Common use of GUARANTEED RENEWABLE Clause in Contracts

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 SECTION CM – CLINICAL MANAGEMENT 18 Utilization Management 18 Care Management 20 Delegation of Utilization Review Activities and Criteria 22 Disease Management Programs 22 Maternity Management Program 22 Quality Management Program 22 Health Education and Wellness Programs 23 How We Evaluate New Technology 23 Alternative Treatment Plans 24 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 Direct Access to Certain Care 25 Selection of a Primary Care Physician 25 How to Obtain a Specialist Referral 25 How to Obtain a Standing Referral 26 Designating a Referred Specialist as a Primary Care Physician 26 Changing Your Primary Care Physician 27 Changing Your Referred Specialist 27 Provider Directory 27 Continuity of Care 27 Preauthorization for Non-Participating Providers 28 Hospital Admissions 28 Recommended Plan of Treatment 29 Member Liability 29 Limitation of the HMO’s Liability 29 Right to Recover Payments Made In Error 30 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 What are Emergency Services 31 What Is Urgent Care? 31 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 Continuing Care 34 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 Member Rights 36 Member Responsibility 37 SECTION APP - MEMBER APPEAL PROCEDURES 38 General Information 38 Member Classification of Appeal as a Complaint or Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 Member Complaint Process 39 Internal Complaint Review 40 External Complaint Review 41 Process for Member Appeal of an Adverse Benefit Determination 41 Internal Review of an Adverse Benefit Determination 42 External Review of a Final Internal Adverse Benefit Determination 42 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 Professional Providers 45 Institutional Providers 45 SECTION CL - CLAIM PROCEDURES 47 Claims and How They Work 47 Allowable Amount 47 Filing a Claim 47 Out-of-Country Claims 49 Claim Filing and Processing Time Frames 49 Coordination of Benefits (COB) 50 Third Party Liability/Subrogation 54 Assignment of Benefits 55 Payments Made In Error 55 Pre-Existing Conditions 56 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 Eligibility 57 Records and Changes of Member Eligibility 58 Termination of Coverage 59 Obligations on Termination of the Agreement 60 Conversion 61 SECTION CSD – COST SHARING DESCRIPTIONS 62 Application of Cost-sharing 62 Copayment 62 Deductible 63 Coinsurance 63 Out-of-Pocket Maximum 64 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 Primary and Preventive Care 65 Inpatient Covered Services 66 Inpatient/Outpatient Covered Services 68 Outpatient Covered Services 73 SECTION EX - EXCLUSIONS 81 SECTION PR – PREMIUMS 87 Premium Rate and Benefit Provisions 87 Premium Rate Changes 87 Age of Member 87 Third Party Payments 87 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 Subsidy 88 Cost Share Reductions 88 Indian – No Cost Sharing 88 Indian – Tribal Services 88 SECTION GP - GENERAL PROVISIONS 89 Benefit Provisions 89 Confidentiality and Disclosure of Medical Information 89 Clerical Error 90 Discounts 90 Entire Agreement and Changes 90 Gender 90 Interpretation of Subscriber Agreement 90 Legal Action 91 Non-Discrimination 91 Notice of Claim 91 Claim Form 91 Proof of Loss 91 Time of Payment of Claims 92 Payment of Claims 92 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 Physical Examination and Autopsy 94 Policies and Procedures 94 Relationship of Parties 95 Relationship to Blue Cross and Blue Shield Plans 95 Required Disclosure of Information 95 Status Change 96 Time Limit on Certain Defenses 96 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with Keystone. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact Keystone’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 SECTION CM – CLINICAL MANAGEMENT 18 Utilization Management 18 Care Management 20 19 Delegation of Utilization Review Activities and Criteria 22 21 Disease Management Programs 22 21 Maternity Management Program 22 21 Quality Management Program 22 21 Health Education and Wellness Programs 23 22 How We Evaluate New Technology 23 Alternative Treatment Plans 24 23 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 24 Direct Access to Certain Care 25 24 Selection of a Primary Care Physician 25 24 How to Obtain a Specialist Referral 25 24 How to Obtain a Standing Referral 26 25 Designating a Referred Specialist as a Primary Care Physician 26 25 Changing Your Primary Care Physician 27 26 Changing Your Referred Specialist 27 26 Provider Directory 27 26 Continuity of Care 27 26 Preauthorization for Non-Participating Providers 28 27 Hospital Admissions 28 27 Recommended Plan of Treatment 29 28 Member Liability 29 28 Limitation of the HMO’s Liability 29 28 Right to Recover Payments Made In Error 30 29 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 30 What are Emergency Services 31 30 What Is Urgent Care? 31 Out-Of-Area Services 32 31 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA Eligibility & Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Continuing Care 34 33 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 34 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 35 Member Rights 36 35 Member Responsibility 37 36 SECTION APP - MEMBER APPEAL PROCEDURES 38 (Non Multi-State) 37 General Information 38 37 Member Classification of Appeal as a Complaint or Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 37 Member Complaint Process 39 38 Internal Complaint Review 40 39 External Complaint Review 41 40 Process for Member Appeal of an Adverse Benefit Determination 41 40 Internal Review of an Adverse Benefit Determination 42 41 External Review of a Final Internal Adverse Benefit Determination 42 41 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 42 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 44 Professional Providers 45 44 Institutional Providers 45 44 SECTION CL - CLAIM PROCEDURES 47 46 Claims and How They Work 47 46 Allowable Amount 47 46 Filing a Claim 47 46 Out-of-Country Claims 49 48 Claim Filing and Processing Time Frames 49 48 Coordination of Benefits (COB) 50 49 Third Party Liability/Subrogation 54 53 Assignment of Benefits 55 54 Payments Made In Error 55 Pre-Existing Conditions 56 55 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 56 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 56 Eligibility 57 56 Records and Changes of Member Eligibility 58 57 Termination of Coverage 59 58 Obligations on Termination of the Agreement 59 Conversion 60 Conversion 61 SECTION CSD – COST SHARING DESCRIPTIONS 62 61 Application of Cost-sharing 61 Copayment 61 Deductible 62 Copayment Coinsurance 62 Deductible 63 Coinsurance 63 Out-of-Pocket Maximum 64 63 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 64 Primary and Preventive Care 65 64 Inpatient Covered Services 66 65 Inpatient/Outpatient Covered Services 68 67 Outpatient Covered Services 73 72 SECTION EX - EXCLUSIONS 81 80 SECTION PR – PREMIUMS 87 86 Premium Rate and Benefit Provisions 87 86 Premium Rate Changes 87 86 Age of Member 87 86 Third Party Payments 87 86 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 87 Subsidy 88 87 Cost Share Reductions 88 87 Indian – No Cost Sharing 88 87 Indian – Tribal Services 88 87 SECTION GP - GENERAL PROVISIONS 89 88 Benefit Provisions 89 88 Confidentiality and Disclosure of Medical Information 89 88 Clerical Error 90 89 Discounts 90 89 Entire Agreement and Changes 90 89 Gender 89 Health Education and Wellness Programs 90 Interpretation of Subscriber Agreement 90 Legal Action 91 90 Non-Discrimination 91 90 Notice of Claim 91 90 Claim Form 91 90 Proof of Loss 91 Time of Payment of Claims 92 91 Payment of Claims 92 91 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 91 Physical Examination and Autopsy 94 Policies and Procedures 94 Relationship of Parties 95 94 Relationship to Blue Cross and Blue Shield shield Plans 95 94 Required Disclosure of Information 95 94 Status Change 96 95 Time Limit on Certain Defenses 96 95 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME WELCOME‌ Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with KeystoneXxxxxxxx. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US US‌ Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its it’s providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact KeystoneXxxxxxxx’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 XxxxxxxxxxPlan Central PO Box 779519 Harrisburg, XX PA 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx XxxxxxxxxxHarrisburg, XX 00000 PA 17177 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 or Capital Blue The Promenade Shops at Saucon Valley 0000 Xxxxxx Xxxxxx Xxxxxxx Center Valley, PA 18034 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..p.m. Language Assistance Keystone offers language assistance for non-English speaking Members. Language assistance includes interpreting services provided directly in the Member’s preferred language and document translation services available upon request. Language assistance is also available to disabled Members. Information in Braille, large print or other alternate formats are available upon request. To access these services, Members can simply call Keystone’s Customer Service Department at the telephone numbers listed above. MEMBER IDENTIFICATION (ID) CARD‌ The member’s identification card is the key to accessing the benefits provided under this coverage with Keystone. Members should show their card and any other identification cards they may have evidencing other coverage each time they seek medical services. ID cards assist providers in submitting claims to the proper location for processing and payment. The following is important information about the ID card: Suitcase Symbol: Keystone provides coverage for benefits through BlueCross and BlueShield affiliated providers when Members are traveling outside Keystone Health Plan Central’s Approved Service Area. This program is called the national BlueCard® Program. Because Keystone participates in this program, the suitcase symbol is on the front of the Keystone ID card. The suitcase symbol means that Keystone Members have access to a national network of providers for urgent care services whenever they travel outside of the Keystone’s Approved Service Area. It also gives providers a better understanding of how to submit urgent care claims. Xxxxxxxx's participation in the BlueCard Program should result in more timely payment of out- of-area claims. A provider locator telephone number is on the back of the ID card. Laboratory Services: Keystone uses several outpatient laboratories. The Member’s ID card includes a field titled “lab” that designates which laboratory is aligned with the Member’s PCP. Members should give this lab indicator information to all providers to assist them in correctly routing laboratory services.

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. PREMIUMS SUBJECT TO CHANGE This Agreement Policy is guaranteed renewable for your lifetime or until the Policy’s maximum benefits have been reached. We cannot cancel, refuse to renew or change this Policy as long as you pay the premiums as they become due or within the grace period. We can change the premiums for this Policy at any time and may from time to time, and premiums also increase based on your attained age. No change in premium will be renewed by payment of renewal Premiums within thirty (30) days after effective before the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium ratespolicy anniversary. Any change will apply to future premiums for all policies with the same form number issued by us to persons in the Premium rate shall become applicable for Subscribers upon the expiration your state of the period covered by the Subscriber's current payment at the time of such changeresidence. We will give you 31 days notice before any premium change under this provision. THIS IS NOT A LONG-TERM CARE POLICY. THIS IS A LIMITED BENEFIT POLICY AND MAY NOT COVER ALL THE COSTS OF HOME HEALTH CARE. READ THIS POLICY CAREFULLY WITH THE OUTLINE OF COVERAGE. HHC-IA-2 Page 1 IA TABLE OF CONTENTS WELCOME Benefits Page 5 Definitions Pages 3 & 4 Exclusions Page 6 Guaranteed Renewable – Premiums Subject to Change Page 1 How To Contact Us Important Notice Page 1 Retail Centers Insured Schedule Page 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 SECTION CM – CLINICAL MANAGEMENT 18 Utilization Management 18 Care Management 20 Delegation of Utilization Review Activities and Criteria 22 Disease Management Programs 22 Maternity Management Program 22 Quality Management Program 22 Health Education and Wellness Programs 23 How We Evaluate New Technology 23 Alternative Treatment Plans 24 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 Direct Access to Certain Care 25 Selection of a Primary Care Physician 25 How to Obtain a Specialist Referral 25 How to Obtain a Standing Referral 26 Designating a Referred Specialist as a Primary Care Physician 26 Changing Your Primary Care Physician 27 Changing Your Referred Specialist 27 Provider Directory 27 Continuity of Care 27 Preauthorization for Maximum Benefit Periods Page 6 Non-Participating Providers 28 Hospital Admissions 28 Recommended Plan Duplication of Treatment 29 Member Liability 29 Limitation of the HMO’s Liability 29 Right to Recover Payments Made In Error 30 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 What are Emergency Services 31 What Is Urgent Care? 31 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Medicare Benefits 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 Continuing Care 34 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 Member Rights 36 Member Responsibility 37 SECTION APP - MEMBER APPEAL PROCEDURES 38 General Information 38 Member Classification of Appeal as a Complaint or Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 Member Complaint Process 39 Internal Complaint Review 40 External Complaint Review 41 Process for Member Appeal of an Adverse Benefit Determination 41 Internal Review of an Adverse Benefit Determination 42 External Review of a Final Internal Adverse Benefit Determination 42 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 Professional Providers 45 Institutional Providers 45 SECTION CL - CLAIM PROCEDURES 47 Claims and How They Work 47 Allowable Amount 47 Filing a Claim 47 Out-of-Country Claims 49 Claim Filing and Processing Time Frames 49 Coordination of Benefits (COB) 50 Third Party Liability/Subrogation 54 Assignment of Benefits 55 Payments Made In Error 55 Page 4 Policy Provisions Page 9 Pre-Existing Conditions 56 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 Annual Limitations Page 4 Premium Payments Page 7 Restoration of Benefits Page 6 Termination and Special Enrollment Periods and Effective Dates Conversion of Coverage 57 Eligibility 57 Records and Changes of Member Eligibility 58 Termination of Coverage 59 Obligations on Termination of the Agreement 60 Conversion 61 SECTION CSD – COST SHARING DESCRIPTIONS 62 Application of Cost-sharing 62 Copayment 62 Deductible 63 Coinsurance 63 Out-of-Pocket Maximum 64 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 Primary and Preventive Care 65 Inpatient for Covered Services 66 Inpatient/Outpatient Covered Services 68 Outpatient Covered Services 73 SECTION EX - EXCLUSIONS 81 SECTION PR – PREMIUMS 87 Premium Rate and Benefit Provisions 87 Premium Rate Changes 87 Age of Member 87 Third Party Payments 87 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 Subsidy 88 Cost Share Reductions 88 Indian – No Cost Sharing 88 Indian – Tribal Services 88 SECTION GP - GENERAL PROVISIONS 89 Benefit Provisions 89 Confidentiality and Disclosure of Medical Information 89 Clerical Error 90 Discounts 90 Entire Agreement and Changes 90 Gender 90 Interpretation of Subscriber Agreement 90 Legal Action 91 Non-Discrimination 91 Spouse Page 7 Notice of Claim 91 Claim Form 91 Proof of Loss 91 Time of Payment of Claims 92 Payment of Claims 92 OutTen Day Right to Examine Policy Page 1 Uniform Provisions Pages 7 & 8 INSURED SCHEDULE Renewal Premium: Direct Bill Bank Draft Policy Number: 00-of00-Area 000000 Monthly N/A $0.00 Effective Date: Jan. 1, 2008 Quarterly $0.00 $0.00 Initial Term Expires: Jan. 1, 2008 Semi Annual $0.00 N/A Initial Premium: $0.00 Annual $0.00 N/A Insured: XXXX XXX Covered Spouse: XXXX XXX Agent RESERVE NATIONAL AGENT Policy Benefits when Outside Keystone’s Approved Service Area HOME HEALTH CARE BENEFIT Daily Maximum Aggregate Benefit $150.00 Maximum Benefit Period 360 Days HOME HEALTH CARE AIDE BENEFIT Daily Benefit $40.00 Maximum Benefit Period 60 Days Optional Benefits EBR-HHC-2 – BlueCard Extra Benefit Rider Effective Date: Jan. 1, 2008 ANNUAL PHYSICAL EXAMINATION BENEFIT VISION BENEFIT HEARING BENEFIT AMBULANCE BENEFIT IN-HOSPITAL PRIVATE DUTY NURSE BENEFIT PD-2 – Prescription Drug Benefit Rider Effective Date: Jan. 1, 2008 - Endorsements and Guest Membership Programs 92 Physical Examination Eliminations continued on reverse side - --HOME OFFICE-- RESERVE NATIONAL INSURANCE COMPANY 000 XXXX XXXXXXX XXXX * OKLAHOMA CITY, OKLAHOMA INSURED SCHEDULE Endorsements and Autopsy 94 Policies and Procedures 94 Relationship of Parties 95 Relationship to Blue Cross and Blue Shield Plans 95 Required Disclosure of Information 95 Status Change 96 Time Limit on Certain Defenses 96 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement Eliminations ("Agreement"Continued) describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. DEFINITIONS The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with Keystone. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under terms in this Subscriber Agreement Policy are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, defined as required by law. HOW TO CONTACT US Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact Keystone’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..follows:

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 SECTION CM – CLINICAL MANAGEMENT 18 Utilization Management 18 Care Management 20 19 Delegation of Utilization Review Activities and Criteria 22 21 Disease Management Programs 22 21 Maternity Management Program 22 21 Quality Management Program 22 21 Health Education and Wellness Programs 23 22 How We Evaluate New Technology 23 Alternative Treatment Plans 24 23 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 24 Direct Access to Certain Care 25 24 Selection of a Primary Care Physician 25 24 How to Obtain a Specialist Referral 25 24 How to Obtain a Standing Referral 26 25 Designating a Referred Specialist as a Primary Care Physician 26 25 Changing Your Primary Care Physician 27 26 Changing Your Referred Specialist 27 26 Provider Directory 27 26 Continuity of Care 27 26 Preauthorization for Non-Participating Providers 28 27 Hospital Admissions 28 27 Recommended Plan of Treatment 29 28 Member Liability 29 28 Limitation of the HMO’s Liability 29 28 Right to Recover Payments Made In Error 30 29 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 30 What are Emergency Services 31 30 What Is Urgent Care? 31 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 31 Continuing Care 34 33 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 34 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 35 Member Rights 36 35 Member Responsibility 37 36 SECTION APP - MEMBER APPEAL PROCEDURES 38 (Multi-State Only) 37 General Information 38 Member Classification of Appeal as a Complaint or For Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 Member Complaint 37 Process 39 Internal Complaint Review 40 External Complaint Review 41 Process for For Member Appeal of an Adverse Benefit Determination 41 38 Internal Review of an Adverse Benefit Determination 42 38 External Review of a Final Internal Adverse Benefit Determination 42 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 39 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 41 Professional Providers 45 41 Institutional Providers 45 41 SECTION CL - CLAIM PROCEDURES 47 43 Claims and How They Work 47 43 Allowable Amount 47 43 Filing a Claim 47 43 Out-of-Country Claims 49 45 Claim Filing and Processing Time Frames 49 45 Coordination of Benefits (COB) 50 46 Third Party Liability/Subrogation 54 50 Assignment of Benefits 55 51 Payments Made In Error 55 52 Pre-Existing Conditions 56 52 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 53 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 53 Eligibility 57 53 Records and Changes of Member Eligibility 58 54 Termination of Coverage 59 55 Obligations on Termination of the Agreement 60 56 Conversion 61 57 SECTION CSD – COST SHARING DESCRIPTIONS 62 58 Application of Cost-sharing 62 58 Copayment 62 58 Deductible 63 59 Coinsurance 63 59 Out-of-Pocket Maximum 64 60 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 61 Primary and Preventive Care 65 61 Inpatient Covered Services 66 62 Inpatient/Outpatient Covered Services 68 64 Outpatient Covered Services 73 69 SECTION EX - EXCLUSIONS 81 77 SECTION PR – PREMIUMS 87 83 Premium Rate and Benefit Provisions 87 83 Premium Rate Changes 87 83 Age of Member 87 83 Third Party Payments 87 83 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 84 Subsidy 88 84 Cost Share Reductions 88 84 Indian – No Cost Sharing 88 84 Indian – Tribal Services 88 84 SECTION GP - GENERAL PROVISIONS 89 85 Benefit Provisions 89 85 Confidentiality and Disclosure of Medical Information 89 85 Clerical Error 90 86 Discounts 90 86 Entire Agreement and Changes 90 86 Gender 90 86 Health Education and Wellness Programs 87 Interpretation of Subscriber Agreement 90 87 Legal Action 91 87 Non-Discrimination 91 87 Notice of Claim 91 87 Claim Form 91 87 Proof of Loss 91 88 Time of Payment of Claims 92 88 Payment of Claims 92 88 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 88 Physical Examination and Autopsy 94 91 Policies and Procedures 94 91 Relationship of Parties 95 91 Relationship to Blue Cross and Blue Shield shield Plans 95 91 Required Disclosure of Information 95 91 Status Change 96 92 Time Limit on Certain Defenses 96 92 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME WELCOME‌ Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with KeystoneXxxxxxxx. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US US‌ Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its it’s providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact KeystoneXxxxxxxx’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 XxxxxxxxxxPlan Central PO Box 779519 Harrisburg, XX PA 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 or Capital Blue The Promenade Shops at Saucon Valley 0000 Xxxxxx Xxxxxx Xxxxxxx Xxxxxx Xxxxxx, XX 00000 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..p.m. Language Assistance Keystone offers language assistance for non-English speaking Members. Language assistance includes interpreting services provided directly in the Member’s preferred language and document translation services available upon request. Language assistance is also available to disabled Members. Information in Braille, large print or other alternate formats are available upon request. To access these services, Members can simply call Keystone’s Customer Service Department at the telephone numbers listed above. MEMBER IDENTIFICATION (ID) CARD‌ The member’s identification card is the key to accessing the benefits provided under this coverage with Keystone. Members should show their card and any other identification cards they may have evidencing other coverage each time they seek medical services. ID cards assist providers in submitting claims to the proper location for processing and payment. The following is important information about the ID card: Suitcase Symbol: Keystone provides coverage for benefits through BlueCross and BlueShield affiliated providers when Members are traveling outside Keystone Health Plan Central’s Approved Service Area. This program is called the national BlueCard® Program. Because Keystone participates in this program, the suitcase symbol is on the front of the Keystone ID card. The suitcase symbol means that Keystone Members have access to a national network of providers for urgent care services whenever they travel outside of the Keystone’s Approved Service Area. It also gives providers a better understanding of how to submit urgent care claims. Xxxxxxxx's participation in the BlueCard Program should result in more timely payment of out- of-area claims. A provider locator telephone number is on the back of the ID card. Laboratory Services: Keystone uses several outpatient laboratories. The Member’s ID card includes a field titled “lab” that designates which laboratory is aligned with the Member’s PCP. Members should give this lab indicator information to all providers to assist them in correctly routing laboratory services.

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 SECTION CM – CLINICAL MANAGEMENT 18 Utilization Management 18 Care Management 20 Delegation of Utilization Review Activities and Criteria 22 Disease Management Programs 22 Maternity Management Program 22 Quality Management Program 22 Health Education and Wellness Programs 23 How We Evaluate New Technology 23 Alternative Treatment Plans 24 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 Direct Access to Certain Care 25 Selection of a Primary Care Physician 25 How to Obtain a Specialist Referral 25 How to Obtain a Standing Referral 26 Designating a Referred Specialist as a Primary Care Physician 26 Changing Your Primary Care Physician 27 Changing Your Referred Specialist 27 Provider Directory 27 Continuity of Care 27 Preauthorization for Non-Participating Providers 28 Hospital Admissions 28 Recommended Plan of Treatment 29 Member Liability 29 Limitation of the HMO’s Liability 29 Right to Recover Payments Made In Error 30 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 What are Emergency Services 31 What Is Urgent Care? 31 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 Continuing Care 34 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 Member Rights 36 Member Responsibility 37 SECTION APP - MEMBER APPEAL PROCEDURES (Multi-State Plan) 38 General Information 38 Member Classification of Appeal as a Complaint or For Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 Member Complaint Process 39 Internal Complaint Review 40 External Complaint Review 41 Process for For Member Appeal of an Adverse Benefit Determination 41 39 Internal Review of an Adverse Benefit Determination 42 39 External Review of a Final Internal Adverse Benefit Determination 42 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 40 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 42 Professional Providers 45 42 Institutional Providers 45 42 SECTION CL - CLAIM PROCEDURES 47 44 Claims and How They Work 47 44 Allowable Amount 47 44 Filing a Claim 47 44 Out-of-Country Claims 49 46 Claim Filing and Processing Time Frames 49 46 Coordination of Benefits (COB) 50 47 Third Party Liability/Subrogation 54 51 Assignment of Benefits 55 52 Payments Made In Error 55 52 Pre-Existing Conditions 56 53 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 54 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 54 Eligibility 57 54 Records and Changes of Member Eligibility 58 55 Termination of Coverage 59 56 Obligations on Termination of the Agreement 60 57 Conversion 61 58 SECTION CSD – COST SHARING DESCRIPTIONS 62 59 Application of Cost-sharing 62 59 Copayment 62 59 Deductible 63 60 Coinsurance 63 60 Out-of-Pocket Maximum 64 61 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 62 Primary and Preventive Care 65 62 Inpatient Covered Services 66 63 Inpatient/Outpatient Covered Services 68 65 Outpatient Covered Services 73 70 SECTION EX - EXCLUSIONS 81 78 SECTION PR – PREMIUMS 87 84 Premium Rate and Benefit Provisions 87 84 Premium Rate Changes 87 84 Age of Member 87 84 Third Party Payments 87 84 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 85 Subsidy 88 85 Cost Share Reductions 88 85 Indian – No Cost Sharing 88 85 Indian – Tribal Services 88 85 SECTION GP - GENERAL PROVISIONS 89 86 Benefit Provisions 89 86 Confidentiality and Disclosure of Medical Information 89 86 Clerical Error 90 87 Discounts 90 87 Entire Agreement and Changes 90 87 Gender 90 87 Interpretation of Subscriber Agreement 90 87 Legal Action 91 88 Non-Discrimination 91 88 Notice of Claim 91 88 Claim Form 91 88 Proof of Loss 91 88 Time of Payment of Claims 92 89 Payment of Claims 92 89 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 89 Physical Examination and Autopsy 94 91 Policies and Procedures 94 91 Relationship of Parties 95 92 Relationship to Blue Cross and Blue Shield Plans 95 92 Required Disclosure of Information 95 92 Status Change 96 93 Time Limit on Certain Defenses 96 93 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with Keystone. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact Keystone’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 Xxxxxxxxxx, XX 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 15 SECTION CM – CLINICAL MANAGEMENT 18 17 Utilization Management 18 17 Care Management 20 19 Delegation of Utilization Review Activities and Criteria 22 21 Disease Management Programs 22 21 Maternity Management Program 22 21 Quality Management Program 22 21 Health Education and Wellness Programs 23 22 How We Evaluate New Technology 23 22 Alternative Treatment Plans 24 23 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 24 Direct Access to Certain Care 25 24 Selection of a Primary Care Physician 25 24 How to Obtain a Specialist Referral 25 24 How to Obtain a Standing Referral 26 25 Designating a Referred Specialist as a Primary Care Physician 26 25 Changing Your Primary Care Physician 27 26 Changing Your Referred Specialist 27 26 Provider Directory 27 26 Continuity of Care 27 26 Preauthorization for Non-Participating Providers 28 27 Hospital Admissions 28 27 Recommended Plan of Treatment 29 28 Member Liability 29 28 Limitation of the HMO’s Liability 29 28 Right to Recover Payments Made In Error 30 29 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 30 What are Emergency Services 31 30 What Is Urgent Care? 31 30 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 31 Continuing Care 34 33 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 34 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 35 Member Rights 36 35 Member Responsibility 37 36 SECTION APP - MEMBER APPEAL PROCEDURES 38 37 General Information 38 37 Member Classification of Appeal as a Complaint or Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 37 Member Complaint Process 39 38 Internal Complaint Review 40 39 External Complaint Review 41 40 Process for Member Appeal of an Adverse Benefit Determination 41 40 Internal Review of an Adverse Benefit Determination 42 41 External Review of a Final Internal Adverse Benefit Determination 42 41 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 42 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 44 Professional Providers 45 44 Institutional Providers 45 44 SECTION CL - CLAIM PROCEDURES 47 46 Claims and How They Work 47 46 Allowable Amount 47 46 Filing a Claim 47 46 Out-of-Country Claims 49 48 Claim Filing and Processing Time Frames 49 48 Coordination of Benefits (COB) 50 49 Third Party Liability/Subrogation 54 53 Assignment of Benefits 55 54 Payments Made In Error 55 54 Pre-Existing Conditions 56 55 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 56 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 56 Eligibility 57 Records and Changes of Member Eligibility 58 Termination of Coverage 59 Obligations on Termination of the Agreement 60 Conversion 61 SECTION CSD – COST SHARING DESCRIPTIONS 62 Application of Cost-sharing 62 Copayment 62 Deductible 63 Coinsurance 63 Out-of-Pocket Maximum 64 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 Primary and Preventive Care 65 Inpatient Covered Services 66 Inpatient/Outpatient Covered Services 68 Outpatient Covered Services 73 SECTION EX - EXCLUSIONS 81 SECTION PR – PREMIUMS 87 Premium Rate and Benefit Provisions 87 Premium Rate Changes 87 Age of Member 87 Third Party Payments 87 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 Subsidy 88 Cost Share Reductions 88 Indian – No Cost Sharing 88 Indian – Tribal Services 88 SECTION GP - GENERAL PROVISIONS 89 88 Benefit Provisions 89 88 Confidentiality and Disclosure of Medical Information 89 88 Clerical Error 90 89 Discounts 90 89 Entire Agreement and Changes 90 89 Gender 90 89 Interpretation of Subscriber Agreement 90 89 Legal Action 91 90 Non-Discrimination 91 90 Notice of Claim 91 90 Claim Form 91 90 Proof of Loss 91 90 Time of Payment of Claims 92 91 Payment of Claims 92 91 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 91 Physical Examination and Autopsy 94 93 Policies and Procedures 93 REINSTATEMENT 94 Relationship of Parties 95 94 Relationship to Blue Cross and Blue Shield Plans 95 94 Required Disclosure of Information 95 94 Status Change 96 95 Time Limit on Certain Defenses 96 95 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with KeystoneXxxxxxxx. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact KeystoneXxxxxxxx’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 XxxxxxxxxxPlan Central PO Box 779519 Harrisburg, XX PA 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx Xxxxxxxxxx, XX 00000 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..p.m.

GUARANTEED RENEWABLE. Upon the payment of the applicable rate, the HMO agrees to make payment for those services as set forth in this Subscriber Agreement. Subject to the right of the HMO to terminate coverage in accordance with Section EL - Eligibility, Change And Termination Rules Under The Plan. This Agreement is guaranteed renewable and may be renewed by payment of renewal Premiums within thirty (30) days after the first day of the month for which payment must be made. Coverage continues for one month from the effective date of the Agreement and from month to month thereafter until terminated as provided in Section EL - Eligibility, Change And Termination Rules Under The Plan. Non-renewal shall not be based on the deterioration of mental or physical health of any individual covered under this Agreement. Subject to the approval of the Pennsylvania Insurance Department, the HMO may adjust Premium rates. Any change in the Premium rate shall become applicable for Subscribers upon the expiration of the period covered by the Subscriber's current payment at the time of such change. TABLE OF CONTENTS WELCOME 1 How To Contact Us 1 Retail Centers 2 Member Identification (ID) Card 2 SECTION DE - DEFINITIONS 4 SECTION MC - USING THE HMO SYSTEM 16 15 SECTION CM – CLINICAL MANAGEMENT 18 17 Utilization Management 18 17 Care Management 20 18 Delegation of Utilization Review Activities and Criteria 22 20 Disease Management Programs 22 20 Maternity Management Program 22 20 Quality Management Program 22 20 Health Education and Wellness Programs 23 21 How We Evaluate New Technology 23 22 Alternative Treatment Plans 24 22 SECTION ACC - ACCESS TO PRIMARY CARE, SPECIALIST AND HOSPITAL CARE NETWORK ........................................................................................................................................................................... 25 23 Direct Access to Certain Care 25 23 Selection of a Primary Care Physician 25 23 How to Obtain a Specialist Referral 25 23 How to Obtain a Standing Referral 26 24 Designating a Referred Specialist as a Primary Care Physician 26 24 Changing Your Primary Care Physician 27 25 Changing Your Referred Specialist 27 25 Provider Directory 27 25 Continuity of Care 27 25 Preauthorization for Non-Participating Providers 28 26 Hospital Admissions 28 26 Recommended Plan of Treatment 29 27 Member Liability 29 27 Limitation of the HMO’s Liability 29 27 Right to Recover Payments Made In Error 30 28 SECTION ER - EMERGENCY, URGENT CARE, FOLLOW-UP CARE 31 29 What are Emergency Services 31 29 What Is Urgent Care? 31 30 Out-Of-Area Services 32 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Limited NETWORK AREA – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 30 Emergency Services, Urgent Care and Follow-Up Care Outside Keystone’s Approved Service Area – The BlueCard Program’s Urgent and Follow-Up Care Benefits 32 30 Continuing Care 34 32 SECTION GM - AWAY FROM HOME CARE PROGRAM® GUEST MEMBERSHIP BENEFITS 35 33 SECTION MR - MEMBERSHIP RIGHTS AND RESPONSIBILITIES 36 34 Member Rights 36 34 Member Responsibility 37 35 SECTION APP - MEMBER APPEAL PROCEDURES 38 (Non Multi-State) 36 General Information 38 36 Member Classification of Appeal as a Complaint or Appeal of an Adverse Benefit Determination Pertaining to Medical Necessity 38 36 Member Complaint Process 39 37 Internal Complaint Review 40 38 External Complaint Review 41 39 Process for Member Appeal of an Adverse Benefit Determination 41 39 Internal Review of an Adverse Benefit Determination 42 40 External Review of a Final Internal Adverse Benefit Determination 42 40 Expedited Review Process for Appeals of an Adverse Benefit Determination or final Internal Adverse Benefit Determination involving Urgent Care 43 41 SECTION PR - ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS 45 43 Professional Providers 45 43 Institutional Providers 45 43 SECTION CL - CLAIM PROCEDURES 47 45 Claims and How They Work 47 45 Allowable Amount 47 45 Filing a Claim 47 45 Out-of-Country Claims 49 47 Claim Filing and Processing Time Frames 49 47 Coordination of Benefits (COB) 50 48 Third Party Liability/Subrogation 54 52 Assignment of Benefits 55 53 Payments Made In Error 55 54 Pre-Existing Conditions 56 54 SECTION EL - ELIGIBILITY, CHANGE AND TERMINATION RULES UNDER THE PLAN 57 55 Annual and Special Enrollment Periods and Effective Dates of Coverage 57 55 Eligibility 57 56 Records and Changes of Member Eligibility 58 57 Termination of Coverage 59 58 Obligations on Termination of the Agreement 59 Conversion 60 Conversion 61 SECTION CSD – COST SHARING DESCRIPTIONS 62 61 Application of Cost-sharing 61 Copayment 61 Deductible 62 Copayment Coinsurance 62 Deductible 63 Coinsurance 63 Out-of-Pocket Maximum 64 63 SECTION CS - DESCRIPTION OF COVERED SERVICES 65 64 Primary and Preventive Care 65 64 Inpatient Covered Services 66 65 Inpatient/Outpatient Covered Services 68 67 Outpatient Covered Services 73 72 SECTION EX - EXCLUSIONS 81 80 SECTION PR – PREMIUMS 87 86 Premium Rate and Benefit Provisions 87 86 Premium Rate Changes 87 86 Age of Member 87 86 Third Party Payments 87 SECTION CSR – SUBSIDY AND COST SHARING REDUCTIONS 88 Subsidy 88 Cost Share Reductions 88 Indian – No Cost Sharing 88 Indian – Tribal Services 88 86 SECTION GP - GENERAL PROVISIONS 89 87 Benefit Provisions 89 87 Confidentiality and Disclosure of Medical Information 89 87 Clerical Error 90 88 Discounts 90 88 Entire Agreement and Changes 90 88 Gender 90 88 Health Education and Wellness Programs 89 Interpretation of Subscriber Agreement 90 89 Legal Action 91 89 Non-Discrimination 91 89 Notice of Claim 91 89 Claim Form 91 89 Proof of Loss 91 90 Time of Payment of Claims 92 90 Payment of Claims 92 90 Out-of-Area Benefits when Outside Keystone’s Approved Service Area – BlueCard and Guest Membership Programs 92 90 Physical Examination and Autopsy 94 93 Policies and Procedures 94 93 Reinstatement 93 Relationship of Parties 95 93 Relationship to Blue Cross and Blue Shield shield Plans 95 93 Required Disclosure of Information 95 94 Status Change 96 94 Time Limit on Certain Defenses 96 94 SECTION SC - SCHEDULE OF COST SHARING SCHEDULE OF PREVENTIVE CARE SERVICES MEDICAL CARE PREAUTHORIZATION SCHEDULE SUPPLEMENTAL DRUG RIDER PEDIATRIC DENTAL POLICY PEDIATRIC VISION POLICY WELCOME WELCOME‌ Thank you for joining Keystone. Our goal is to provide our Members with access to quality health care coverage. This Subscriber Agreement ("Agreement") describes Member benefits and the procedures required in order to receive the benefits and services to which Members are entitled. Member specific benefits covered by the HMO are described in Section CS - Description of Of Covered Services of this Agreement. If changes are made to this Agreement, Members will be notified by the HMO. Changes to the Agreement will apply to benefits for services received after the effective date of change. Please read this Agreement thoroughly and keep it handy. It will answer most Member questions regarding the HMO's procedures and services. Keystone is committed to providing excellent service to our Members. The following pages outline various ways that Members can contact Keystone. Members may contact us if they have any questions or encounter difficulties using their coverage with KeystoneXxxxxxxx. Members may also access information on standard benefits, wellness programs and information regarding when a referral/authorization is needed at Keystone’s website at xxxxxxxxxxxx.xxx Any rights of a Member to receive Benefits under this Subscriber Agreement are personal to the Member and may not be assigned in whole or in part to any person, Provider or entity, nor may benefits of this Agreement be transferred, either before or after Covered Services are rendered. However, a Member can assign benefit payments to the custodial parent of a Dependent covered under this Subscriber Agreement, as required by law. HOW TO CONTACT US US‌ Telephone Monday through Friday, 8:00 a.m. to 6:00 p.m., Members can call the following telephone numbers and speak with a Customer Service Representative. Members can call the telephone number on their Identification Card or call: Telephone: 0-000-000-0000 Telephone (TTY): 711 Physical Disabilities Keystone and its it’s providers accommodate Members with physical disabilities or other special needs. If Members have any questions regarding access to providers with these accommodations, they should contact KeystoneXxxxxxxx’s Customer Service Department. Preauthorization or Other Clinical Management Programs Members can call the telephone number on their ID card or call Keystone’s Customer Service at 1-800-730- 7219 with questions on Preauthorization. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for more information. Internet and Electronic Mail (E-Mail) The website, xxxxxxxxxxxx.xxx, contains information about Keystone’s products and how to utilize benefits and access services. Members may access material on standard benefits, wellness programs and search the online provider directory to locate area physicians, Hospitals, and ancillary providers. Members may also access and update personal information through the Secure Services feature on the website. By using this feature Members may verify eligibility, check claims status, change primary care physicians, update their name and address, and request an ID card. Members can e-mail us at XxxxxxxxXxxxxxx@xxxx.xxx. E-mail inquiries are reviewed Monday through Friday, 8:00 a.m. to 4:30 p.m. A Customer Service Representative will respond within 24 hours or one business day of receiving the Member’s inquiry. Mail Members can contact Keystone through the United States mail. When writing to Keystone, Members should include their name, the identification number from their Keystone ID card, and explain their concern or question. Inquiries should be sent to: Keystone Health Xxxx Xxxxxxx XX Xxx 000000 XxxxxxxxxxPlan Central PO Box 779519 Harrisburg, XX PA 00000-0000 Fax: 000-000-0000 In Person Members can meet with a Customer Service Representative at our offices at: 0000 Xxxxxxxx Xxxxxx XxxxxxxxxxHarrisburg, XX 00000 PA 17177 or 0000 X. Xxxxxxxx Street Allentown, PA 18102 or Capital Blue The Promenade Shops at Saucon Valley 0000 Xxxxxx Xxxxxx Xxxxxxx Center Valley, PA 18034 Staff is available to assist Members Monday through Friday from 8:00 a.m. to 4:30 p.m..p.m. Language Assistance Keystone offers language assistance for non-English speaking Members. Language assistance includes interpreting services provided directly in the Member’s preferred language and document translation services available upon request. Language assistance is also available to disabled Members. Information in Braille, large print or other alternate formats are available upon request. To access these services, Members can simply call Keystone’s Customer Service Department at the telephone numbers listed above. MEMBER IDENTIFICATION (ID) CARD‌ The member’s identification card is the key to accessing the benefits provided under this coverage with Keystone. Members should show their card and any other identification cards they may have evidencing other coverage each time they seek medical services. ID cards assist providers in submitting claims to the proper location for processing and payment. The following is important information about the ID card: Suitcase Symbol: Keystone provides coverage for benefits through BlueCross and BlueShield affiliated providers when Members are traveling outside Keystone Health Plan Central’s Approved Service Area. This program is called the national BlueCard® Program. Because Keystone participates in this program, the suitcase symbol is on the front of the Keystone ID card. The suitcase symbol means that Keystone Members have access to a national network of providers for urgent care services whenever they travel outside of the Keystone’s Approved Service Area. It also gives providers a better understanding of how to submit urgent care claims. Xxxxxxxx's participation in the BlueCard Program should result in more timely payment of out- of-area claims. A provider locator telephone number is on the back of the ID card. Laboratory Services: Keystone uses several outpatient laboratories. The Member’s ID card includes a field titled “lab” that designates which laboratory is aligned with the Member’s PCP. Members should give this lab indicator information to all providers to assist them in correctly routing laboratory services.