Common use of Rehabilitation and Therapy Clause in Contracts

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy therapy, occupational therapy, and occupational speech therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitationsCost-Sharing amounts. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician PCP must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Bariatric Surgery • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Gender Confirmation Surgery • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Healthcare Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Special Inpatient services (including but not limited to private room and board and/or special duty nursing) Special Inpatient services (including but not limited to private room and board and/or special duty nursing) require Prior Authorization. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not Covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung • multi-visceral (3 or more abdominal Organs) • simultaneous multi-Organ transplants – unless investigational • pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization. Wireless Capsule Endoscopy Wireless capsule endoscopy is a noninvasive procedure in which a capsule containing a miniature video camera is swallowed. Capsule endoscopy is used as an adjunctive therapy in patients who have had an esophagogastroduodenoscopy (EGD) or colonoscopy, and these tests have failed to reveal evidence of disease or a source of bleeding. This procedure requires Prior Authorization.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy therapy, occupational therapy, and occupational speech therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitationsCost Sharing amounts. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician PCP must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Bariatric Surgery • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Gender Confirmation Surgery • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Healthcare Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Special Inpatient services (including but not limited to private room and board and/or special duty nursing) Special Inpatient services (including but not limited to private room and board and/or special duty nursing) require Prior Authorization. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe may be extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung • multi-visceral (3 or more abdominal Organs) • simultaneous multi-Organ transplants – unless investigational • pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization. Wireless Capsule Endoscopy Wireless capsule endoscopy is a noninvasive procedure in which a capsule containing a miniature video camera is swallowed. Capsule endoscopy is used as an adjunctive therapy in patients who have had an esophagogastroduodenoscopy (EGD) or colonoscopy, and these tests have failed to reveal evidence of disease or a source of bleeding. This procedure requires Prior Authorization.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy therapy, occupational therapy, and occupational speech therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner PCP or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitationsCost-Sharing amounts. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Healthcare Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy therapy, speech therapy, and occupational therapy, provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Bariatric Surgery • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Gender Confirmation Surgery • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement • Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Healthcare Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine Services PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards. A determination by PHP that services delivered through the use of telemedicine are not covered is subject to review and appeal. Transplants This benefit has one or more exclusions as specified in the Exclusions Section. All Organ transplants must be performed at an approved center and require Prior Authorization. Human Solid Organ transplant benefits are Covered for: • Kidney • Liver • Pancreas • Intestine • Heart • Lung • multi-visceral (3 or more abdominal Organs) • simultaneous multi-Organ transplants – unless investigational • pancreas islet cell infusion • Meniscal Allograft • Autologous Chondrocyte Implantation – knee only • Hematopoietic Transplant Benefits are Covered for: o Bone Marrow Transplant including peripheral blood bone marrow stem cell harvesting and transplantation (stem cell transplant) following high dose chemotherapy. Bone marrow transplants are Covered for the following indications: o multiple myeloma o leukemia o aplastic anemia o lymphoma o severe combined immunodeficiency disease (SCID) o Wiskott Xxxxxxx syndrome x Xxxxx’x Sarcoma o germ cell tumor o neuroblastoma o Wilms Tumor o myelodysplastic Syndrome o myelofibrosis o sickle cell disease o thalassemia major If there is a living donor that requires surgery to make an Organ available for a Covered transplant for our Member, Coverage is available for expenses incurred by the living donor for surgery, laboratory and X-ray services, Organ storage expenses, and Inpatient follow-up care only. We will pay the Total Allowable Charges for a living donor who is not entitled to benefits under any other health benefit plan or policy. Limited travel benefits are available for the transplant recipient, live donor and one other person. Transportation costs will be Covered only if out-of-state travel is required. Reasonable expenses for lodging and meals will be Covered for both out-of-state and instate, up to a maximum of $150 per day for the transplant recipient, live donor and one other person combined. Benefits will only be Covered for transportation, lodging and meals and are limited to a lifetime maximum of $10,000. All Organ transplants must be performed at site that we approve and require Prior Authorization.

Rehabilitation and Therapy. This benefit has one or more exclusions as specified in the Exclusions Section. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitation benefits are available for physical therapy and occupational therapy, speech therapy provided in a Rehabilitation Facility, Skilled Nursing Facility, Home Health Agency, or Outpatient setting. Short-term Rehabilitation is designed to assist you in restoring functions that were lost or diminished due to a specific episode of illness or injury (for example, stroke, motor vehicle accident, or heart attack). Coverage is subject to the following requirements and limitations: • Outpatient physical and occupational therapy require that your Primary Care Practitioner or other appropriate treating Practitioner/Provider must determine in advance that Rehabilitation Services can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitationsCost Sharing amounts. • The treatment plans that define expected Significant Improvement must be established at the initial visit. Therapy treatments must be provided and/or directed by a licensed physical or occupational therapist. • Treatments by a physical or occupational therapy technician must be performed under the direct supervision and in the presence of a licensed physical or occupational therapist. • Massage Therapy is only Covered when provided by a licensed physical therapist and as part of a prescribed Short-term Rehabilitation physical therapy program. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. • Outpatient Speech therapy means language, dysphagia (difficulty swallowing) and hearing therapy. Speech therapy is Covered when provided by a licensed or certified speech therapist. • Your Primary Care Physician must determine, in advance, in consultation with us, that speech therapy can be expected to result in Significant Improvement in your condition. Refer to your Summary of Benefits and Coverage for your visit limitations and Cost Sharing. If your Short Term Rehabilitation therapy is provided in an Inpatient setting (such as, but not limited to, Rehabilitation Facilities, Skilled Nursing Facilities, intensive day-Hospital programs that are delivered by a Rehabilitation Facility) or through Home Health Care Services, the therapy is not subject to the time limitation requirements of the Outpatient therapies outlined in the Summary of Benefits and Coverage. These Inpatient and Home Health therapies are not included with Outpatient services when calculating the total accumulated benefit usage. Selected Surgical/Diagnostic Procedures • Blepharoplasty/Brow Ptosis Surgery • Breast Reconstruction following Mastectomy • Breast reduction for gynecomastia • Cholecystectomy by Laparoscopy • Endoscopy Nasal/Sinus balloon dilation • Hysterectomy • Lumbar/Cervical Spine Surgery • Meniscus Implant and Allograft/Meniscus Transplant • Panniculectomy • Rhinoplasty • Tonsillectomy • Total Ankle Replacement • Total Hip Replacement • Total Knee Replacement Skilled Nursing Facility Care This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at an In-network Practitioner’s/Provider’s office is Covered under the medical benefit. The Primary Care Practitioner or the In-network specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at an In-network Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Telemedicine PHP provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PHP will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.