Common use of Benefit Limitations Clause in Contracts

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does not impose any limitation on the availability of Coverage for services provided by Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreement.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network (outside of the 5-county area) Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Health Care Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network (outside of the 5-county area) Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does not impose any limitation on the availability of Coverage for services provided by Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreement. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits will not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Health Care Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Health Care Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services Emergency Health Care Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for deceased Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or health care expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-health care service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost Sharing‌‌‌‌ requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photoprotective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network (outside of the 5-county area) Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network (outside of the 5-county area) Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico unless in an urgent or emergent situation as defined by your benefits. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost Sharing‌‌‌‌ requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photo-protective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does not impose any limitation on the availability of Coverage for services provided by Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreement. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Except as required by state or federal law. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Health Care Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services Emergency Health Care Services – Use of an emergency facility for non-emergent services is not Covered. This does not include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for deceased Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Prior Authorization is required for any Out-of-network Services and such services must be provided in New Mexico. The cost of a non-FDA approved Investigational drug, device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. If you are denied coverage of a cost and you contend that the denial is in violation of NMSA 1978 59A-22-43, you may appeal the decision to deny the coverage of a cost to the superintendent, and that appeal shall be expedited to ensure resolution of the appeal within no more than 30 days after the date of appeal to the superintendent. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered for the following services: • Food, housing, and delivered meals are not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits) are not Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered.‌‌‌ • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the Cost Sharing requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable and charges we determine to be unreasonable based on usual, customary, and reasonable charges are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, including prescribed photo-protective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of medical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Health Care Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • · Some Benefits may be subject to dollar amount and/or visit limitations. • · Benefits may be excluded if the services are provided by Out-of-network (outside of the 5-county area) Practitioners/Providers. • · Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network (outside of the 5-county area) Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost-Sharing requirements:‌‌‌‌ o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photoprotective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost-Sharing requirements:‌‌‌‌‌ o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photo-protective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost Sharing‌‌‌‌ requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photo-protective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This provision Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not Covered. This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at the time the service is provided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not impose any limitation on include situations in which a covered person, acting in good faith and possessing an average knowledge of health and medicine, visits the availability emergency room for what appears to be an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance has been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or After the Effective Date of Coverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for services provided by government, biotechnical, pharmaceutical or medical device industry sources are not Covered.‌ Services from Out-of-network Practitioners/Providers, unless services from an In- network Practitioner/Provider is not available are not Covered. Presbyterian Insurance CompanyPrior Authorization is required for any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, Inc. (PIC) Continuation If device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered by our continuation policy for the following services: • Food, housing, and delivered meals are also not Covered. • Volunteer services are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered by another group medical plan you shall receive our benefits to the extent that we under Durable Medical Equipment benefits) are the secondary payer of all eligible chargesnot Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered. • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the termsCost Sharing‌‌‌‌ requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider visits by other than a Certified Hospice Practitioner/Provider o Ambulance Services Charges in Excess of Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable Charges and charges we determine to be unreasonable are not Covered. Clothing or Other Protective Devices Clothing or other protective devices, conditions including prescribed photoprotective clothing, windshield tinting, lighting fixtures and/or xxxxxxx, and limitations other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of this Agreementmedical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the purpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, except those specified in the Complementary Therapies Benefits Section, are not Covered. • Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • · Some Benefits may be subject to dollar amount and/or visit limitations. • · Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • · Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Health Care Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits will not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.

Benefit Limitations. Your Covered Benefits may have specific limitations or requirements and are listed under the specific benefit section of this document: • Some Benefits may be subject to dollar amount and/or visit limitations. • Benefits may be excluded if the services are provided by Out-of-network (outside of the 5-county area) Practitioners/Providers. • Some Benefits may be subject to Prior Authorization. Refer to your Summary of Benefits and Coverage and the Benefits Section for details about these limitations. Coverage while away from the Service Area When you are away from the Service Area, Covered Benefits are limited to Emergency Healthcare Services and Urgent Care. Major Disasters In the event of any major disaster, epidemic or other circumstances beyond our control, we shall render or attempt to arrange Covered Benefits with In-network Practitioners/Providers insofar as practical, according to our best judgment, and within the limitations of facilities and personnel as are then available. However, no liability or obligation shall result from nor shall be incurred for the delay or failure to provide any such service due to the lack of available facilities or personnel if such lack is the result of such disaster, epidemic or other circumstances beyond our control, and if we have made a good-faith effort to provide or arrange for the provision of such services. Such circumstances include complete or partial disruption of facilities, war, act(s) of terrorism, riot, civil insurrection, disability of a significant part of a Hospital, our personnel or In-network Practitioners/Providers or similar causes. This provision does Prior Authorization Benefits for certain services and supplies are subject to Prior Authorization as specified in the Prior Authorization Section. Benefits may not impose any limitation on the availability of Coverage be payable for services provided by from Out-of-network (outside of the 5-county area) Practitioners/Providers. Presbyterian Insurance Company, Inc. (PIC) Continuation If Providers if you are Covered by our continuation policy and are also Covered by another group medical plan you shall receive our benefits fail to the extent that we are the secondary payer of all eligible charges, subject to the terms, conditions and limitations of this Agreementobtain Prior Authorization.