Services are provided. Your in-network provider can call Us at the number listed on Your ID card to request a Prior Authorization.Responding to Prior Authorizations

We will respond to a request for Prior Authorization within 2 business days of receipt of all information necessary to make a decision. If Your situation is clinically urgent (meaning that Your life or health would be put in serious jeopardy if You did not receive treatment right away), You may request to have your Prior Authorization reviewed as expedited. Once We have been given all the necessary information to make a decision. We will provide Our decision in



writing.

The Prior Authorization will be binding to Us when related to eligibility and obtained no more than five business days before the date of Service. Our Prior Authorization will be valid for 30 calendar days for benefit coverage and Medical Necessity determinations. This 30 calendar day period is subject to Your continued coverage under the Plan. If You do not receive the Services within that time, You or Your provider will have to ask Us for another Prior Authorization.Services that must be Prior AuthorizedThe following are types of Services that require Prior Authorization. You can see the detailed list on Our website lifewiseor.com or You can call Customer Service.The following types of Services require Prior Authorization: Planned Inpatient admission into Hospitals, Skilled

Nursing Facilities, and rehabilitation facilities Non-emergency ground, air, or ambulance

transport Transplant and donor services Injectable medications You get from a healthcare

provider’s office Prosthetics and Orthotics other than foot Orthotics

or orthopedic shoes Reconstructive surgery Home Medical Equipment (HME), costing $500 or

more Selected surgical, medical therapeutic, and

diagnostic procedures Outpatient advanced imaging, such as MRI, CT,

and echocardiograms Some Outpatient Services. See the detailed list on

Our website at lifewiseor.com. Certain Prescription Drugs. See the Pharmacy

section on our website at lifewiseor.com.

Prior Authorization Penalty

For Services from In-Network Providers

In-network providers will get a Prior Authorization for You. You should verify with Your provider that a Prior Authorization request has been approved in writing by Us before You receive the Services.

Services listed below are not subject to a Prior Authorization penalty: Emergency hospital admissions. See Emergency

Hospital Admission Notification described below. Prescription Drugs. See Prior Authorization for

Prescription Drugs described below.

Non-Emergency Services from out-of-network providers. See Non-Emergency Services From Out-of-Network Providers described below.

Prior Authorization for Prescription Drugs

Certain Prescription Drugs require a Prior Authorization before You get them at a pharmacy. You or Your provider can ask for a Prior Authorization by faxing a Prior Authorization form to Us. This form is in the Pharmacy section of Our website at lifewiseor.com.

Your provider can tell You if a new Prescription Drug requires Prior Authorization. Your provider can check with Us to see if Prior Authorization is required. You may also view Our list of Prescription Drugs that require Prior Authorization through the Member portal on Our website at lifewiseor.com. Once You “Sign-in”, please go to “My Plan Information” then, select the “Pharmacy” tab, and finally You’ll select “View drugs that require Prior Authorization”.

You can also find the Prior Authorization form that Your Physician can completes and sends to Pharmacy Services with their request for a Prior Authorization. Sometimes You may not know if a Prescription Drug needs Prior Authorization. For example, You may go directly from Your provider’s office to the pharmacy with a new prescription. If the pharmacy tells you that the Prescription Drug Your provider prescribed requires Prior Authorization, You or Your pharmacy should call Your provider to let them know. Your provider will then need to fax Us a completed Prior Authorization form for review.

While your provider’s request is in review, You have the option to buy the Prescription Drug before it is Prior Authorized, but You must pay the full cost. Once the Prior Authorization is reviewed, if the drug is authorized after You bought it, You can send Us a Claim for reimbursement. However, the amount of reimbursement will be based on the allowed amount. See the Sending Us A Claim section for details.

Non-Emergency Services from Out-of-Network Providers

This Plan's benefits are provided only when You see in-network providers for non-Emergency Services. There may be times when You want to see an out-of-network provider for non-Emergency Services. In some cases when Services are Medically Necessary and only available from an out-of-network provider, this Plan will provide benefits for those Covered Services. You must ask for a Prior Authorization before You see the out-of-network provider. The Prior Authorization request must include the following: Information that the out-of-network provider has

unique skills that are Medically Necessary for Your



care You cannot get the same care from an in-network

provider Medical records supporting Your request

If We approve Your request, benefits for these Services will be covered as if they were provided by an in-network provider. In addition to Your usual cost shares, You will also pay any amounts over the allowed amount.

If there are in-network providers who can give You the same care, Your Prior Authorization request will not be approved, the Services will not be covered, and You will pay the full cost for the Services.

Emergency Admission Notification

The following Services do not need Prior Authorization, but they have separate requirements. Emergency Hospital admissions, including

admissions for drug and alcohol Detoxification. They do not require Prior Authorization, but You must notify Us as soon as reasonably possible.If You are admitted to an out-of-network Hospital due to an Emergency Condition, those Services will always be covered. We will continue to cover those Services until You are medically stable and can safely transfer to an in-network Hospital. If You choose to remain at the out-of-network Hospital after You are medically stable to safely transfer, Services will not be covered. We pay Services based on Our allowed amount. If the Hospital is non-contracted, You may be billed for any charges over the allowed amount.

Childbirth admission to a Hospital, or admissions for newborns that need medical care at birth. They do not require Prior Authorization, but You must notify Us as soon as reasonably possible. Admissions to an out-of-network Hospital will not be covered unless the admission was an emergency.

UTILIZATION REVIEWLifeWise has developed or adopted guidelines and medical policies that outline clinical criteria used to make Medical Necessity determinations. The clinical criteria is reviewed annually and is updated as needed to ensure Our determinations are consistent with current medical practice standards and follows national and regional norms. Practicing community doctors are involved in the review and development of Our internal criteria. You or Your provider may request a copy of the criteria used to make a Medical Necessity decision for a particular condition, treatment or procedure. To obtain the information, please send Your request to:

LifeWiseUtilization Review

P.O. Box 7709Bend, OR 97708

1-800-722-3372Fax 800-843-1114

LifeWise reserves the right to deny payment for Services that are not Medically Necessary or that are considered Experimental/Investigational. A decision by LifeWise following this review may be appealed in the manner described in the Grievance and Appeals section. When there is more than one alternative available, coverage will be provided for the least costly among medically appropriate alternatives.

PERSONAL HEALTH SUPPORT PROGRAMSLifeWise’s personal health support programs are designed to help make sure Your health care and treatment improve Your health. You will receive individualized and integrated support based on Your specific needs. These Services could include working with You and Your doctor to ensure appropriate and cost-effective medical care, to consider effective alternatives to hospitalization, or to support both of You in managing chronic conditions.

Your participation in a treatment plan through Our personal health support programs are voluntary. To learn more about these programs, contact Customer Service at the number listed on your LifeWise ID card.

CONTINUITY OF CAREYou may be able to continue to receive Covered Services from an in-network provider for a limited period of time at the in-network benefit level after the provider ends their contract with LifeWise. To be eligible for continuity of care You must be covered under this Plan, in an active treatment plan and receiving Covered Services from an in-network provider at the time the provider ends his/her contract with LifeWise. The treatment must be Medically Necessary and You and this provider agree that it is necessary for You to maintain continuity of care.

We will not provide continuity of care if Your provider: Will not accept the reimbursement rate applicable

at the time the provider contract terminates Retired Died No longer holds an active license Relocates out of the Service Area Goes on sabbatical



Is prevented from continuing to care for patients because of other circumstances

Terminates the contractual relationship in accordance with provisions of contract relating to quality of care and exhausts his/her contractual appeal rights

We will not provide continuity of care if You are no longer covered under this Plan.

We will notify You no later than 10 days after Your provider’s LifeWise contract ends if We reasonably know that You are under an active treatment plan. If We learn that You are under an active treatment plan after Your provider’s contract termination date, We will notify You no later than the 10th day after We become aware of this fact.

To receive continuity of care, You must request continuity of care from Us.

You can call Us at 1-800-722-3372 or send Your request to:

LifeWiseUtilization Review

P.O. Box 7709Bend, OR 977081-800-722-3372

Fax 800-843-1114

Duration of Continuity Of Care

If You are eligible for continuity of care, You will get continuity of care until the earlier of the following: The day after You complete the active course of

treatment entitling You to continuity of care The 120th day after We notified You that Your

provider’s contract ended, or the date Your request for continuity of care was received or approved by Us, whichever is earlier

If You are pregnant and become eligible for continuity of care after commencement of the second trimester of the pregnancy, You will receive continuity of care until the later of: The 45th day after the birth As long as You continue under an active course

of treatment, but no later than the 120th day after We notified You that Your provider’s contract ended, or the date Your request for continuity of care was received or approved by Us, whichever is earlier

When continuity of care terminates, You may continue to receive Services from this same provider. However, You must pay the full cost of the treatment.

If We deny Your request for continuity of care, You may request an appeal of the denial. Refer to the Appeals and Grievances section for information on

how to submit a Grievance.

COVERED SERVICESThis section describes the Services this Plan covers. Covered Service means Medically Necessary Services (see Definitions) and specified preventive care Services You get when You are covered for that benefit. This Plan provides benefits for Covered Services only if all of the following are true when You get the Services: The reason for the Service is to prevent, diagnose

or treat a covered Illness, disease or injury The Service takes place in a Medically Necessary

setting. This Plan covers Inpatient care only when You cannot get the Services in a less intensive setting.

The Service is not excluded The provider is working within the scope of their

license or certification

This Plan may exclude or limit benefits for some Services. See the specific benefits in this section and the Exclusions section for details.

Benefits for Covered Services are subject to the following: Copays Deductibles Coinsurance Benefit limits Prior Authorization. Some Services must be

authorized in writing by Us before You get them. These Services are identified in this section. For more information see the Prior Authorization and Emergency Admission Notification section.

Medical and payment policies. The Plan has policies used to administer the terms of the Plan. Medical policies are generally used to further define Medical Necessity or investigational status for specific procedures, drugs, biologic agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards, accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to You and Your provider on Our website at lifewiseor.com or by calling Customer Service.

If You have any questions regarding Your benefits and how to use them, call Customer Service at the number listed on the inside cover of this booklet or on Your LifeWise ID card.



COMMON MEDICAL SERVICESThe Services listed in this section are covered as shown on the Summary of Your Costs. Please see the Summary of Your Costs for Your Copays, deductible, Coinsurance and benefit limits.

Office and Clinic Visits

This Plan covers professional office and home visits. The visits can be for examination, consultation and diagnosis of an Illness or injury by Your primary care provider or a Specialist. Some Outpatient Services You get from a Specialist must be Prior Authorized. See the Prior Authorization and Emergency Admission Notification section for details.

Primary Care Visits

For this Plan, primary care providers include general practice, family practice, internal medicine, pediatric, geriatric and obstetrical and gynecology (OB/GYN) Physicians, nurses, nurse practitioners and Physician Assistants and naturopaths.

This Plan provides benefits for the first 2 primary care visits with Your designated PCP as described on the Summary of Your Costs. Urgent Care, Telehealth, preventive and specialty visits are not included in this limit.

Specialist Visits

For this Plan, a Specialist includes providers such as surgeons, anesthesiologists, psychologists, psychiatrists.

You may have to pay a separate Copay or Coinsurance for other Services You get during a visit. This includes Services such as, but not limited to, x-rays, lab work, therapeutic injections and office surgeries.

Preventive Care

This Plan covers preventive care as described below. Covered Services include preventive care Services with a rating of “A” or “B” set by the United States Preventive Task Force; immunizations recommended by the Centers for Disease Control and Prevention and as required by state law; and preventive care and screenings recommended by the Health Resources and Services Administration (HRSA).

These Services have limits on how often You should get them. These limits are based on Your age and if You are a male or female. Some of the Services You get as part of a routine exam may not meet these guidelines. You can get a complete list of the preventive care Services with these limits on Our website at lifewiseor.com or call Us at the number listed on Your LifeWise ID card for a list. You may also review the federal guidelines at

www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm and www.hrsa.gov/womensguidelines. This list may be changed as required by law.

Covered Services include: Routine exams and well-baby care. Exams for

school, sports and employment are also covered. Women’s pelvic exam. Pap smear and clinical

breast exams. Mammograms. See Diagnostic Lab, X-ray and

Imaging for mammograms needed because of a medical condition.

Pregnant women’s Services such as breast feeding counseling before and after delivery and maternity diagnostic screening, diabetic supplies from conception to six weeks postpartum.

Electric breast pumps and supplies. Includes the purchase of a non-Hospital grade breast pump or 12-month rental of a hospital grade breast pump. The cost of the rental cannot be more than the purchase price.

Prostate cancer screening. Includes digital rectal exams and prostate-specific antigen (PSA) tests.

Colon cancer screening. Includes exams, colonoscopy, sigmoidoscopy, double contrast barium enemas, removal of polyps in the colon and fecal occult blood tests. Including anesthesia services performed in connection with preventive colonoscopy, when the attending provider determines anesthesia is medically appropriate for the individual.

Outpatient lab and radiology for preventive screening and tests

Routine immunizations and vaccinations as recommended by Your Physician. You can also get flu shots, flu mist, and immunizations for shingles, pneumonia and Pertussis at a pharmacy or other center.

Contraceptive management. Includes exams, treatment You get at Your provider’s office, emergency contraceptives, supplies and devices. Tubal ligation and vasectomy are also covered. See Prescription Drugs for prescribed oral contraceptives and devices.

Health education and training for covered conditions such as diabetes, high cholesterol and obesity. Includes Outpatient self-management programs, training, classes and instruction.

Nutritional therapy. Includes Outpatient visits with a Physician, nurse, pharmacist or registered dietitians. The purpose of the therapy must be to manage a chronic disease or condition such as diabetes, high cholesterol and obesity.

Preventive drugs required by federal law. See



Prescription Drugs. Approved tobacco use cessation programs

recommended by Your Physician. After You have completed the program, please provide Us with proof of payment and a completed reimbursement form. You can get a reimbursement form on Our website at lifewiseor.com. See Prescription Drugs for covered drug benefits.

Fall prevention age 65 and older

This benefit does not cover: Charges for Services that do not meet federal

guidelines. This includes Services provided more often that the guidelines allow.

Oral prescription contraceptives dispensed and billed by Your provider or a Hospital

Over the counter (OTC) drugs, contraceptive foams, jellies, sponges or condoms, unless prescribed by a physician. See Prescription Drugs for prescribed oral contraceptives and devices.

Gym memberships or exercise classes and programs

Inpatient newborn exams while the child is in the Hospital following birth. See Maternity and Newborns for those Covered Services.

Facility charges. When You get preventive Services at a hospital based Physician’s office or clinic and they charge a separate facility fee in addition to the Service, You must pay Your deductible and Coinsurance for the facility charges. See Hospital Services for those costs.

Lab and Pathology Services for colonoscopy or sigmoidoscopy. See Diagnostic Lab, X-ray and Imaging.

Physical exams for basic life or disability insurance Work-related disability evaluations or medical

disability evaluations The use of an anesthesiologist for monitoring and

administering general anesthesia for colon health screenings, unless Medically Necessary when specific medical conditions and risk factors are present

PEDIATRIC CAREThis Plan covers hearing and vision Services for covered children as stated in the Summary of Your Costs, unless otherwise stated below.

Vision Exams and Glasses

This Plan covers routine eye exams and glasses and includes the following: Vision exams by an ophthalmologist or an

optometrist. A vision analysis may consist of external and ophthalmoscope examination,

determination of the best corrected visual acuity, determination of the refractive state, gross visual fields, basic sensorimotor examination and glaucoma screening.

Glasses; frames and lenses Contact lenses in lieu of corrective vision hardware Contact lenses required for medical reasons

This Plan covers pediatric vision Services until the end of the month of the child’s 19th birthday, when all eligibility requirements are met.

Hearing Aids

This Plan covers hearing aids, ear molds and attachments or accessories for the hearing aid or device for Members under the age of 19 and Dependents up to age 26. Benefits are provided when the aids are prescribed, fitted and dispensed by a licensed audiologist with the approval of Your provider.

The maximum benefit stated under the Summary of Your Costs will be reviewed on January 1st of each year based on the U.S. City Average Consumer Price Index (CPI). The maximum benefit will be adjusted to the CPI if the CPI is greater than the limit stated on the Summary of Your Costs.

The pediatric benefit does not cover: Batteries or cords for hearing aids Services for Members that do not meet the age

requirements Services not listed above as covered

DIAGNOSTIC X-RAY, LAB AND IMAGINGThis Plan covers diagnostic medical tests that help find or identify diseases. Covered Services include interpreting these tests for covered medical conditions. Some diagnostic tests, such as MRA, MRI, CT and echocardiograms require Prior Authorization. See the Prior Authorization and Emergency Admission Notification section for details.

Diagnostic tests include: Diagnostic imaging and scans like x-rays, MRIs

and EKGs Mammograms for a medical condition MRI and ultrasound of the breast Men’s bone density screening for osteoporosis Barium enema Lab Services Pathology tests

This benefit does not cover: Preventive screening and tests. See Preventive



Care for Covered Services. Diagnostic Services from an Inpatient facility, an

Outpatient facility, or emergency room that are billed with other Hospital or emergency room Services. These Services are covered under Inpatient, Outpatient or Emergency Room benefit.

Diagnostic surgeries, biopsies and scope insertion procedures. These Services covered under the Outpatient Surgery Services benefit.

Allergy tests. These Services are covered under the Allergy Testing and Treatment benefit.

PRESCRIPTION DRUGSPrescription Drugs are covered when they are used outside a medical facility. You must get these drugs from a licensed pharmacist in a pharmacy licensed by the state. Some Prescription Drugs require Prior Authorization. See the Prior Authorization and Emergency Admission Notification section for details.

Prescription Drugs are also covered when drugs are dispensed by a Physician at a rural health clinic for an urgent medical condition if there is no pharmacy within 15 miles of the clinic or if dispensed outside of the normal business hours of any pharmacy within 15 miles of the clinic. For the purposes of this benefit, urgent medical condition means a medical condition that arises suddenly, is not life-threatening and requires prompt treatment to avoid the development of more serious medical problems.

This Plan covers only formulary generic drugs and formulary brand name drugs listed on the LifeWise Formulary. Drugs not listed on the LifeWise formulary are not covered by this Plan. Visit the Pharmacy section on Our website at lifewiseor.com for a complete list of current Prescription Drugs covered by Your Plan. You can also contact Customer Service for questions about covered drugs. The number for Customer Service is on Your LifeWise ID card.

Your provider may request that You get a non-formulary drug or a dose that is not on the drug list. In some circumstances, a non-formulary drug may be covered when one of the following is true: There is no formulary drug or alternative available You cannot tolerate the formulary drug The formulary drug or dose is not safe or effective

for Your condition

You must also provide medical records to support Your request. We will review Your request and let You know in writing if it is approved. If approved, Your cost will be as shown on the Summary of Your Costs for Formulary generic and preferred brand name drugs. If Your request is not approved, the drug will not be covered.

If You disagree with Our decision You may ask for an appeal. See the Grievance and Appeals section for details.

Covered Prescription Drugs FDA approved formulary Prescription Drugs and

vitamins. Federal law requires a prescription for these drugs. They are known as “legend drugs.”

Off-label use of FDA-approved drugs. Off label oral chemotherapy prescription drugs are not covered under this benefit. See Chemotherapy and Radiation Therapy

See the Definitions section for Prescription Drugs and off-label use

Compound drugs, only when the main drug ingredient is a covered Prescription Drug

Oral drugs for controlling blood sugar levels, insulin and insulin pens

Throw-away diabetic test supplies such as test strips, testing agents and lancets

Drugs for shots that You give yourself Needles, syringes and alcohol swabs You use for

shots You give Yourself Glucagon emergency kits Inhalers, supplies and peak flow meters Drugs for nicotine dependency Human growth hormone drugs when Medically

Necessary Oral contraceptive drugs and devices such as

diaphragms and cervical caps

Pharmacy Management

Sometimes benefits for Prescription Drugs may be limited to one or more of the following: A specific number of days’ supply or a specific drug

or drug dosage appropriate for a usual course of treatment

Certain drugs for a specific diagnosis Certain drugs from certain pharmacies, or You may

need to get prescriptions from an appropriate medical Specialists or a specific provider

Step therapy, meaning You must try a generic drug or a specified brand name drug first

These limitations are based on medical criteria, the drug maker’s recommendations, and the circumstances of the individual case. They are also based on U.S. Food and Drug Administration guidelines, published medical literature and standard medical references.

Dispensing Limits

Benefits are limited to a certain number of days’



supply as shown in the Summary of Your Costs. Sometimes a drug maker’s packaging may affect the supply in some other way. We will cover a supply greater than normally allowed under Your Plan if the packaging does not allow a lesser amount. You must pay a Copay for each limited days’ supply.

Preventive Drugs

Your prescription benefit includes certain Outpatient drugs as preventive drugs. This benefit includes only those drugs required by federal health care reform. Preventive drugs do not include drugs for treating an existing Illness, injury or condition.

You can get a list of covered preventive drugs by calling Customer Service. You can also get this list in the Pharmacy section on Our website at lifewiseor.com.

Using In-Network Pharmacies

When You use an in-network pharmacy, always show Your LifeWise ID Card. As a Member, You will not be charged more than the allowed amount for each covered prescription or refill. The pharmacy will also submit Your Claims to us. You only have to pay the deductible, Copay or Coinsurance as shown in the Summary of Your Costs.

If You do not show Your LifeWise ID Card at an in-network pharmacy, You will pay the full retail cost of the prescription. Then You must send Us Your Claim for reimbursement. Reimbursement is based on the allowed amount, not retail costs. See Sending Us A Claim for instructions.

This Plan does not cover Prescription Drugs from out-of-network pharmacies.

Prescription Drug Volume Discount Program

Your Prescription Drug benefit program includes per-claim rebates that LifeWise received from its pharmacy benefit manager. We consider these rebates when We set the Premium charges, or We credit them to administrative charges that We would otherwise pay. These rebates are not reflected in Your cost share. If the allowable charge for Prescription Drugs is higher than the price We pay Our pharmacy benefit manager for those Prescription Drugs. LifeWise does one of two things with this difference: We keep the difference and apply it to the cost of

Our operations and the Prescription Drug benefit program

We credit the difference to premium rates for the next benefit year

If Your Prescription Drug benefit includes a Copay, Coinsurance calculated as a percentage, or a deductible, the amount You pay and Your account

calculations are based on the allowed amount.

Refill

The Plan covers prescription refills only after You use up 75% of Your medication, except as required by law. The 75% is based on these two factors: The number of units and days’ supply You got on

the last refill The total units or days’ supply You got for the same

medication in the 180-day period before the last refill

Specialty Pharmacy Programs

The Specialty Pharmacy Program includes drugs that are used to treat complex or rare conditions. These drugs need special handling, storage, administration, or patient monitoring. This Plan covers these drugs as shown in the Summary of Your Costs.

Specialty drugs are high-cost often self-administered injectable drugs. They are used to treat conditions such as rheumatoid arthritis, hepatitis or multiple sclerosis. We contract with specific specialty pharmacies that specialize in these drugs. You and Your provider must work with these specialty pharmacies to get these drugs.

This Plan covers specialty drugs only when they are dispensed by Our in-network specialty pharmacies. Visit the pharmacy section of Our website at lifewiseor.com or call Customer Service for more information.

This Plan uses the LifeWise Pharmacy Network.

This benefit does not cover: Drugs and medicines that You can legally buy over

the counter (OTC) without a prescription. OTC drugs are not covered even if You have a prescription. Examples include, but are not limited to, non-prescription drugs and vitamins, herbal or naturopathic medicines, and nutritional and dietary supplements, such as infant formulas or protein supplements.This exclusion does not apply to OTC drugs that are required by state or federal law.

Non-formulary generic and brand name drugs Drugs from out-of-network pharmacies Drugs from out-of-network specialty pharmacies Drugs for cosmetic use such as for wrinkles Drugs to promote or stimulate hair growth Biological, blood or blood derivatives Any prescription refill beyond the number of refills

shown on the prescription or any refill after one year from the original prescription



Infusion therapy drugs or solutions, drugs requiring parenteral administration or use, and injectable medications. Exceptions to this exclusion are injectable drugs for self-administration such as insulin and glucagon and growth hormones. See Infusion Therapy for covered infusion therapy Services.

Drugs dispensed for use in a health care facility or provider’s office or take-home medications. Exceptions to this exclusion are injectable drugs for self-administration such as insulin and glucagon and growth hormones.

Immunizations. See Preventive Care. Drugs to treat infertility, to enhance fertility or to

treat sexual dysfunction of organic origin, including impotence and decreased libido. This exclusion does not apply to sexual dysfunction diagnoses listed in the current Diagnosis and Statistical Manual (DSM).

Weight management drugs or drugs for the treatment of obesity

Therapeutic devices or appliances. See Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics

Off Label oral chemotherapy Prescription Drugs. See Chemotherapy and Radiation Therapy.

OUTPATIENT SURGERY SERVICESThis Plan covers Outpatient surgical Services at a Hospital or Ambulatory Surgical Facility, surgical suite or provider’s office. Some Outpatient surgeries must be prior authorized before You have them. See the Prior Authorization and Emergency Admission Notification section for details.

Covered Services include: Anesthesia and postoperative care Cornea transplants and skin grafts Cochlear implants, including bilateral implants Blood transfusion, including blood derivatives Biopsies and scope insertion procedures such as

endoscopies Colonoscopy and sigmoidoscopy for a medical

condition Voluntary termination of pregnancy Reconstructive Surgery that is needed because of

an injury, infection or other Illness

Services of an assistant surgeon are covered only when Medically Necessary. Benefits for an assistant surgeon will not be more than 20% of the primary surgeon’s allowed amount.

Sometimes more than one procedure is done during

the same surgery. These may be two separate procedures or the same procedure on both sides of the body. In these cases, benefits are based on the allowed amount for the primary or main procedure and half of the allowed amount for secondary procedures.

This benefit does not cover: Routine colonoscopy, sigmoidoscopy and barium

enema screening. See the Preventive Care section for details.

Breast reconstruction. See Mastectomy and Breast Reconstruction for those Covered Services.

Transplant Services. See Transplant for details. Vasectomy. See Preventive Care for these

Covered Services.

EMERGENCY ROOMThis Plan covers Services You get in a Hospital emergency room for an Emergency Medical Condition. An Emergency Medical Condition could be a heart attack, stroke, serious burn, chest pain, severe pain or bleeding that does not stop. If You are having a medical emergency You should call 911 or the emergency assistance number for Your local area. You can go to the nearest Hospital emergency room that can take care of You. If it is possible, call Your Physician first and follow their instructions.

You do not need Prior Authorization for emergency room Services. You must let Us know if You are admitted as an Inpatient from the emergency room, as soon as reasonably possible. See the Prior Authorization and Emergency Admission Notification section for details.

Covered Services include the following: The emergency room Emergency room Physician, as shown on the

Summary of Your Costs Services used for Emergency Medical Screening

Exams and for stabilizing an Emergency Medical Condition

Outpatient diagnostic tests billed by the emergency room, that You get with other emergency room Services

Hospital based Urgent Care facilities

Emergency Services benefits are covered at the in-network cost share, up to the allowed amount from any Hospital emergency room or other provider. You pay any amounts over the allowed amount when You get Services from out-of-network Physicians and other providers, even if the Hospital emergency room is in Our network.



This benefit does not cover the inappropriate (non-emergency) use of an emergency room. This means Services that could be delayed until You can be seen in Your Physician’s office. This could be for things like minor Illnesses such as cold, check-ups, follow-up visits and Prescription Drug requests.

EMERGENCY AMBULANCE SERVICESThis Plan covers emergency ambulance Services to the nearest facility that can treat Your condition. The medical care You get during the trip is also covered. These Services are covered only when any other type of transport would put Your health or safety at risk. Covered Services also include transport from one medical facility to another as needed for Your condition.

This Plan covers emergency ambulance Services from licensed providers only and only for the Member who needs transport. Payment for Covered Services will be paid directly to the ambulance provider.

Prior Authorization is required for non-emergency ambulance Services. See the Prior Authorization and Emergency Admission Notification section for details.

URGENT CARE CENTERSThis Plan covers care You get in an Urgent Care center. Urgent Care centers have extended hours and are open to the public. You can go to an Urgent Care center for an Illness or injury that needs treatment right away. Examples are minor sprains, cuts and ear, nose and throat infections. Covered Services include the Physician's Services.

An Affiliated Urgent Care Center is not hospital based and is part of Your PCP’s clinic or medical practice organization.

You may have to pay a separate Copay or Coinsurance for other Services You get during a visit. This includes things such as x-rays, lab work, therapeutic injections and office surgeries. See those Covered Services for details.

Services You get in an Urgent Care center that are billed by the Hospital or emergency room are covered under the Emergency Services benefits.

HOSPITAL SERVICESThis Plan covers Services You get in a Hospital. At an in-network Hospital, You may get Services from doctors or other providers who are not in Our network. When You get covered Services from out-of-network providers, You will pay any amount over the allowed amount.

Inpatient Care

Covered Services include:

Room and board, general duty nursing and special diets

Doctor Services and visits Use of an intensive care or special care units Operating rooms, surgical supplies, anesthesia,

drugs, blood, dressing, equipment and oxygen X-ray, lab and testing

Outpatient Care

Covered Services include: Operating rooms, procedure rooms and recovery

rooms Doctor Services Anesthesia Services, medical supplies and drugs that the

Hospital provides for Your use in the Hospital Lab and testing Services billed by the Hospital and

done with other Hospital Services

Anesthesia for Dental Services

In some cases, this Plan covers anesthesia Services for dental procedures. Covered Services include general anesthesia and fees paid to the anesthesiologist. Also covered are the related facility charges (Inpatient or Outpatient) for a Hospital or Ambulatory Surgical Facility or center. These Services are covered only when they are Medically Necessary and for one of the following reasons: The Member is under age 7 or has a disability and

it would not be safe and effective for the treatment to take place in a dental office

You have a medical condition (besides the dental condition) that makes it unsafe to do the dental treatment outside a Hospital or ambulatory surgical center

This benefit does not cover: Hospital stays that are only for testing, unless the

tests cannot be done without Inpatient Hospital facilities, or Your condition makes Inpatient care Medically Necessary

Any days of Inpatient care beyond what is Medically Necessary to treat the condition

Dental treatment or procedures

MENTAL HEALTH, BEHAVIORAL HEALTH AND SUBSTANCE ABUSEThis Plan covers mental health care and treatment for alcohol and drug dependence. This Plan will only cover alcohol and drug Services from a state-approved treatment program. You must also get these Services in the lowest cost type of setting that can give You the care You need. This Plan complies



with federal mental health parity requirements.

You must get Prior Authorization from Us before You get treatment. See the Prior Authorization and Emergency Admission Notification section for details.

Medically Necessary reconstructive surgery services due to a Mental Health condition, listed in the current Diagnostic and Statistical Manual (DSM), are Covered Services under the Outpatient Surgery Services benefit or Hospital Services section for inpatient care.

Mental Health (Behavioral Health) Care

This Plan covers all of the following Services: Inpatient, residential treatment and Outpatient care

to manage or reduce the effects of the Mental Condition. Benefits include physical and occupational therapy provided for treatment of a mental condition, including autism spectrum disorders and Pervasive Developmental Disorder (PDD).

Individual, family or group therapy Lab and testing Take-home drugs You get in a facility

In this benefit, “Outpatient visit” means a clinical treatment session with a mental health provider.

Alcohol and Drug Dependence (Substance Abuse)

This Plan covers all of the following Services: Inpatient and residential treatment and Outpatient

care to manage or reduce the effects of alcohol or drug dependence, including screening and treatment after a conviction of driving under the influence of intoxicants

Individual, family or group therapy Lab and testing Take-home drugs You get in a facility

Applied Behavioral Analysis (ABA) Therapy

This Plan covers ABA therapy. The Member must be diagnosed with one of the following disorders: Autistic disorder Autism spectrum disorder Asperger’s disorder Childhood disintegrative disorder Pervasive Development Disorder Rett’s disorder

Services must be provided by: A Physician (MD or DO) who is a psychiatrist,

developmental pediatrician or pediatric neurologist A state-licensed psychiatric nurse practitioner (NP),

advanced nurse practitioner (ANP) or advanced

registered nurse practitioner (ARNP) A state-licensed masters-level mental health

clinician (such as, licensed clinical social worker, licensed marriage and family counselor, licensed mental health counselor)

A state-licensed occupational or speech therapist when providing ABA therapy

A state-licensed psychologist Licensed Community Mental Health or Behavioral

Health agency that is also state certified for ABA therapy

Board-Certified Behavioral Analyst (BCBA), licensed in states with behavioral analyst licensure, otherwise certified by the Behavioral Analyst Certification Board

Therapy assistants/behavioral technicians/ paraprofessionals; when Services are supervised and billed by a licensed provider or BCBA

This Plan covers all of the following Services: Direct treatment or direct therapy Services for

identified patients and/or family members when provided by a licensed provider, BCBA or therapy assistants who are supervised by a licensed provider or BCBA

Initial evaluation/assessment when performed by a licensed provider or BCBA

Treatment review and planning when performed by a licensed provider or BCBA

Supervision of therapy assistants when performed by a licensed provider or BCBA

Communication/coordination with other providers or school personnel when performed by a licensed provider or BCBA

Delivery of ABA covered Services for an individual may be managed by a BCBA or licensed provider who is called a “program manager.”

This benefit does not cover: Prescription Drugs. These are covered under

Prescription Drug benefit. Treatment of sexual dysfunctions, such as

impotence dysfunctions of organic origin, including impotence and decreased libido. This exclusion does not apply to sexual dysfunction diagnoses listed in the current Diagnostic and Statistical Manual (DSM).

Institutional care, except that Services are covered when provided for an Illness or injury treated in an acute care Hospital

Dementia Sleep disorders. See Diagnostic Lab, X-ray and

Imaging.



EEG biofeedback or neurofeedback Family and marriage counseling or therapy, except

when it is Medically Necessary to treat Your Mental Condition

Therapeutic or group homes, foster homes, nursing homes boarding homes or schools and child welfare facilities

Outward bound, wilderness, camping or tall ship programs or activities

Phone Services, unless they are done in a crisis or when the Member cannot get out of bed for medical reasons. See Telemedicine Services for phone that use real time video or audio.

Mental health tests that are not used to assess a covered mental condition or plan treatment. This Plan does not cover tests to decide legal competence or for school or job placement.

Support groups, such as Al-Anon or Alcoholics Anonymous

Services that are not Medically Necessary Sober living homes, such as halfway houses Addiction to foods Caffeine dependence Training of therapy assistants/behavioral

technicians/paraprofessionals (as distinct from supervision)

Accompanying the Member/identified patient to appointments or activities outside of the home (such as, recreational activities, eating out, shopping, play activities, medical appointments), except when the Member/identified patient has demonstrated a pattern of significant behavioral difficulties during specific activities

Transporting the Member/identified patient in lieu of parental/other family member transport

Assisting the Member with academic work or functioning as a tutor, except when the Member has demonstrated a pattern of significant behavioral difficulties during school work

Functioning as an educational or other aide for the Member/identified patient in school

Provision of Services that are part of an Individual Education Program (IEP) and therefore should be provided by school personnel, or other services that schools are obligated to provide

Provider doing house work or chores, or assisting the Member/identified patient with house work or chores, except when the Member has demonstrated a pattern of significant behavioral difficulties during specific house work or chores, or acquiring the skills to do specific house work or chores is part of the ABA treatment plan for the

Member/identified patient Provider travel time Babysitting Respite for parents or family members Provider residing in the Member’s home and

functioning as live-in help (such as. in an au-pair role)

Peer-mediated groups or interventions Training or classes for groups of parents of

different patients Hippotherapy or equestrian therapy Pet therapy Auditory Integration Therapy (as part of ABA

Therapy) Sensory Integration Therapy (as part of ABA

Therapy) Prescription Drugs. These are covered under the

Prescription Drugs benefit Any other activity that is not considered to be a

behavioral assessment or intervention utilizing applied behavior analysis techniques

MATERNITY AND NEWBORN CAREMaternity

This Plan covers Physicians and facility charges for prenatal care, delivery and postnatal care. The hospital stay for the mother is not limited to less than 48 hours for a vaginal delivery or less than 96 hours following a cesarean section. A length of stay that will be longer than these limits must be prior authorized. See the Prior Authorization and Emergency Admission Notification section for details.

Home birth Services are also covered. The Services must be provided by a licensed women’s health care provider who is working within their license and scope of practice.

Newborn Care

This Plan covers newborn hospital nursery care and includes pediatrician Services. Benefits for the newborn Services are subject to the newborn’s deductible and Coinsurance. The Hospital stay for the newborn is not limited to less than 48 hours for a vaginal delivery or less than 96 hours following a cesarean section. A length of stay that will be longer than these limits must be Prior Authorized. See the Prior Authorization and Emergency Admission Notification section for details.

This benefit does not cover: Complications of Pregnancy. Complications of

pregnancy are covered as other medical services



and benefits are based on the type of Services You get. For example, office visits are covered as shown under Office and Clinic Visits; treatment for diabetes is covered as described under Preventive Care. See the Definitions section for a description of Complications of Pregnancy.

Outpatient x-ray, lab and imaging. These Services are covered under Diagnostic Lab, X-ray and Imaging.

Home birth Services provided by family Members or volunteers

HOME HEALTH CAREHome health care Services must be part of a home health care plan. These Services are covered when a qualified provider certifies that the Services are provided or coordinated by a state-licensed or Medicare-certified Home Health Agency or certified rehabilitation agency.

Covered Services include: Home visits and acute nursing (short-term nursing

care for Illness or injury) by a home health agency Therapeutic Services such as respiratory therapy

and phototherapy provided by the home health agency

Prescription Drugs and insulin provided by and billed by a home health care provider or home health agency

This benefit does not cover: Over-the-counter drugs, solutions and nutritional

supplements Services provided to someone other than the ill or

injured Member Services provided by family Members or volunteers Services or providers not in the written plan of care

or not named as covered in this benefit Custodial Care Non-medical Services, such as housekeeping Services that provide food, such as Meals on

Wheels or advice about food

HOSPICE CAREA hospice care program must be provided in a hospice facility or in Your home by a hospice care agency or program.

You must get Prior Authorization from Us before You get Inpatient treatment. See the Prior Authorization and Emergency Admission Notification section for details.

Covered Services include: Nursing care provided by or under the supervision

of a registered nurse Medical social Services provided by a medical

social worker who is working under the direction of a Physician; this may include counseling for the purpose of helping You and Your caregivers to adjust to the approaching death

Services provided by a qualified provider associated with the hospice program

Short term Inpatient care provided in a hospice Inpatient unit or other designated hospice bed in a Hospital or Skilled Nursing Facility; this care may be for the purpose of occasional respite for Your caregivers (not to exceed 5 days), or for pain control and symptom management

Home Medical Equipment, medical supplies and devices, including medications used primarily for the relief of pain and control of symptoms related to the terminal Illness

Home health aide Services for personal care, maintenance of a safe and healthy environment and general support to the goals of the plan of care

Rehabilitation therapies provided for purposes of symptom control or to enable You to maintain activities of daily living and basic functional skills

Continuous home care during a period of crisis in which You require skilled intervention to achieve palliation or management of acute medical symptoms

This benefit does not cover: Over-the-counter drugs, solutions and nutritional

supplements Services provided to someone other than the ill or

injured Member Services provided by family Members or volunteers Services or providers not in the written plan of car

Documents

The ShutterbugLWO SG 01-2016 SYC The Shutterbug/4009062 SUMMARY OF YOUR COSTS This is a summary of Your costs for Covered Services. Your costs are subject to the all of the following: