Common use of Emergency Health Care Services Clause in Contracts

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Out-of-network Hospital you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours so we can review your Hospital stay. For Emergency Health Care Services outside of our Service Area, you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 seven days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Out-of-network Hospital Hospital, you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive health care healthcare procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours so we can review your Hospital stay. For Emergency Health Care Services outside of our Service Area, you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:.

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 seven (7) days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for (outside of the initial treatment are paid 5-county area) facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to (outside of the 5-county area) Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Health Care Services Coverage for trauma services and all other Emergency Health Care Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In-network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Health Care Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network (outside of the 5-county area) and/or outside of New Mexico (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received outside of the 5-county area is not Covered unless transfer to an In-network Practitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non- emergent follow-up care outside of the 5-county area is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network (outside of the 5-county area) Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, requires our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:.

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 seven days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for (outside of the initial treatment are paid 5-county area) facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to (outside of the 5-county area) Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network (outside of the 5-county area) and/or outside of the 5-county area (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received outside of the 5-county area is not Covered unless transfer to an In-network Practitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non- emergent follow-up care outside of the 5-county area is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network (outside of the 5-county area) Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, requires our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:.

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 seven (7) days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for the initial treatment are paid Network facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Health Care Services Coverage for trauma services and all other Emergency Health Care Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In-network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Health Care Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Non-emergent follow-up care received outside of New Mexico is not Covered as unless transfer to an In-network servicesPractitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non-emergent follow-up care received outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefitsrequires our Prior Authorization. Observation Services Services‌ Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation Within New Mexico, to the nearest In-network facility where Emergency Health Care Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: are:‌ • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-co- morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a an In-network facility that is designated by Presbyterian Insurance Company, Inc.Health Plan, and designated as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for the initial treatment are paid Network facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Health Care Services Coverage for trauma services and all other Emergency Health Care Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In-network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Health Care Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Non-emergent follow-up care received outside of New Mexico is not Covered as unless transfer to an In-network servicesPractitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non-emergent follow-up care received outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefitsrequires our Prior Authorization. Observation Services Services‌ Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation Within New Mexico, to the nearest In-network facility where Emergency Health Care Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: are:‌ • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-co- morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a an In-network facility that is designated by Presbyterian Insurance Company, Inc.Health Plan, and designated as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 seven (7) days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for the initial treatment are paid Network facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Health Care Services Coverage for trauma services and all other Emergency Health Care Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In-network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Health Care Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Non-emergent follow-up care received outside of New Mexico is not Covered as unless transfer to an In-network servicesPractitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non-emergent follow-up care received outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, requires our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:.

Emergency Health Care Services. This Agreement covers acute An Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Out-of-network Hospital you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severityor psychiatric condition, including Active Labor or severe pain, manifesting itself by acute symptoms of a sufficient severity such that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result inin any of the following: • Jeopardy ◆ Placing the Member’s health or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, or ◆ Causing serious impairment to the personMember’s health • Serious impairment of bodily functions • Serious functions, or ◆ Causing serious dysfunction of any of the Member’s bodily organ organs or part • Disfigurement parts. ◆ Examples include: ❖ Broken bones ❖ Chest pain ❖ Severe xxxxx ❖ Fainting ❖ Drug overdose ❖ Paralysis ❖ Severe cuts that won’t stop bleeding ❖ Psychiatric emergency conditions If you have a medical emergency, call 911 or go to the person Prior Authorization is nearest emergency room. Emergency Services are covered inside and outside of HPSM’s service area and in and out of HPSM’s participating facilities. When you have a Medical Emergency, call 911 or go to the closest emergency room for help. You do not required have to go to the hospital where your PCP works if you have a Medical Emergency. WHAT TO DO IF YOU ARE NOT SURE IF YOU HAVE AN EMERGENCY If you are not sure whether you have an Emergency or require Urgent Care, contact your PCP for advice. FOLLOW-UP CARE After receiving any Emergency Health or Urgent Care Servicesservices, you will need to call your PCP for follow-up care. NON-COVERED SERVICES HPSM does not cover medical services that are received in an Emergency or Urgent Care setting for conditions that are not Emergencies or urgent if you reasonably should have known that an Emergency or Urgent Care situation did not exist. You will be responsible for all charges related to these services. HPSM will also be working with its Providers to let you know what to do if you cannot pay all your Copayments. If you have to pay more than $25 in Copayments in one month, many Providers will allow you to make the payment within 30 or 60 days rather than at the time of the appointment. If paying the Copayments becomes a problem for you, please talk with your doctor or other Provider. If you need assistance, please call HPSM’s Member Services staff at 0-000-000-0000 or 000-000-0000 and we will help you make the arrangements you need. HEALTH PLAN COVERED BENEFITS MATRIX THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERED BENEFITS AND IS A SUMMARY ONLY. THE BENEFIT DESCRIPTION SECTION SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERED BENEFITS AND LIMITATIONS. Inpatient Hospital Room and board, nursing care, and all No Copayment Services medically necessary ancillary services Professional Services Services and consultations by a physician $5 per office or home visit except or other licensed health care Provider. • No Copayment for hospital inpatient professional services • No Copayment for surgery, anesthesia, or radiation, chemotherapy, or dialysis treatments • No Copayment for Members 24 months of age and younger • No Copayment for vision or hearing testing, or for hearing aids BENEFITS SERVICES COST TO MEMBER (COPAYMENT) Outpatient Hospital Services Diagnostic, therapeutic, and surgical services performed at a hospital or outpatient facility. No Copayment except • $5 per visit for physical, occupational and speech therapy performed on an outpatient basis. • $5 per visit for emergency health care services (waived if the Member is hospitalized) Preventive Health Service Diagnostic, X-Ray and Laboratory Services ** Periodic health examinations, routine diagnostic testing and laboratory services, immunizations, and services for the detection of asymptomatic diseases. Laboratory services, diagnostic imaging and diagnostic and therapeutic radiological services necessary to appropriately evaluate, diagnose, and treat Members. No Copayment No Copayment BENEFITSDiabetic Care ** Prescription Drug Program ** SERVICES Equipment and supplies for the management and treatment of insulin- using diabetes, non-insulin-using diabetes, and gestational diabetes as medically necessary, even if the items are available without prescription. Drugs prescribed by a licensed practitioner. COST TO MEMBER (COPAYMENT) $5 Copayment per office visit. Copayment for prescriptions as described in the “Prescription Drug Program” Section. $5 per prescription for a 30 day supply for brand name or generic drugs. $5 per prescription for a 90 day supply of maintenance drugs • No Copayment for prescription drugs provided in an inpatient setting. • No Copayment for drugs administered in the doctor’s office or in an outpatient facility. • No Copayment for FDA- approved contraceptive drugs and devices. Durable Medical Equipment ** Medical equipment appropriate for use in the home which primarily serves a No Copayment medical purpose, is intended for repeated use, and is generally not useful to a person in the absence of illness or injury. Orthotics and Prosthetics ** Original and replacement devices as prescribed by a licensed practitioner. No Copayment Cataract Spectacles and Lenses ** Cataract spectacles and lenses, cataract contact lenses, or intraocular lenses that replace the natural lens of the eye after No Copayment cataract surgery. Maternity Care Professional and hospital services relating No Copayment to maternity care. Medical Emergency ambulance transportation and $5 per visit (waived if the Member is TransportationServices ** non-emergency transportation to transfer a Member from a hospital to another admitted as an Inpatient to the Hospitalhospital.) hospital or facility, you or your Practitioner needs facility to notify us within 48 hours so we can review your Hospital stayhome. For BENEFITS SERVICES COST TO MEMBER (COPAYMENT) Emergency Health Care Services outside ** Emergency services are covered both in and out of our Service Areathe plan’s service area and in and out of the plan’s participating No Copayment facilities. Confinement in a participating hospital. Inpatient Mental Health Services Services are arranged and managed by the San Mateo County Health Plan. No Copayment Benefit is limited to 30 days per benefit year, you may seek Emergency except for the treatment of severe mental illnesses or serious emotional disturbance of a child. Outpatient Mental Health Services Services are arranged and managed by the San Mateo County Health Plan. $5 per visit Benefit is limited to 20 visits per benefit year, except for the treatment of severe mental illnesses and SED. Inpatient Alcohol / Drug Abuse Services Hospitalization to remove toxic substances from the system. No Copayment Outpatient Alcohol / Drug Abuse Services Crisis intervention and treatment of alcoholism or drug abuse. $5 per visit Benefit is limited to 20 visits per benefit year Home Health Services provided at the home by health No Copayment, except Care Services care personnel. • $5 per visit for physical, Skilled Nursing Care Physical, Occupational, and Speech Therapy ** Services provided in a licensed skilled nursing facility. Therapy may be provided in a medical office or other appropriate outpatient settings. occupational, and speech therapy No Copayment $5 per visit when performed in an outpatient setting No Copayment for inpatient therapy BENEFITS SERVICES COST TO MEMBER (COPAYMENT) Blood and Blood Products ** Includes processing, storage, and administration of blood and blood No Copayment products in inpatient and outpatient settings. Health Education Education regarding personal health No Copayment behavior and health care, and recommendations regarding the optimal use of health care services. Hospice For Members who are diagnosed with a No Copayment terminal illness and who elect hospice care instead of traditional health care services. Organ Transplants ** Coverage for organ transplants and bone marrow transplants which are not No Copayment experimental or investigational. Reconstructive Surgery ** Performed on abnormal structures of the body caused by congenital defects, No Copayment developmental anomalies, trauma, infection, tumors, or disease and are performed to improve function or create a normal appearance. Phenylketonuria (PKU) ** Testing and treatment of PKU. No Copayment Clinical Cancer Coverage for a Member’s participation in $ 5 Copayment per office visit. Trials a cancer clinical trial, phase I through IV, when the Member’s physician has Copayment for prescriptions as recommended participation in the trial, described in the “Prescription Drug and Member meets certain requirements. Program” Section. BENEFITS SERVICES COST TO MEMBER (COPAYMENT) California Children’s Services Program (CCS) CCS is a California medical program that treats children who have certain physically handicapping conditions and who need specialized medical care. Services No Copayment provided through the CCS Program are coordinated by the county CCS office. If the Member’s condition is determined to be eligible for CCS services, the Member remains enrolled in the Healthy Kids and continues to receive medical care from plan Providers for services not related to the CCS eligible condition. The Member will receive treatment for the CCS eligible condition through the specialized network of CCS Providers and/or CCS approved specialty centers. Acupuncture Does not require referral from the nearest appropriate facility where Emergency Health Care Services can $5 per visit Member’s Provider but services must be renderedobtained from a Plan Provider. These Benefit is limited to 20 visits per benefit year Chiropractic Does not require referral from the $5 per visit Member’s Provider but services must be obtained from a Plan Provider and are Benefit is limited to 20 visits per benefit restricted to Members 16 and older. year DEDUCTIBLES No deductibles will be Covered as In-network servicescharged for covered benefits LIFETIME MAXIMUMS No lifetime maximum limits on benefits apply under this plan. Non-emergent follow-up care received from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits* Benefits are provided only for services that are medically necessary. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. ** These services may include be covered and paid for by the California Children’s Services (CCS) program, if the Member is found to be eligible for CCS services. DETAILED BENEFIT DESCRIPTIONS INPATIENT HOSPITAL SERVICES Cost to Member: No Copayment. Description: General hospital services received in a room of two (2) or more individuals containing customary furnishings and equipment, meals (including special diets as medically necessary), and general nursing care. Benefit includes all medically necessary ancillary services, including, but not limited to: • Use of operating room and related facilities • Intensive care unit and services • Drugs, medications, and biologicals • Anesthesia and oxygen • Diagnostic, laboratory, and x-ray services • Special duty nursing • Physical, occupational, and speech therapy • Respiratory therapy • Administration of blood and blood products • Other diagnostic, therapeutic, and rehabilitative services • Coordinated discharge planning, including the planning of such continuing care as may be necessary General anesthesia and associated facility charges in connection with dental procedures are also covered when hospitalization is necessary because of an underlying medical condition or clinical status, or because of the severity of the dental procedure. This benefit is only available to Members under seven (7) years of age; the developmentally disabled, regardless of age; and Members whose health is compromised and for whom general anesthesia is medically necessary, regardless of age. HPSM will coordinate the services with the Member’s dental plan. Exclusions: Personal or comfort items or a private room in a hospital are excluded unless medically necessary. Services of dentists or oral surgeons are excluded for dental procedures. OUTPATIENT HOSPITAL SERVICES Cost to Member: No Copayment, except: • $5 per visit for physical, occupational and speech therapy performed on an outpatient basis. • $5 per visit for emergency health care services, which is waived if the Member is hospitalized. Description: Diagnostic, therapeutic, and surgical services performed at a hospital or outpatient facility including: • Physical, speech, and occupational therapy as appropriate • Hospital services that can reasonably be provided on an ambulatory basis • Related services and supplies in connection with outpatient services including operating room, treatment room, ancillary services, and medications that are supplied by the hospital or facility for use during the Member’s stay at the facility General anesthesia and associated facility charges and outpatient services in connection with dental procedures are also covered when the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate hospital or surgery center is required because of an outpatient’s underlying medical condition • Determine the need for a possible admission to the Hospital • When rapid improvement or clinical status, or because of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility severity of the facility to notify usdental procedure. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered is only available to a Member who requires Emergency Health Care Services Members under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:seven

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network Practitioner/Provider, benefits for the initial treatment are paid Network facility at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Whether Out-of-network Hospital you may choose to Emergency Health Care Service is appropriate will be transferred to a Hospital that is in our Practitionerdetermined by the Reasonable/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will applyPrudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Health Care Services Coverage for trauma services and all other Emergency Health Care Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In-network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Health Care Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coinsurance and/or Copayment) rather than the emergency room visit Copayment. Refer to your Summary of Benefits and Coverage for the Cost Sharing amount. For Emergency Health Care Services received Out-of-network and/or outside of New Mexico (our Service Area), you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Non-emergent follow-up care received outside of New Mexico is not Covered as unless transfer to an In-network servicesPractitioner/Provider would be medically inappropriate and a risk to your health. In such circumstances, we must Authorize the Health Care Services. Non-emergent follow-up care received outside of New Mexico is not Covered for your convenience or preference. You are responsible for any such charges that we do not Authorize. Follow-up care from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, requires our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • For transportation to the nearest appropriate facility where Emergency medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at a facility that is designated by Presbyterian Insurance Company, Inc., and as a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the bariatric surgical Center of Excellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:.