Common use of Prior Authorization Clause in Contracts

Prior Authorization. This Section explains what Covered Health Care Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further information can be obtained through your PCP or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency.  Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services 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 from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-

Prior Authorization. This Section explains what Covered Health Care Services require Benefits for certain services and supplies are subject to Prior Authorization before as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you receive these services and how fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Except as required by state or federal law. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not an exhaustive listCovered. Further information can be obtained through your PCP This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospitalpractice guidelines developed by the federal government, Skilled Nursing Facility national or other facility professional medical societies, boards and associations, or before you receive certain Covered Health Care Services and suppliesany applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefitnational, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time or any service for which the Authorization required approval of a government agency has not been granted at the time the service is validprovided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not include situations in which a covered person, acting in no event shall good faith and possessing an average knowledge of health and medicine, visits the emergency room for what appears to be for more than twenty-four an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (24ground or air) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on coroner’s office or to a mortuary is not Covered, unless the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them Ambulance has been dispatched prior to the actual service pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or delivery After the Effective Date of suppliesCoverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Authorization means our decision Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that a Health Care Service requested do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for by your Practitioner/Provider government, biotechnical, pharmaceutical or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is medical device industry sources are not obtained for services by Covered.‌ Services from Out-of-Network network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization unless services from an In- network Practitioner/Provider is not available and are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible required for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. If you are denied coverage of a cost and you contend that the denial is in violation of XXXX 0000 59A-22-43, you may appeal the decision to deny the coverage of a cost to the superintendent, and that appeal shall be expedited to ensure resolution of the appeal within no more than 30 days after the date of appeal to the superintendent. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered for the following services: • Food, housing, and delivered meals are not Covered. • Volunteer services obtained from an Out-of-network are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits) are not Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered.‌‌‌ • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the Cost Sharing requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network visits by other than a Certified Hospice Practitioner/Provider or o Ambulance Services Charges in cases Excess of an emergency.  Important Information If required medical services Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable and charges we determine to be unreasonable based on usual, customary, and reasonable charges are not available from InCovered. Clothing or Other Protective Devices Clothing or other protective devices, including prescribed photo-network Practitioners/Providersprotective clothing, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessarywindshield tinting, we, in consultation with your referring In-network Physician lighting fixtures and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissionsxxxxxxx, and all services other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of medical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Providerpurpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, Health Care Facility or other Health Care Professionalexcept those specified in the Complementary Therapies Benefits Section, are not Covered. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-• Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Prior Authorization. This Section explains what Covered Health Care Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further information can be obtained through your PCP or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency.  🖐 Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  ⮚ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  ⮚ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  ⮚ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  ⮚ Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  ⮚ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services 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 from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-

Prior Authorization. This Section explains what Covered Health Care Services require Benefits for certain services and supplies are subject to Prior Authorization before as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you receive these services and how fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Except as required by state or federal law. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not an exhaustive listCovered. Further information can be obtained through your PCP This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines developed by the Health Care Insurer consistent with such federal, national, and professional practice guidelines, or any service for which the required approval of a government agency has not been granted at our website at xxx.xxx.xxxthe time the service is provided. Before you are admitted as an Inpatient to a HospitalAccidental Injury (Trauma), Skilled Nursing Facility or other facility or before you receive certain Covered Urgent Care, Emergency Health Care Services, and Observation Services Emergency Health Care Services – Use of an emergency facility for non-emergent services is not Covered. This does not include situations in which a covered person, acting in good faith and suppliespossessing an average knowledge of health and medicine, you must request and obtain approval, known as Authorizationvisits the emergency room for what appears to be an acute condition that requires immediate medical attention. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer Ambulance Services Ambulance service (ground or air) to the Diabetes Services section. What coroner’s office or to a mortuary is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if not Covered, unless the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them Ambulance has been dispatched prior to the actual service pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for deceased Members are not Covered. Before or delivery After the Effective Date of suppliesCoverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Authorization means our decision Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that a Health Care Service requested do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for by your Practitioner/Provider government, biotechnical, pharmaceutical or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is medical device industry sources are not obtained for services by Covered.‌ Services from Out-of-Network network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization unless services from an In- network Practitioner/Provider is not available are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible required for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when any Out-of-network Services and such services must be provided for in New Mexico. The cost of a non-FDA approved Investigational drug, device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. If you are denied coverage of a cost and you contend that the denial is in violation of XXXX 0000 59A-22-43, you may appeal the decision to deny the coverage of a cost to the superintendent, and that appeal shall be expedited to ensure resolution of the appeal within no more than 30 days after the date of appeal to the superintendent. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered for the following services: • Food, housing, and delivered meals are not Covered. • Volunteer services obtained from an Out-of-network are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits) are not Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered.‌‌‌ • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the Cost Sharing requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network visits by other than a Certified Hospice Practitioner/Provider or o Ambulance Services Charges in cases Excess of an emergency.  Important Information If required medical services Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable and charges we determine to be unreasonable based on usual, customary, and reasonable charges are not available from InCovered. Clothing or Other Protective Devices Clothing or other protective devices, including prescribed photo-network Practitioners/Providersprotective clothing, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessarywindshield tinting, we, in consultation with your referring In-network Physician lighting fixtures and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissionsxxxxxxx, and all services other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of medical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Providerpurpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, Health Care Facility or other Health Care Professionalexcept those specified in the Complementary Therapies Benefits Section, are not Covered. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-• Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Prior Authorization. This Section explains what Covered Health Care Services require Benefits for certain services and supplies are subject to Prior Authorization before as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you receive these services and how fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Except as required by state or federal law. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not an exhaustive listCovered. Further information can be obtained through your PCP This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospitalpractice guidelines developed by the federal government, Skilled Nursing Facility national or other facility professional medical societies, boards and associations, or before you receive certain Covered Health Care Services and suppliesany applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefitnational, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time or any service for which the Authorization required approval of a government agency has not been granted at the time the service is validprovided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not include situations in which a covered person, acting in no event shall good faith and possessing an average knowledge of health and medicine, visits the emergency room for what appears to be for more than twenty-four an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (24ground or air) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on coroner’s office or to a mortuary is not Covered, unless the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them Ambulance has been dispatched prior to the actual service pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or delivery After the Effective Date of suppliesCoverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Authorization means our decision Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that a Health Care Service requested do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for by your Practitioner/Provider government, biotechnical, pharmaceutical or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is medical device industry sources are not obtained for services by Covered.‌ Services from Out-of-Network network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization unless services from an In- network Practitioner/Provider is not available and are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible required for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when any Out-of-network Services and such services must be provided in New Mexico. The cost of a non-FDA approved Investigational drug, device or procedure is not Covered. The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. If you are denied coverage of a cost and you contend that the denial is in violation of NMSA 1978 59A-22-43, you may appeal the decision to deny the coverage of a cost to the superintendent, and that appeal shall be expedited to ensure resolution of the appeal within no more than 30 days after the date of appeal to the superintendent. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered for the following services: • Food, housing, and delivered meals are not Covered. • Volunteer services obtained from an Out-of-network are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits) are not Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered.‌‌‌ • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the Cost Sharing requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network visits by other than a Certified Hospice Practitioner/Provider or o Ambulance Services Charges in cases Excess of an emergency.  Important Information If required medical services Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable and charges we determine to be unreasonable based on usual, customary, and reasonable charges are not available from InCovered. Clothing or Other Protective Devices Clothing or other protective devices, including prescribed photo-network Practitioners/Providersprotective clothing, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessarywindshield tinting, we, in consultation with your referring In-network Physician lighting fixtures and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissionsxxxxxxx, and all services other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of medical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Providerpurpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, Health Care Facility or other Health Care Professionalexcept those specified in the Complementary Therapies Benefits Section, are not Covered. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-• Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Prior Authorization. This Section explains what Covered Health Care Services require Benefits for certain services and supplies are subject to Prior Authorization before as specified in the Prior Authorization Section. Benefits may not be payable for services from Out-of-network Practitioners/Providers if you receive these services and how fail to obtain Prior Authorization. Exclusions‌‌‌‌‌ This Section lists services that are not Covered (Excluded Services) under your Health Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be Excluded Services. Except as required by state or federal law. Any service, treatment, procedure, facility, equipment, drugs, drug usage, device or supply determined to be not Medically Necessary when subject to medical necessity review, is not an exhaustive listCovered. Further information can be obtained through your PCP This includes any service, which is not recognized according to any applicable generally accepted principles and practices of good medical care or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospitalpractice guidelines developed by the federal government, Skilled Nursing Facility national or other facility professional medical societies, boards and associations, or before you receive certain Covered Health Care Services and suppliesany applicable clinical protocols or practice guidelines developed by the Healthcare Insurer consistent with such federal, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefitnational, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time or any service for which the Authorization required approval of a government agency has not been granted at the time the service is validprovided. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services Emergency Healthcare Services – Use of an emergency facility for non-emergent services is not Covered. This does not include situations in which a covered person, acting in no event shall good faith and possessing an average knowledge of health and medicine, visits the emergency room for what appears to be for more than twenty-four an acute condition that requires immediate medical attention. Ambulance Services Ambulance service (24ground or air) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on coroner’s office or to a mortuary is not Covered, unless the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them Ambulance has been dispatched prior to the actual service pronouncement of death by an individual authorized under state law to make such pronouncements. Autopsies Autopsy costs for Covered Members are not Covered. Before or delivery After the Effective Date of suppliesCoverage Services received, items purchased, prescriptions filled or healthcare expenses incurred before your effective date of Coverage or after the termination of your Coverage are not Covered. Authorization means our decision Clinical Trials Any Clinical Trials provided outside of New Mexico, as well as those that a Health Care Service requested do not meet the requirements indicated in the Benefits Section, are not Covered. Costs of the Clinical Trial that are customarily paid for by your Practitioner/Provider government, biotechnical, pharmaceutical or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is medical device industry sources are not obtained for services by Covered.‌ Services from Out-of-Network network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization unless services from an In- network Practitioner/Provider is not available and are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible required for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when any Out-of-network Services and such services must be provided in New Mexico. The cost of a non-FDA approved Investigational drug, device or procedure is not Covered. The cost of a non- healthcare service that the patient is required to receive as a result of participation in the Clinical Trial is not Covered. Costs associated with managing the research that is associated with the Clinical Trials are not Covered. Costs that would not be Covered if non-Investigational treatments were provided are not Covered. Costs of tests that are necessary for the research of the Clinical Trial are not Covered. Costs paid for or not charged by the Clinical Trial Providers are not Covered. If you are denied coverage of a cost and you contend that the denial is in violation of NMSA 1978 59A-22-43, you may appeal the decision to deny the coverage of a cost to the superintendent, and that appeal shall be expedited to ensure resolution of the appeal within no more than 30 days after the date of appeal to the superintendent. Care for Military Service Connected Disabilities Care for military service connected disabilities to which you are legally entitled and for which facilities are reasonably available to you is not Covered. Certified Hospice Care Benefits Certified Hospice Care Benefits are not Covered for the following services: • Food, housing, and delivered meals are not Covered. • Volunteer services obtained from an Out-of-network are not Covered. • Personal or comfort items such as, but not limited to, aromatherapy, clothing, pillows, special chairs, pet therapy, fans, humidifiers, and special beds (excluding those Covered under Durable Medical Equipment benefits) are not Covered. • Homemaker and housekeeping services are not Covered. • Private duty nursing is not Covered. • Pastoral and spiritual counseling are not Covered.‌‌‌ • Bereavement counseling is not Covered. • The following services are not Covered under Hospice care, but may be Covered Benefits elsewhere in this Agreement subject to the Cost Sharing requirements: o Acute Inpatient Hospital care for curative services – requires Prior Authorization o Durable Medical Equipment o Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network visits by other than a Certified Hospice Practitioner/Provider or o Ambulance Services Charges in cases Excess of an emergency.  Important Information If required medical services Medicare Allowable Unreasonable Charges that we determine to be in excess of Medicare Allowable and charges we determine to be unreasonable based on usual, customary, and reasonable charges are not available from InCovered. Clothing or Other Protective Devices Clothing or other protective devices, including prescribed photo-network Practitioners/Providersprotective clothing, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessarywindshield tinting, we, in consultation with your referring In-network Physician lighting fixtures and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissionsxxxxxxx, and all services other items or devices whether by prescription or not, are not Covered. Clinical Preventive Health Services Physical examinations, vaccinations, drugs and immunizations for the primary intent of medical research or non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance, flight, foreign travel, passports or functional capacity examinations related to employment are not Covered. Immunizations for the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Providerpurpose of foreign travel are not Covered. Complementary Therapies Complementary Therapies, Health Care Facility or other Health Care Professionalexcept those specified in the Complementary Therapies Benefits Section, are not Covered. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-• Acupuncture – Except as specified under Complementary Therapies in the Benefits Section.

Prior Authorization. This Section explains what Covered Health Care Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further information can be obtained through your PCP or or, at our website at xxx.xxx.xxx. If you have questions about a prior authorization submitted by your PCP/Provider please contact us Monday through Friday from 8 a.m. to 5 p.m. at [(000) 000-0000, or 0-000-000-0000]. Hearing impaired users may call the TTY line at 711. Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services sectionSection. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) 24 months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. This does not apply to Benefits mandated by law. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization are may not be Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-In- network Practitioner/Provider or in cases of an emergency.  Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will may not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- of-network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services 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 from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-.

Prior Authorization. This Section explains what Covered Health Care Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further You can obtain further information can be obtained through your PCP or at our website at xxx.xxx.xxx. If you have questions about a prior authorization submitted by your PCP/Provider, please contact us Monday through Friday from 8 a.m. to 5 p.m. at (000) 000-0000, or 0-000-000-0000. Hearing impaired users may call TTY 711. Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Healthcare Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services sectionSection. You may be responsible for the resulting charge except in cases of emergency. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Healthcare Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care healthcare setting. Our Medical Director or other clinical professional will review the requested Health Care Healthcare Service andin consultation with your medical provider, and if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) 24 months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain Benefits for certain services and supplies are Covered subject to Prior Authorization as specified in the Prior Authorization Section. Benefits only may not be payable for services from Out-of-network Practitioners/Providers if we Authorize them prior you fail to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approvedobtain Prior Authorization. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization are may not be Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-In- network Practitioner/Provider or in cases of an emergency.  Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician PCP must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will may not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- of-network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  • Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  • Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services 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 from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-.

Prior Authorization. This Section explains what Covered Health Care Services What Is Prior Authorization? At the request of some Sponsors, certain medications or classes of medications will require additional information to be obtained to determine whether the use or the quantity above-stated plan limits are covered. Prior Authorization before you receive these services and how to obtain is a feature or a program that provides prescription benefit coverage if certain circumstances are met. Claim Message on Prior Authorization. This Authorization The following components on the claim message indicate that a Prior Authorization is needed: A reject code of “70” with message “drug not an exhaustive list. Further covered” or reject code “75” with message “prior authorization required.” After the above claim information can be obtained through your PCP or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospitalhas been received, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer communicate to the Diabetes Services section. Eligible Person the information outlined above in “What is Prior Authorization? ?” Initiating Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically NecessaryAt times, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member telephone number will be responsible for the resulting charges. Services provided beyond the scope of displayed along with the Prior Authorization are not Coveredclaim message. The telephone number displayed may lead to Medco Health’s Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining unit or a Prior Authorization from us before providing unit arranged by the Covered Services, except Sponsor. □ Contact the Prescriber and review the reason for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. If required, the Prescriber can initiate a coverage review by contacting the toll-free number displayed on your screen. The Pharmacist and Patient may also initiate the coverage review process by calling the toll-free number. When requested Medco Health Managed Care will fax the Prescriber a questionnaire. □ If no telephone number is displayed on the claim reply, for a Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency.  Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider will not be Covered unless this Authorization is obtained prior to receiving refer the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested Out-of-network 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 thirty (30) days as needed to ensure continuity of care.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissions, and all services related Eligible Person to the inpatient admission before you receive these services InClaims Submission Protocols toll-network or Out-of-network from any Practitioner/Provider, Health Care Facility or other Health Care Professionalfree number for Member Service for further assistance. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-The Eligible Person’s Member Service number can be found on the prescription benefit card.

Prior Authorization. This Section explains what Covered Health Care Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further information can be obtained through your PCP or at our website at xxx.xxx.xxx. Before you are admitted as an Inpatient to a Hospital, Hospital or Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized or Certified (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization are not Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’sPractitioner/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network When you seek specific Covered services obtained Services from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services (including National PPO Providers), you are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency.  Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request responsible for obtaining Prior Authorization and obtain written Authorization from our Medical Director us before you may receive receiving the Out-of-network servicesServices. Services of an If Prior Authorization (Certification) is not obtained when required, then we may not Cover the services and you may be responsible for the resulting charge. You may have your Out-of-network Practitioner/Provider will contact us on your behalf in order to provide necessary clinical information, but it is not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available Provider’s responsibility to see obtain Prior Authorization. If you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required need to render the service or treatment.  Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk.  Continuity – If the requested obtain Prior Authorization for Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problemServices, you will be allowed please call our Presbyterian Customer Service Center, as soon as possible before services are provided, CSC Call P 505‐923‐6980 1‐800‐923‐6980 onday through Friday from 7:00 a.m. to continue seeing that specialist for a minimum of thirty 6:00 p.m. at (30000) days as needed to ensure continuity of care000-0000 or toll-free at 1-877- 23-6980.  Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonableHearing impaired users may call the TTY line at 711 or toll-free 0-000-000-0000. M Services 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 Network from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In-