Common use of Geography Clause in Contracts

Geography. The In-network Practitioner/Provider is not located within a reasonable distance from your residence. Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network (outside of the 5-county area) Practitioner/Provider will not be Covered unless in an urgent or emergent situation as defined by your benefits. this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation. Out-Of-Network Care and Bills If you receive care under any of the circumstances below from a Provider who is not in your network, these are your rights: If you receive emergency care Out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an In- network Provider or Facility. • You do NOT need to get Prior Authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilization, call us at 0-000-000-0000 and we will help you receive that care from an In-network Provider. • You cannot be balance billed. If you receive care from an Out-of-network Provider at an In-network Facility, such as a Hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an In-network Provider if: • you did not consent to services from an Out-of-network Provider, • you were not offered the service from an In-network Provider, or • the service was not available from an In-network Provider - as determined by your Healthcare Provider and your health insurance company. If you get a bill from an Out-of-network Provider under any of the above circumstances that you do not believe is owed: • Call us first at (000) 000-0000 or 0-000-000-0000. We will try to the resolve the issue with the Provider on your behalf. • If the problem has not been resolved by us, you can contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx or (0-000-000-0000). To help stop improper Out-of-network bills, we will: • Notify you if your Provider leaves our network and allow you transitional care with that Provider at the In-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our Provider directory information at least every 90 days. • Confirm whether a Provider is In-network if you contact us at 0-000-000-0000. If our representative provides inaccurate information that you rely on in choosing a Provider, you will only be responsible for paying your In-network Cost Sharing amount for care received from that Provider. You have the right to receive notice of the following before you receive Out-of-network care at an In-network Facility: A “good faith estimate” of the charges for Out-of-network care. At least five days to change your mind before you receive a scheduled Out-of-network service. If you choose to receive Out-of-network care you will be responsible for Out-of- network charges that we do not cover. A list of In-network Providers and the option to be referred to any such Provider who can provide necessary care. If you pay an Out-of-network Provider more than we determine you owe: The Provider will owe you a refund within 45 days of receipt of payment by us. If you do not receive a refund within that 45-day period, the Provider will owe you the refund plus interest. You may contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx and (0-000-000-0000) for assistance or to appeal the Provider's failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration. Restrictions on Services Received Outside of the PHP Service Area Emergency Healthcare Services and/or Urgent Care services outside of the State of the 5-county area will be Covered. For Emergency Healthcare Services and/or Urgent Care services received outside of the 5-county area, you may seek services from the nearest appropriate facility where Emergency Healthcare Services / Urgent Care services may be rendered. Cost-Sharing and benefits for an Emergency Healthcare service rendered by a non-participating Provider shall be the same as if rendered by a participating Provider.

Geography. The In-network Practitioner/Provider is not located within a reasonable distance from your residence. Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an Out-of-network (outside of the 5-county area) Practitioner/Provider will not be Covered unless in an urgent or emergent situation as defined by your benefits. this Prior Authorization is obtained prior to receiving the services. You may be liable for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation. Out-Of-Network Care and Bills If you receive care under any of the circumstances below from a Provider who is not in your network, these are your rights: If you receive emergency care Out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an In- network Provider or Facility. • You do NOT need to get Prior Authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilization, call us at 0-000-000-0000 and we will help you receive that care from an In-network Provider. • You cannot be balance billed. If you receive care from an Out-of-network Provider at an In-network Facility, such as a Hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an In-network Provider if: • you did not consent to services from an Out-of-network Provider, • you were not offered the service from an In-network Provider, or • the service was not available from an In-network Provider - as determined by your Healthcare Provider and your health insurance company. If you get a bill from an Out-of-network Provider under any of the above circumstances that you do not believe is owed: • Call us first at (000) 000-0000 or 0-000-000-0000. We will try to the resolve the issue with the Provider on your behalf. • If the problem has not been resolved by us, you can contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx or (0-000-000-0000). To help stop improper Out-of-network bills, we will: • Notify you if your Provider leaves our network and allow you transitional care with that Provider at the In-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our Provider directory information at least every 90 days. • Confirm whether a Provider is In-network if you contact us at 0-000-000-0000. If our representative provides inaccurate information that you rely on in choosing a Provider, you will only be responsible for paying your In-network Cost Sharing amount for care received from that Provider. You have the right to receive notice of the following before you receive Out-of-network care at an In-network Facility: A “good faith estimate” of the charges for Out-of-network care. At least five days to change your mind before you receive a scheduled Out-of-network service. If you choose to receive Out-of-network care you will be responsible for Out-of- network charges that we do not cover. A list of In-network Providers and the option to be referred to any such Provider who can provide necessary care. If you pay an Out-of-network Provider more than we determine you owe: • The Provider will owe you a refund within 45 days of receipt of payment by us. • If you do not receive a refund within that 45-day period, the Provider will owe you the refund plus interest. • You may contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx and (0-000-000-0000) for assistance or to appeal the Provider's failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration. Restrictions on Services Received Outside of the PHP Service Area Emergency Healthcare Services and/or Urgent Care services outside of the State of the 5-county area will be Covered. For Emergency Healthcare Services and/or Urgent Care services received outside of the 5-county area, you may seek services from the nearest appropriate facility where Emergency Healthcare Services / Urgent Care services may be rendered. Cost-Sharing and benefits for an Emergency Healthcare service rendered by a non-participating Provider shall be the same as if rendered by a participating Provider.

Geography. The In-network Practitioner/Provider is not located within a reasonable distance from your the patient’s residence. Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an That Require Prior Authorization In or Out-of-network (outside of the 5-county area) Prior Authorization is required for Inpatient admissions, and all services related to the inpatient admission before you receive these services In-network or Out-of-network (outside of the 5- county area) from any Practitioner/Provider Provider, Healthcare Facility or other Healthcare Professional. Our network of Practitioners/Providers will not be Covered unless in an obtain Prior Authorization for you when you receive care In-network. You are responsible for obtaining Prior Authorization before you receive care Out-of- network, except for urgent or emergent situation as defined by your benefits. this Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and Prior Authorization is obtained prior to receiving the requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. Mental Health or Substance Use Disorder Hospital admissions, Inpatient non-emergent and Substance Use Disorder services. You may be liable for the charges resulting from failure to obtain , and Substance Use Disorder Inpatient services do not require Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of initial service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation. Out-Of-Network Care and Bills If you receive care under any of the circumstances below from a Provider who is not in your network, these are your rights: If you receive emergency care Out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an In- network Provider or Facility. • You do NOT need to get Prior Authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilizationwant to know more about Prior Authorization, please call us at 0-000-000-0000 and we will help you receive that care our Presbyterian Customer Service Center, as soon as possible before services are provided, Monday through Friday, from an In-network Provider. • You cannot be balance billed. If you receive care from an Out-of-network Provider at an In-network Facility, such as a Hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an In-network Provider if: • you did not consent 7 a.m. to services from an Out-of-network Provider, • you were not offered the service from an In-network Provider, or • the service was not available from an In-network Provider - as determined by your Healthcare Provider and your health insurance company. If you get a bill from an Out-of-network Provider under any of the above circumstances that you do not believe is owed: • Call us first 6 p.m. at (000) 000-0000 or 0-000-000-0000. We will try to the resolve the issue with the Provider on your behalf. • If the problem has not been resolved by us, you can contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx or (00000 Hearing impaired users may call TTY 711 The following services and supplies require Prior Authorization In-000-000-0000). To help stop improper network and Out-of-network bills, we will: • Notify you if your Provider leaves our network and allow you transitional care with that Provider at the In-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our Provider directory information at least every 90 days. • Confirm whether a Provider is In-network if you contact us at 0-000-000-0000. If our representative provides inaccurate information that you rely on in choosing a Provider, you will only be responsible for paying your In-network Cost Sharing amount for care received from that Provider. You have the right to receive notice of the following before you receive Out-of-network care at an In-network Facility: A “good faith estimate” of the charges for Out-of-network care. At least five days to change your mind before you receive a scheduled Out-of-network service. If you choose to receive Out-of-network care you will be responsible for Out-of- network charges that we do not cover. A list of In-network Providers and the option to be referred to any such Provider who can provide necessary care. If you pay an Out-of-network Provider more than we determine you owe: The Provider will owe you a refund within 45 days of receipt of payment by us. If you do not receive a refund within that 45-day period, the Provider will owe you the refund plus interest. You may contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx and (0-000-000-0000) for assistance or to appeal the Provider's failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration. Restrictions on Services Received Outside of the PHP Service Area Emergency Healthcare Services and/or Urgent Care services outside of the State of the 5-county area will be Covered. For Emergency Healthcare Services and/or Urgent Care services received outside of the 5-county area). Refer to the Benefits Section for detailed information about these services. After inception of coverage, Presbyterian Health Plan. (PHP) will not expand the list of benefits for which prior authorization is required except when a new covered benefit is added to the plan, when safety or other concerns have arisen with respect to the benefit, when authorized by a state or federal regulatory agency, or as indicated by changes in nationally recognized clinical guidance. After inception of coverage, PHP will notify its network providers before adding a Prior Authorization requirement. PHP may remove a prior authorization requirement at any time. When PHP removes a Prior Authorization requirement during a plan year, PHP will notify its network providers of the change as soon as practicable, and no more than 60 days after the requirement is removed. For a guide of services that require prior authorization, visit xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=OB_000000002930 All Hospital Inpatient Admissions Autologous Chondrocyte Implantation (Carticel) Bariatric Surgery (Weight Loss Surgery) Blepharoplasty/Brow Ptosis Surgery Breast Reconstruction following Mastectomy Breast Reduction for Gynecomastia Chimeric Antigen Receptor T-cell Therapy Clinical Trial Computed Tomography (CT) Corneal Cross-linking CT Angiography (CTA) CV: Mobile Cardiac Outpatient Telemetry (MCOT) and Real-time Continuous Attended Cardiac Monitoring Systems Detoxification – Inpatient Acute requiring medical intervention (alcohol / substance) Durable Medical Equipment (DME) Dialysis ENT: Rhinoplasty ENT: Tonsillectomy or tonsillectomy with adenoidectomy ENT: Endoscopy Nasal/Sinus: Surgical (Balloon Dilation) Gastric Electric Stimulation for Treatment of Chronic Gastroparesis Gender Affirming Surgical Intervention Genetic Testing GI: Wireless Capsule Endoscopy Hip Resurfacing Total Hip Replacement Total Gyn: Hysterectomy Hypoglossal Nerve stimulation Home Health Services Hormone Pellet Insertion, Subcutaneous Hospice Hyperbaric Oxygen Knee, Arthroscopy Knee Replacement Total Lumbar/Cervical Spine Surgery Magnetic Resonance Angiography (MRA) Magnetic Resonance Imaging (MRI) Ortho: Ankle – Total Ankle Replacement Surgery (Arthroplasty) Ortho: Knee – Meniscus Implant and Allograft / Meniscus Transplant Orthotics Outpatient Observation Pain: Epidural Corticosteroid Injections for Back Pain Plastic surgery: Panniculectomy and Abdominoplasty and Body Contouring Procedures Plastic Surgery: Restorative / Reconstructive / Cosmetic Surgery and Treatment Positron Emission Tomography (PET) Prescription Drugs/Medications o (please see the Presbyterian Health Insurance Exchange Metal Level Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wc mdev1001476.pdf. Proton Beam Irradiation Respite Sacral Nerve Stimulation for Urinary and Fecal Incontinence Scans & Cardiac Imaging including Echocardiogram Selected Surgical/Diagnostic procedures o Blepharoplasty/Brow Ptosis Surgery o Breast Reconstruction following Mastectomy o Breast reduction for gynecomastia o Endoscopy Nasal/Sinus balloon dilation o Gender Confirmational Surgery o Hysterectomy o Lumbar/Cervical Spine Surgery o Major endoscopic procedures o Meniscus Implant and Allograft/Meniscus Transplant o Operative and cutting procedures o Panniculectomy o Preoperative and postoperative care o Rhinoplasty o Tonsillectomy o Total Ankle Replacement o Total Hip Replacement o Total Knee Replacement o Varicose Vein Procedures Skilled Nursing Facility (SNF) Services Skin Substitutes (Tissue-Engineered / Bioengineered) Sleep Studies (In a Facility) Transplants: Bone marrow/stem cell transplant: Allogeneic, Autologous Transplants: Heart (includes ventricular assist and artificial heart devices.) Transplants: Heart and Lung Transplants: Kidney Transplants: Liver Transplants: Lung and Lobar Lung Transplants: Pancreas and Kidney Transplants: Pancreas Islet Cell Transplants: Procurement, Transportation Transplants: Small Bowel, Small Bowel/Liver Veins: Varicose Vein Procedures including Echo sclerotherapy Virtual Colonoscopy Water Vapor Thermal Therapy for LUTS/BPH XSTOP Interspinous Process Decompression Authorizing Inpatient Hospital Admission following an Emergency You do not need to get Prior Authorization when you may seek services from the nearest appropriate facility where receive Emergency Healthcare Services / Urgent Care services may be renderedServices. Cost-Sharing and benefits for If you are admitted as an Inpatient to the Hospital following your Emergency Healthcare service rendered by a non-participating Services, your Practitioner/Provider shall be the same or you should contact us as if rendered by a participating Providersoon as possible.

Geography. The In-network Practitioner/Provider is not located within a reasonable distance from your the patient’s residence. Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an That Require Prior Authorization In or Out-of-Network Prior Authorization is required for Inpatient admissions, and all services related to the inpatient admission before you receive these services In-network or Out-of-network (outside of the 5-county area) from any Practitioner/Provider Provider, Healthcare Facility or other Healthcare Professional. Our network of Practitioners/Providers will not be Covered unless in an obtain Prior Authorization for you when you receive care In- network. You are responsible for obtaining Prior Authorization before you receive care Out-of- network, except for urgent or emergent situation as defined by your benefits. this Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and Prior Authorization is obtained prior to receiving the requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. Mental Health or Substance Use Disorder Hospital admissions, Inpatient non-emergent and Substance Use Disorder services. You may be liable for the charges resulting from failure to obtain , and Substance Use Disorder Inpatient services do not require Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of initial service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation. Out-Of-Network Care and Bills If you receive care under any of the circumstances below from a Provider who is not in your network, these are your rights: If you receive emergency care Out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an In- network Provider or Facility. • You do NOT need to get Prior Authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilizationwant to know more about Prior Authorization, please call us at 0-000-000-0000 and we will help you receive that care our Presbyterian Customer Service Center, as soon as possible before services are provided, Monday through Friday from an In-network Provider. • You cannot be balance billed. If you receive care from an Out-of-network Provider at an In-network Facility, such as a Hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an In-network Provider if: • you did not consent 7 a.m. to services from an Out-of-network Provider, • you were not offered the service from an In-network Provider, or • the service was not available from an In-network Provider - as determined by your Healthcare Provider and your health insurance company. If you get a bill from an Out-of-network Provider under any of the above circumstances that you do not believe is owed: • Call us first 6 p.m. at (000) 000-0000 or 0-000-000-00000000 Hearing impaired users may call TTY 711. We will try to the resolve the issue with the Provider on your behalf. • If the problem has not been resolved by us, you can contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx or (0The following services and supplies require Prior Authorization In-000-000-0000). To help stop improper network and Out-of-network. Refer to the Benefits Section for detailed information about these services. After inception of coverage, Presbyterian Health Plan. (PHP) will not expand the list of benefits for which prior authorization is required except when a new covered benefit is added to the plan, when safety or other concerns have arisen with respect to the benefit, when authorized by a state or federal regulatory agency, or as indicated by changes in nationally recognized clinical guidance. After inception of coverage, PHP will notify its network billsproviders before adding a prior authorization requirement. PHP may remove a prior authorization requirement at any time. When PHP removes a prior authorization requirement during a plan year, we will: • Notify you if your Provider leaves our PHP will notify its network and allow you transitional care with that Provider at the In-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our Provider directory information at least every 90 days. • Confirm whether a Provider is In-network if you contact us at 0-000-000-0000. If our representative provides inaccurate information that you rely on in choosing a Provider, you will only be responsible for paying your In-network Cost Sharing amount for care received from that Provider. You have the right to receive notice providers of the change as soon as practicable, and no more than 60 days after the requirement is removed. For a guide of services that require prior authorization, visit xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=OB_000000002930. All Hospital Inpatient Admissions Autologous Chondrocyte Implantation (Carticel) Bariatric Surgery (Weight Loss Surgery) Blepharoplasty/Brow Ptosis Surgery Breast Reconstruction following before Mastectomy Breast Reduction for Gynecomastia Chimeric Antigen Receptor T-cell Therapy Clinical Trial Computed Tomography (CT) Corneal Cross-linking CT Angiography (CTA) CV: Mobile Cardiac Outpatient Telemetry (MCOT) and Real-time Continuous Attended Cardiac Monitoring Systems Detoxification – Inpatient Acute requiring medical intervention (alcohol / substance) Durable Medical Equipment (DME) Dialysis ENT: Rhinoplasty ENT: Tonsillectomy or tonsillectomy with adenoidectomy ENT: Endoscopy Nasal/Sinus: Surgical (Balloon Dilation) Gastric Electric Stimulation for Treatment of Chronic Gastroparesis Gender Affirming Surgical Intervention Genetic Testing GI: Wireless Capsule Endoscopy Hip Resurfacing Total Hip Replacement Total Gyn: Hysterectomy Hypoglossal Nerve stimulation Home Health Services Hormone Pellet Insertion, Subcutaneous Hospice Hyperbaric Oxygen Knee, Arthroscopy Knee Replacement Total Lumbar/Cervical Spine Surgery Magnetic Resonance Angiography (MRA) Magnetic Resonance Imaging (MRI) Ortho: Ankle – Total Ankle Replacement Surgery (Arthroplasty) Ortho: Knee – Meniscus Implant and Allograft / Meniscus Transplant Orthotics Outpatient Observation Pain: Epidural Corticosteroid Injections for Back Pain Plastic surgery: Panniculectomy and Abdominoplasty and Body Contouring Procedures Plastic Surgery: Restorative / Reconstructive / Cosmetic Surgery and Treatment Positron Emission Tomography (PET) Prescription Drugs/Medications o Please see the Presbyterian Health Insurance Exchange Metal Level Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wc mdev1001476.pdf. Proton Beam Irradiation Respite Sacral Nerve Stimulation for Urinary and Fecal Incontinence Scans & Cardiac Imaging including Echocardiogram Selected Surgical/Diagnostic procedures o Blepharoplasty/Brow Ptosis Surgery o Breast Reconstruction following Mastectomy o Breast reduction for gynecomastia o Endoscopy Nasal/Sinus balloon dilation o Gender Confirmational Surgery o Hysterectomy o Lumbar/Cervical Spine Surgery o Major endoscopic procedures o Meniscus Implant and Allograft/Meniscus Transplant o Operative and cutting procedures o Panniculectomy o Preoperative and postoperative care o Rhinoplasty o Tonsillectomy o Total Ankle Replacement o Total Hip Replacement o Total Knee Replacement o Varicose Vein Procedures Skilled Nursing Facility (SNF) Services Skin Substitutes (Tissue-Engineered / Bioengineered) Sleep Studies (In a Facility) Transplants: Bone marrow/stem cell transplant: Allogeneic, Autologous Transplants: Heart (includes ventricular assist and artificial heart devices.) Transplants: Heart and Lung Transplants: Kidney Transplants: Liver Transplants: Lung and Lobar Lung Transplants: Pancreas and Kidney Transplants: Pancreas Islet Cell Transplants: Procurement, Transportation Transplants: Small Bowel, Small Bowel/Liver Veins: Varicose Vein Procedures including Echo sclerotherapy Virtual Colonoscopy Water Vapor Thermal Therapy for LUTS/BPH XSTOP Interspinous Process Decompression Authorizing Inpatient Hospital Admission following an Emergency You do not need to get Prior Authorization when you receive Out-of-network care at an In-network Facility: A “good faith estimate” of the charges for Out-of-network care. At least five days to change your mind before you receive a scheduled Out-of-network serviceEmergency Healthcare Services. If you choose are admitted as an Inpatient to receive Outthe Hospital following your Emergency Healthcare Services your Practitioner/Provider or you should contact us as soon as possible. Prior Authorization Protocols After January 1, 2014, a health care plan shall accept the uniform prior authorization form developed pursuant to Sections 2 [59A-2-of9.8 NMSA 1978] and 3 [61-network 11-6.2 NMSA 1978] of this 2013 act as sufficient to request prior authorization for prescription drug benefits. No later than twenty-four months after the adoption of national standards for electronic Prior Authorization, a health insurer shall exchange prior authorization requests with providers who have e-prescribing capability. If a health care plan fails to use or accept the uniform prior authorization form or fails to respond within three business days upon receipt of a uniform Prior Authorization form, the Prior Authorization request shall be deemed to have been granted. As used in this section, "health care plan" means a nonprofit corporation authorized by the superintendent to enter into contracts with subscribers and to make health care expense payments but does not include: A person that only issues a limited-benefit policy intended to supplement major medical coverage, including Medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income; A physician or a physician group to which a health care plan has delegated financial risk for prescription drugs and that does not use a Prior Authorization process for prescription drugs; or A health care plan or its affiliated providers, if the health care plan owns and operates its pharmacies and does not use a Prior Authorization process. Prior Authorization and Your Coverage Eligibility and benefits are based on the date you will be responsible for Out-of- network charges that we do received the services, not cover. A list of In-network Providers and the option to be referred to any such Provider who can provide necessary caredate you received Prior Authorization. If you pay lose Coverage under this plan, services received after Coverage ends will not be Covered, even if we provided Prior Authorization. Prior Authorization Decisions – Non-Emergency We will evaluate non-emergent Prior Authorization requests and advise you and your Practitioner/Provider of our decision within seven working days after receiving all needed information. Prior Authorization Decision – Expedited (Accelerated) If your medical condition requires that we make a Prior Authorization decision quickly, we will notify you and your Practitioner/Provider of an Out-of-network Provider more than we determine you owe: The Provider will owe you a refund expedited decision, within 45 days 24 hours of our receipt of payment by us. If you do not receive a refund within that 45-day period, the Provider will owe you the refund plus interest. You may contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx and (0-000-000-0000) for assistance written or to appeal the Provider's failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration. Restrictions on Services Received Outside of the PHP Service Area Emergency Healthcare Services and/or Urgent Care services outside of the State of the 5-county area will be Covered. For Emergency Healthcare Services and/or Urgent Care services received outside of the 5-county area, you may seek services from the nearest appropriate facility where Emergency Healthcare Services / Urgent Care services may be rendered. Cost-Sharing and benefits verbal request for an Emergency Healthcare service rendered by a non-participating Provider shall be the same as if rendered by a participating Providerexpedited decision.

Geography. The In-network Practitioner/Provider is not located within a reasonable distance from your the patient’s residence. Continuity – If the requested Out-of-network (outside of the 5-county area) Practitioner/Provider has a well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of 30 days as needed to ensure continuity of care. Any Prior Authorization requested simply for your convenience will not be considered to be reasonable. Services of an That Require Prior Authorization In or Out-of-network (outside of the 5-county area) Prior Authorization is required for Inpatient admissions, and all services related to the inpatient admission before you receive these services In-network or Out-of-network (outside of the 5- county area) from any Practitioner/Provider Provider, Healthcare Facility or other Healthcare Professional. Our network of Practitioners/Providers will not be Covered unless in an obtain Prior Authorization for you when you receive care In-network. You are responsible for obtaining Prior Authorization before you receive care Out-of- network, except for urgent or emergent situation as defined by your benefits. this Presbyterian will provide material that contains in a clear, conspicuous and readily understandable form, a full and fair disclosure of the plan’s benefits, limitations, exclusions, conditions of eligibility and Prior Authorization is obtained requirements, within a reasonable time after enrollment and at subsequent periodic times as appropriate. Mental Health or Substance Use Disorder Hospital admissions, Inpatient non-emergent and Substance Use Disorder services, and Substance Use Disorder Inpatient services do not require prior to receiving the services. You may be liable authorization for the charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network (outside of the 5-county area) Practitioner/Provider. Out-of-network (outside of the 5-county area) Practitioners/Providers may require you to pay them in full at the time of initial service. You may have to pay them and then file your claim for reimbursement with us. We will only pay this claim if the service provided was Authorized by us or was due to an Urgent or Emergency Healthcare situation. Out-Of-Network Care and Bills If you receive care under any of the circumstances below from a Provider who is not in your network, these are your rights: If you receive emergency care Out-of-network, including air ambulance service: • You are only responsible for paying what you would owe for the same care from an In- network Provider or Facility. • You do NOT need to get Prior Authorization for emergency services. • Your care can continue until your condition has stabilized. If you require additional care after stabilizationwant to know more about Prior Authorization, please call us at 0-000-000-0000 and we will help you receive that care our Presbyterian Customer Service Center, as soon as possible before services are provided, Monday through Friday, from an In-network Provider. • You cannot be balance billed. If you receive care from an Out-of-network Provider at an In-network Facility, such as a Hospital that is in your plan, you are only responsible for paying what you would owe for the same care from an In-network Provider if: • you did not consent 7 a.m. to services from an Out-of-network Provider, • you were not offered the service from an In-network Provider, or • the service was not available from an In-network Provider - as determined by your Healthcare Provider and your health insurance company. If you get a bill from an Out-of-network Provider under any of the above circumstances that you do not believe is owed: • Call us first 6 p.m. at (000) 000-0000 or 0-000-000-0000. We will try to the resolve the issue with the Provider on your behalf. • If the problem has not been resolved by us, you can contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx or (00000 Hearing impaired users may call TTY 711 The following services and supplies require Prior Authorization In-000-000-0000). To help stop improper network and Out-of-network bills, we will: • Notify you if your Provider leaves our network and allow you transitional care with that Provider at the In-network benefit level for up to 90 days depending on your condition and course of treatment. • Verify the accuracy of our Provider directory information at least every 90 days. • Confirm whether a Provider is In-network if you contact us at 0-000-000-0000. If our representative provides inaccurate information that you rely on in choosing a Provider, you will only be responsible for paying your In-network Cost Sharing amount for care received from that Provider. You have the right to receive notice of the following before you receive Out-of-network care at an In-network Facility: A “good faith estimate” of the charges for Out-of-network care. At least five days to change your mind before you receive a scheduled Out-of-network service. If you choose to receive Out-of-network care you will be responsible for Out-of- network charges that we do not cover. A list of In-network Providers and the option to be referred to any such Provider who can provide necessary care. If you pay an Out-of-network Provider more than we determine you owe: The Provider will owe you a refund within 45 days of receipt of payment by us. If you do not receive a refund within that 45-day period, the Provider will owe you the refund plus interest. You may contact the New Mexico Office of Superintendent of Insurance at xxx.xxx.xxxxx.xx.xx and (0-000-000-0000) for assistance or to appeal the Provider's failure to provide a refund. You need to file the appeal within 180 days of the 45-day refund period expiration. Restrictions on Services Received Outside of the PHP Service Area Emergency Healthcare Services and/or Urgent Care services outside of the State of the 5-county area will be Covered. For Emergency Healthcare Services and/or Urgent Care services received outside of the 5-county area). Refer to the Benefits Section for detailed information about these services. After inception of coverage, Presbyterian Health Plan. (PHP) will not expand the list of benefits for which Prior Authorization is required except when a new covered benefit is added to the plan, when safety or other concerns have arisen with respect to the benefit, when authorized by a state or federal regulatory agency, or as indicated by changes in nationally recognized clinical guidance. After inception of coverage, PHP will notify its network providers before adding a Prior Authorization requirement. PHP may remove a prior authorization requirement at any time. When PHP removes a Prior Authorization requirement during a plan year, PHP will notify its network providers of the change as soon as practicable, and no more than 60 days after the requirement is removed. For a guide of services that require prior authorization, visit xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=OB_000000002930 o All Hospital Inpatient Admissions o Autologous Chondrocyte Implantation (Carticel) o Bariatric Surgery (Weight Loss Surgery) o Blepharoplasty/Brow Ptosis Surgery o Breast Reconstruction following Mastectomy o Breast Reduction for Gynecomastia o Chimeric Antigen Receptor T-cell Therapy o Clinical Trial o Computed Tomography (CT) o Corneal Cross-linking o CT Angiography (CTA) o CV: Mobile Cardiac Outpatient Telemetry (MCOT) and Real-time Continuous Attended Cardiac Monitoring Systems o Detoxification – Inpatient Acute requiring medical intervention (alcohol / substance) o Durable Medical Equipment (DME) o Dialysis o ENT: Rhinoplasty o ENT: Tonsillectomy or tonsillectomy with adenoidectomy o ENT: Endoscopy Nasal/Sinus: Surgical (Balloon Dilation) o Gastric Electric Stimulation for Treatment of Chronic Gastroparesis o Gender Affirming Surgical Intervention o Genetic Testing o GI: Wireless Capsule Endoscopy o Hip Resurfacing Total o Hip Replacement Total o Gyn: Hysterectomy o Hypoglossal Nerve stimulation o Home Health Services o Hormone Pellet Insertion, Subcutaneous o Hospice o Hyperbaric Oxygen o Knee, Arthroscopy o Knee Replacement Total o Lumbar/Cervical Spine Surgery o Magnetic Resonance Angiography (MRA) o Magnetic Resonance Imaging (MRI) o Ortho: Ankle – Total Ankle Replacement Surgery (Arthroplasty) o Ortho: Knee – Meniscus Implant and Allograft / Meniscus Transplant o Orthotics o Outpatient Observation o Pain: Epidural Corticosteroid Injections for Back Pain o Plastic surgery: Panniculectomy and Abdominoplasty and Body Contouring Procedures o Plastic Surgery: Restorative / Reconstructive / Cosmetic Surgery and Treatment o Positron Emission Tomography (PET) o Prescription Drugs/Medications o Please see the Presbyterian Health Insurance Exchange Metal Level Formulary list at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wc mdev1001476.pdf. Proton Beam Irradiation Respite Sacral Nerve Stimulation for Urinary and Fecal Incontinence Scans & Cardiac Imaging including Echocardiogram Selected Surgical/Diagnostic procedures o Blepharoplasty/Brow Ptosis Surgery o Breast Reconstruction following Mastectomy o Breast reduction for gynecomastia o Endoscopy Nasal/Sinus balloon dilation o Gender Confirmational Surgery o Hysterectomy o Lumbar/Cervical Spine Surgery o Major endoscopic procedures o Meniscus Implant and Allograft/Meniscus Transplant o Operative and cutting procedures o Panniculectomy o Preoperative and postoperative care o Rhinoplasty o Tonsillectomy o Total Ankle Replacement o Total Hip Replacement o Total Knee Replacement o Varicose Vein Procedures Skilled Nursing Facility (SNF) Services Skin Substitutes (Tissue-Engineered / Bioengineered) Sleep Studies (In a Facility) Transplants: Bone marrow/stem cell transplant: Allogeneic, Autologous Transplants: Heart (includes ventricular assist and artificial heart devices.) Transplants: Heart and Lung Transplants: Kidney Transplants: Liver Transplants: Lung and Lobar Lung Transplants: Pancreas and Kidney Transplants: Pancreas Islet Cell Transplants: Procurement, Transportation Transplants: Small Bowel, Small Bowel/Liver Veins: Varicose Vein Procedures including Echo sclerotherapy Virtual Colonoscopy Water Vapor Thermal Therapy for LUTS/BPH XSTOP Interspinous Process Decompression Authorizing Inpatient Hospital Admission following an Emergency You do not need to get Prior Authorization when you may seek services from the nearest appropriate facility where receive Emergency Healthcare Services / Urgent Care services may be renderedServices. Cost-Sharing and benefits for If you are admitted as an Inpatient to the Hospital following your Emergency Healthcare service rendered by a non-participating Services, your Practitioner/Provider shall be the same or you should contact us as if rendered by a participating Providersoon as possible.