Common use of Expedited Review Clause in Contracts

Expedited Review. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB) of the Office of Superintendent of Insurance at: Telephone: 0-000-000-0000 Office of Superintendent of Insurance-MHCB X.X. Xxx 1689, 0000 Xxxxx xx Xxxxxxx Xxxxx Fe, NM 87504-1689 E-mail: xxxx.xxxxxxxxx@xxxxx.xx.xx This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These items replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Welcome 13 Welcome to Presbyterian Health Plan! 13 Our Agreement with You 13 Understanding This Agreement 14 Customer Assistance 15 Member Rights and Responsibilities 17 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 17 Additional Member Rights and Responsibilities 18 Consumer Advisory Board 20 How the Plan Works 21 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 22 Obtaining Healthcare 22 How to Obtain a PCP 22 Women’s Healthcare Provider/Practitioner 22 Specialist Care 23 Obtaining Care after Normal Provider Office Hours 23 In-Network Practitioners/Providers 23 Out-of-Network Practitioners/Providers 24 Restrictions on Services Received Outside of the PHP Service Area 26 Out-Of-Network Care And Bills 26 If you pay an Out-of-network Provider more than we determine you owe: 27 Restrictions on Services Received Outside of the PHP Service Area 27 National Health Care Practitioner/Provider Network 28 Cost sharing – Your Out-of-Pocket Costs 28 Annual Contract Year Deductible 28 Coinsurance 29 Annual Out-of-Pocket Maximum 29 Office Visit Copayment 30 Utilization Management and Quality 30 Technology Assessment Committee 30 Transition of Care 31 Advance Directives 31 Prior Authorization 32 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 32 Prior Authorization Is Required 32 Prior Authorization when In-Network 33 Prior Authorization when Out-of-Network 33 Services That Require Prior Authorization In or Out-of-Network 34 Authorizing Inpatient Hospital Admission following an Emergency 36 Prescription drug Prior Authorization protocols 36 Prior Authorization and Your Coverage 36 Prior Authorization Decisions – Non-Emergency 36 Prior Authorization Decision – Expedited (Accelerated) 37 Prior Authorization Review – Initial Adverse Determination 37 Prior Authorization 37 Benefits 40 This Health Care Benefit Plan offers Coverage for a wide range of Healthcare Service. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 40 Medical Necessity 40 Care Coordination and Case Management 41 PresRN 41 Health Management Programs 41 Covered Benefits 43 Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 43 Ambulance Services 45 Bariatric Surgery 47 Clinical Trials 47 Certified Hospice Care 49 Clinical Preventive Health Services 50 Complementary Therapies 54 COVID-19 55 Dental Services (Limited) 55 Diabetes Services 57 Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) 58 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 59 Electroconvulsive Therapy (ECT) 61 Employee Assistance Program 61 Family, Infant and Toddler (FIT) Program 62 Genetic Inborn Errors of Metabolism Disorders (IEM) 62 Genetic/Genomic Testing 63 Habilitative Services 63 Heart Artery Calcification Scan 64 Home Health Care Services/Home Intravenous Services and Supplies 64 Hospital Services – Inpatient 65 Hyperbaric Oxygen Therapy 65 Infertility 66 Mental Health Services and Alcohol and Substance Use Disorder Services 66 No Cost Sharing For Behavioral Health Services 66 Nutritional Support and Supplements 67 Orthotics 68 Outpatient Medical Services 68 Positron Emissions Tomography (PET) Scans in an Outpatient Setting 69 Practitioner/Provider Services 69 Prescription Drugs/Medications 70 Benefit Limitations 79 Proton Beam Irradiation 81 Reconstructive Surgery 82 Rehabilitation and Therapy 82 Selected Surgical/Diagnostic Procedures 83 Skilled Nursing Facility Care 84 Smoking Cessation Counseling/Program 84 Telemedicine 85 Transplants 85 Women’s Healthcare 86 General Limitations 90 This Section explains the general limitations that apply to your Covered Benefits and other Sections of this Agreement Benefit Limitations 90 Major Disasters 90 Prior Authorization 90 Exclusions 91 This Section lists services that are not Covered for certain Benefits in your Health Benefits 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. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 91 Ambulance Services 91 Autopsies 91 Before or After the Effective Date of Coverage 91 Clinical Trials 91 Care for Military Service Connected Disabilities 92 Certified Hospice Care Benefits 92 Charges in Excess of Medicare Allowable Unreasonable 93 Clothing or Other Protective Devices 93 Clinical Preventive Health Services 93 Complementary Therapies 93 Cosmetic Surgery 93 Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications ...........................................................................................................................94 Costs for Extended Warranties and Premiums for Other Insurance Coverage 94 Dental Services 94 Diabetes Services 94 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 94 Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices 96 Extracorporeal Shock Wave Therapy 97 Foot Care 97 Genetic Testing 97 Genetic Inborn Errors of Metabolism Coverage 98 Hair-loss (or baldness) 98 Home Health Care Services/Home Intravenous Services and Supplies 98 Hospital Services 98 Mental Health and Alcohol and Substance Use Disorder 98 Nutritional Support and Supplements 99 Out-of-State Surcharges 99 Palliative Care 99 Practitioner/Provider Services 99 Prescription Drugs/Medications 100 Radiation 101 Reconstructive Surgery for Cosmetic Purposes 101 Rehabilitation and Therapy 101 Services for Which You or Your Dependent are Eligible under Any Governmental Program 102 Services Requiring Prior Authorization When Out-of-network 102 Sexual Dysfunction Treatment 102 Skilled Nursing Facility Care 102 Smoking Cessation Services 103 Thermography 103 Transplant Services 103 Treatment While Incarcerated 103 War 103 Women’s Healthcare 103 Work-related Illnesses or Injuries 104 Claims 105 Your Healthcare Benefits are paid according to the conditions outlined in the Section. If you paid Practitioners/Providers for services, this Section also outlines the process you should follow if you need to be reimbursed. Notice of Claim 105 Claim Forms 105 In-Network Practitioners/Providers 105 Out-of-Network Practitioners/Providers 106 Procedure for Reimbursement 106 Services Received Outside the United States 107 Claim Fraud 107 Effects of Other Coverage 108 This Section explains how we will coordinate benefits hsould you have medical coverage through another group Health Benefits Plan. Coordination of Benefits 108 Medicare 110 Medicaid 110 Subrogation (Recovering Healthcare Expenses from Others) 110 Summary of Health Insurance Grievance Procedures 112 This Section explains how to file a Complaint, Grievance and Appeal. What types of decisions can be reviewed? 112 Review of an Adverse Determination 112 Review of an Administrative Decision 118 General Information 119 Records 121 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 121 Accuracy of Information 121 Consent for Use and Disclosure of Medical Records 121 Professional Review 121 Confidentiality of Protected Health Information/Medical Records 122 Eligibility, Enrollment, Effective Dates, Termination and Continuation 128 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. How You Can Enroll as a Member 128 Residence of a Dependent Child 130 Enrollment and Effective Dates 131 Full, Accurate and Complete Information 138 Change in Address, Family Status and Employment 139 Termination of Coverage 139 Continuation of Coverage of Your Group Plan 142 Discontinuance of Your Plan 145 General Provisions 150 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments (Group) 150 Assignment 150 Entire Contract 150 Execution of Contract - Application for Coverage 150 Federal and State Healthcare Reform 150 Fraud 151 Practitioner/Provider Activity 151 Member Activity 151 Governing Law 152 Identification Cards 152 Legal Actions 152 Misrepresentation of Information 152 Misstatements 152 Notice 153 Policies and Procedures 153 Reinstatements 153 Right to Examine 153 Waiver by Agents 153 Workers' Compensation Insurance 153 Glossary of Terms 155 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Statement of ERISA Rights 177 Welcome‌‌ Welcome to Presbyterian Health Plan! Welcome and thank you for joining Presbyterian Health Plan. We are a Healthcare Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico healthcare system. When we use the words “Presbyterian Health Plan”, “PHP”, “we”, “us”, and “our” in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your,” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community services to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your healthcare Practitioners and Providers to provide a quality, affordable healthcare plan. Our Agreement with You This is your Group Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Healthcare Benefits and plan features that you and your eligible Dependents may receive when you enroll. This policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurance company and unless such approval and countersignature be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Information you will find in this Agreement includes: • Your rights and responsibilities as a Member • Covered Benefits available through this Plan • How to access services from physicians, Practitioners, Providers, and Pharmacies • Services that require Prior Authorization • Limitations and Exclusions for certain Covered Benefits • Coverage for your Dependents who are outside of New Mexico • A Glossary of Terms used in this Agreement • What to do when you need assistance

Expedited Review. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB) of the Office of Superintendent of Insurance at: Telephone: 0-000-000-0000 Office of Superintendent of Insurance-MHCB X.X. Xxx 1689, 0000 Xxxxx xx Xxxxxxx Xxxxx Fe, NM 87504-1689 E-mail: xxxx.xxxxxxxxx@xxxxx.xx.xx This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These items replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Welcome 13 Welcome to Presbyterian Health Plan! 13 Our Agreement with You 13 Understanding This Agreement 14 Customer Assistance 15 Member Rights and Responsibilities 17 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 17 Additional Member Rights and Responsibilities 18 Consumer Advisory Board 20 How the Plan Works 21 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 22 Obtaining Healthcare 22 How to Obtain a PCP 22 Women’s Healthcare Provider/Practitioner 22 Specialist Care 23 Obtaining Care after Normal Provider Office Hours 23 In-Network Practitioners/Providers 23 Out-of-Network network Practitioners/Providers 24 Restrictions on Services Received Outside of the PHP Service Area 26 Out-Of-Network Care And Bills 26 If you pay an Out-of-network Provider more than we determine you owe: 27 Restrictions on Services Received Outside of the PHP Service Area 27 National Health Care Practitioner/Provider Network 28 27 Cost sharing Sharing – Your Out-of-Pocket Costs 28 Annual Contract Year Deductible 28 Coinsurance 29 Annual Out-of-Pocket pocket Maximum 29 Office Visit Copayment 30 29 Utilization Management and Quality 30 Technology Assessment Committee 30 Transition of Care 31 30 Advance Directives 31 Prior Authorization 32 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 32 Prior Authorization Is Required 32 Prior Authorization when In-Network 33 Prior Authorization when Out-of-Network 33 Services That Require Prior Authorization In or Out-of-Network 34 Authorizing Inpatient Hospital Admission following an Emergency 36 Prescription drug Prior Authorization protocols 36 Prior Authorization and Your Coverage 36 Prior Authorization Decisions – Non-Emergency 36 Prior Authorization Decision – Expedited (Accelerated) 37 Prior Authorization Review – Initial Adverse Determination 37 Prior Authorization 37 Benefits 40 This Health Care Benefit Plan offers Coverage for a wide range of Healthcare Service. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 40 Medical Necessity 40 Care Coordination and Case Management 41 PresRN 41 Health Management Programs 41 Covered Benefits 43 Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 43 Ambulance Services 45 Bariatric Surgery 47 Clinical Trials 47 Certified Hospice Care 49 Clinical Preventive Health Services 50 Complementary Therapies 54 COVID-19 55 Dental Services (Limited) 55 Diabetes Services 57 56 Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) 58 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 59 Electroconvulsive Therapy (ECT) 61 Employee Assistance Program 61 Family, Infant and Toddler (FIT) Program 62 61 Genetic Inborn Errors of Metabolism Disorders (IEM) 62 Genetic/Genomic Testing 63 62 Habilitative Services 63 Heart Artery Calcification Scan 64 63 Home Health Care Services/Home Intravenous Services and Supplies 64 Hospital Services – Inpatient 65 Hyperbaric Oxygen Therapy 65 Infertility 66 65 Mental Health Services and Alcohol and Substance Use Disorder Services 66 No Cost Sharing For Behavioral Health Services 66 Nutritional Support and Supplements 67 Orthotics 68 Outpatient Medical Services 68 Positron Emissions Tomography (PET) Scans in an Outpatient Setting 69 Practitioner/Provider Services 69 Prescription Drugs/Medications 70 Benefit Limitations 79 Proton Beam Irradiation 81 82 Reconstructive Surgery 82 Rehabilitation and Therapy 82 Selected Surgical/Diagnostic Procedures 83 Skilled Nursing Facility Care 84 Smoking Cessation Counseling/Program 84 Telemedicine 85 Transplants 85 Women’s Healthcare 86 87 General Limitations 90 91 This Section explains the general limitations that apply to your Covered Benefits and other Sections of this Agreement Agreement. Benefit Limitations 90 91 Major Disasters 90 91 Prior Authorization 90 91 Exclusions 91 92 This Section lists services that are not Covered for certain Benefits in your Health Benefits 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. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 91 92 Ambulance Services 91 92 Autopsies 91 92 Before or After the Effective Date of Coverage 91 92 Clinical Trials 91 92 Care for Military Service Connected Disabilities 92 93 Certified Hospice Care Benefits 92 93 Charges in Excess of Medicare Allowable Unreasonable 93 94 Clothing or Other Protective Devices 93 94 Clinical Preventive Health Services 93 Trials 94 Complementary Therapies 93 95 Cosmetic Surgery 93 95 Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications ...........................................................................................................................94 96 Costs for Extended Warranties and Premiums for Other Insurance Coverage 94 96 Dental Services 94 96 Diabetes Services 94 96 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 94 96 Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices 96 98 Extracorporeal Shock Wave Therapy 97 Foot Care 97 99 Genetic Testing 97 99 Genetic Inborn Errors of Metabolism Coverage 98 99 Hair-loss (or baldness) 98 99 Home Health Care Services/Home Intravenous Services and Supplies 98 99 Hospital Services 98 100 Mental Health and Alcohol and Substance Use Disorder 98 100 Nutritional Support and Supplements 99 100 Out-of-State Surcharges 99 100 Palliative Care 99 100 Practitioner/Provider Services 99 101 Prescription Drugs/Medications 100 101 Radiation 101 102 Reconstructive Surgery for Cosmetic Purposes 101 103 Rehabilitation and Therapy 101 103 Services for Which You or Your Dependent are Eligible under Any Governmental Program 102 104 Services Requiring Prior Authorization When Out-of-network 102 104 Sexual Dysfunction Treatment 102 104 Skilled Nursing Facility Care 102 104 Smoking Cessation Services 103 104 Thermography 103 104 Transplant Services 103 104 Treatment While Incarcerated 103 105 War 103 105 Women’s Healthcare 103 105 Work-related Illnesses or Injuries 104 105 Claims 105 106 Your Healthcare Benefits are paid according to the conditions outlined in the Section. If you paid Practitioners/Providers for services, this Section also outlines the process you should follow if you need to be reimbursed. Notice of Claim 105 106 Claim Forms 105 106 In-Network network Practitioners/Providers 105 106 Out-of-Network network Practitioners/Providers 106 107 Procedure for Reimbursement 106 107 Services Received Outside the United States 107 108 Claim Fraud 107 108 Effects of Other Coverage 108 109 This Section explains how we will coordinate benefits hsould you have medical coverage through another group Health Benefits Plan. Coordination of Benefits 108 109 Medicare 110 111 Medicaid 110 111 Subrogation (Recovering Healthcare Expenses from Others) 110 111 Summary of Health Insurance Grievance Procedures 112 113 This Section explains how to file a Complaint, Grievance and Appeal. What types of decisions can be reviewed? 112 113 Review of an Adverse Determination 112 113 Review of an Administrative Decision 118 119 General Information 119 120 Records 121 122 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 121 122 Accuracy of Information 121 122 Consent for Use and Disclosure of Medical Records 121 122 Professional Review 121 122 Confidentiality of Protected Health Information/Medical Records 122 123 Eligibility, Enrollment, Effective Dates, Termination and Continuation 128 129 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. How You Can Enroll as a Member 128 129 Residence of a Dependent Child 130 131 Enrollment and Effective Dates 131 132 Full, Accurate and Complete Information 138 139 Change in Address, Family Status and Employment 139 Termination of Coverage 139 Continuation of Coverage of Your Group Plan 142 Discontinuance of Your Plan 145 General Provisions 150 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments (Group) 150 Assignment 150 Entire Contract 150 Execution of Contract - Application for Coverage 150 Federal and State Healthcare Reform 150 Fraud 151 Practitioner/Provider Activity 151 Member Activity 151 Governing Law 152 Identification Cards 152 Legal Actions 152 Misrepresentation of Information 152 Misstatements 152 Notice 153 Policies and Procedures 153 Reinstatements 153 Right to Examine 153 Waiver by Agents 153 Workers' Compensation Insurance 153 Glossary of Terms 155 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Statement of ERISA Rights 177 Welcome‌‌ Welcome‌‌‌ Welcome to Presbyterian Health Plan! Welcome and thank you for joining Presbyterian Health Plan. We are a Healthcare Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico healthcare system. When we use the words “Presbyterian Health Plan”, “PHP”, “we”, “us”, and “our” in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your,” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community services to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your healthcare Practitioners and Providers to provide a quality, affordable healthcare plan. Our Agreement with You This is your Group Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Healthcare Benefits and plan features that you and your eligible Dependents may receive when you enroll. This policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurance company and unless such approval and countersignature be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Information you will find in this Agreement includes: • Your rights and responsibilities as a Member • Covered Benefits available through this Plan • How to access services from physicians, Practitioners, Providers, and Pharmacies • Services that require Prior Authorization • Limitations and Exclusions for certain Covered Benefits • Coverage for your Dependents who are outside of New Mexico • A Glossary of Terms used in this Agreement • What to do when you need assistance

Expedited Review. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB) of the Office of Superintendent of Insurance at: Telephone: 0-000-000-0000 Office of Superintendent of Insurance-MHCB X.X. Xxx P.O. Box 1689, 0000 Xxxxx xx Xxxxxxx Xxxxx Fe, NM 87504-1689 E-mail: xxxx.xxxxxxxxx@xxxxx.xx.xx This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These items replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Welcome 13 Welcome to Presbyterian Health Plan! 13 Our Agreement with You 13 Understanding This Agreement 14 Customer Assistance 15 Member Rights and Responsibilities 17 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 17 Additional Member Rights and Responsibilities 18 Consumer Advisory Board 20 How the Plan Works 21 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 22 Obtaining Healthcare 22 How to Obtain a PCP 22 Women’s Healthcare Provider/Practitioner 22 23 Specialist Care 23 Obtaining Care after Normal Provider Office Hours 23 24 In-Network Practitioners/Providers 23 24 Out-of-Network Practitioners/Providers 24 Restrictions on Services Received Outside of the PHP Service Area 26 25 Out-Of-Network Care And Bills 26 If you pay an Out-of-network Provider more than we determine you owe: 27 Restrictions on Services Received Outside of the PHP Service Area 27 28 National PPO Providers 28 Restrictions on Services Received Outside of the PHP Service Area 29 National Health Care Practitioner/Provider Network 28 29 Cost sharing Sharing – Your Out-of-Pocket Costs 28 29 Annual Contract Year Deductible 28 30 Coinsurance 29 30 Annual Out-of-Pocket Maximum 29 30 Office Visit Copayment 30 31 Utilization Management and Quality 30 31 Technology Assessment Committee 30 32 Transition of Care 31 32 Advance Directives 31 32 Prior Authorization 32 33 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 32 33 Prior Authorization Is Required 32 33 Prior Authorization when In-Network 33 34 Prior Authorization when Out-of-Network 33 34 Services That Require Prior Authorization In In- or Out-of-Network 34 35 Authorizing Inpatient Hospital Admission following an Emergency 36 37 Prescription drug Prior Authorization protocols 36 37 Prior Authorization and Your Coverage 36 37 Prior Authorization Decisions – Non-Emergency 36 37 Prior Authorization Decision – Expedited (Accelerated) 37 38 Prior Authorization Review – Initial Adverse Determination 37 38 Prior Authorization 37 38 Benefits 40 41 This Health Care Benefit Plan offers Coverage for a wide range of Healthcare Service. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 40 41 Medical Necessity 40 41 Care Coordination and Case Management 41 42 PresRN 41 42 Health Management Programs 41 42 Covered Benefits 43 44 Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 43 44 Ambulance Services 45 46 Bariatric Surgery 47 48 Clinical Trials 47 48 Certified Hospice Care 49 50 Clinical Preventive Health Services 50 51 Complementary Therapies 54 55 COVID-19 55 56 Dental Services (Limited) 55 56 Diabetes Services 57 Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) 58 59 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 59 60 Electroconvulsive Therapy (ECT) 61 62 Employee Assistance Program 61 62 Family, Infant and Toddler (FIT) Program 62 63 Genetic Inborn Errors of Metabolism Disorders (IEM) 62 63 Genetic/Genomic Testing 63 64 Habilitative Services 63 64 Heart Artery Calcification Scan 64 Home Health Care Services/Home Intravenous Services and Supplies 64 65 Hospital Services – Inpatient 65 66 Hyperbaric Oxygen Therapy 65 66 Infertility 66 67 Mental Health Services and Alcohol and Substance Use Disorder Services 66 No Cost Sharing For Behavioral Health Services 66 67 Nutritional Support and Supplements 67 68 Orthotics 68 69 Outpatient Medical Services 68 69 Positron Emissions Emission Tomography (PET) Scans in an Outpatient Setting 69 70 Practitioner/Provider Services 69 70 Prescription Drugs/Medications 70 Benefit Limitations 79 71 Covered Prescription Drugs/Medications 72 Proton Beam Irradiation 81 82 Reconstructive Surgery 82 Rehabilitation and Therapy 82 83 Selected Surgical/Diagnostic Procedures 83 84 Skilled Nursing Facility Care 84 Smoking Cessation Counseling/Program 84 85 Telemedicine 85 Services 86 Transplants 85 86 Women’s Healthcare 86 87 General Limitations 90 91 This Section explains the general limitations that apply to your Covered Benefits and other Sections of this Agreement Agreement. Benefit Limitations 90 91 Major Disasters 90 91 Prior Authorization 90 91 Exclusions 91 92 This Section lists services that are not Covered for certain Benefits in your Health Benefits 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. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 91 92 Ambulance Services 91 92 Autopsies 91 92 Before or After the Effective Date of Coverage 91 92 Clinical Trials 91 92 Care for Military Service Connected Disabilities 92 93 Certified Hospice Care Benefits 92 93 Charges in Excess of Medicare Allowable Unreasonable 93 94 Clothing or Other Protective Devices 93 94 Clinical Preventive Health Services 93 94 Complementary Therapies 93 94 Cosmetic Surgery 93 94 Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications ...........................................................................................................................94 95 Costs for Extended Warranties and Premiums for Other Insurance Coverage 94 95 Dental Services 94 95 Diabetes Services 94 95 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 94 96 Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices 96 97 Extracorporeal Shock Wave Therapy 97 98 Foot Care 97 98 Genetic Testing 97 98 Genetic Inborn Errors of Metabolism Coverage 98 99 Hair-loss (or baldness) 98 99 Home Health Care Services/Home Intravenous Services and Supplies 98 99 Hospital Services 98 99 Mental Health and Alcohol and Substance Use Disorder 98 99 Nutritional Support and Supplements 99 100 Out-of-State Surcharges 99 100 Palliative Care 99 100 Practitioner/Provider Services 99 100 Prescription Drugs/Medications 100 101 Radiation 101 102 Reconstructive Surgery for Cosmetic Purposes 101 102 Rehabilitation and Therapy 101 102 Services for Which You or Your Dependent are Eligible under Any Governmental Program 102 103 Services Requiring Prior Authorization When Out-of-network 102 103 Sexual Dysfunction Treatment 102 103 Skilled Nursing Facility Care 102 103 Smoking Cessation Services 103 104 Thermography 103 104 Transplant Services 103 104 Treatment While Incarcerated 103 104 War 103 104 Women’s Healthcare 103 104 Work-related Illnesses or Injuries 104 105 Claims 105 106 Your Healthcare Benefits are paid according to the conditions outlined in the Section. If you paid Practitioners/Providers for services, this Section also outlines the process you should follow if you need to be reimbursed. Notice of Claim 105 106 Claim Forms 105 106 In-Network Practitioners/Providers 105 106 Out-of-Network Practitioners/Providers 106 107 Procedure for Reimbursement 106 107 Services Received Outside the United States 107 108 Claim Fraud 107 108 Effects of Other Coverage 108 109 This Section explains how we will coordinate benefits hsould you have medical coverage through another group Health Benefits Plan. Coordination of Benefits 108 109 Medicare 110 111 Medicaid 110 111 Subrogation (Recovering Healthcare Expenses from Others) 110 111 Summary of Health Insurance Grievance Procedures 112 113 This Section explains how to file a Complaint, Grievance and Appeal. What types of decisions can be reviewed? 112 113 Review of an Adverse Determination 112 113 Review of an Administrative Decision 118 119 General Information 119 120 Records 121 122 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 121 122 Accuracy of Information 121 122 Consent for Use and Disclosure of Medical Records 121 122 Professional Review 121 122 Confidentiality of Protected Health Information/Medical Records 122 123 Eligibility, Enrollment, Effective Dates, Termination and Continuation 128 Your medical records are important documents needed in order to administer your Health Benefits Plan. This 129 The Section explains how we ensure the confidentiality eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of these records Coverage and how these records are used to administer your plancontinuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 128 129 Residence of a Dependent Child 130 131 Enrollment and Effective Dates 131 132 Full, Accurate and Complete Information 138 139 Change in Address, Family Status and Employment 139 Termination of Coverage 139 140 Continuation of Coverage of Your Group Plan 142 143 Discontinuance of Your Plan 145 146 General Provisions 150 151 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments (Group) 150 151 Assignment 150 151 Entire Contract 150 151 Execution of Contract - Application for Coverage 150 151 Federal and State Healthcare Reform 150 151 Fraud 151 152 Practitioner/Provider Activity 151 152 Member Activity 151 152 Governing Law 152 153 HSA Note: Health Savings Account Information 153 Identification Cards 152 153 Legal Actions 152 153 Misrepresentation of Information 152 153 Misstatements 152 154 Notice 153 154 Policies and Procedures 153 154 Reinstatements 153 154 Right to Examine 153 154 Waiver by Agents 153 154 Workers' Compensation Insurance 153 155 Glossary of Terms 155 156 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Statement of ERISA Rights 177 Welcome‌‌ 178 Welcome Welcome to Presbyterian Health Plan! Welcome and thank you for joining Presbyterian Health Plan. We are a Healthcare Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico healthcare system. When we use the words “Presbyterian Health Plan”, “PHP”, “we”, “us”, and “our” in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your,” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community services to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your healthcare Practitioners and Providers to provide a quality, affordable healthcare plan. Our Agreement with You This is your Group Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Healthcare Benefits and plan features that you and your eligible Dependents may receive when you enroll. This policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurance company and unless such approval and countersignature be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Information you will find in this Agreement includes: • · Your rights and responsibilities as a Member • · Covered Benefits available through this Plan • · How to access services from physicians, Practitioners, Providers, and Pharmacies • · Services that require Prior Authorization • · Limitations and Exclusions for certain Covered Benefits • · Coverage for your Dependents who are outside of New Mexico • · A Glossary of Terms used in this Agreement • · What to do when you need assistance

Expedited Review. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB) of the Office of Superintendent of Insurance at: Telephone: 0-000-000-0000 Office of Superintendent of Insurance-MHCB X.X. Xxx P.O. Box 1689, 0000 Xxxxx xx Xxxxxxx Xxxxx Fe, NM 87504-1689 E-mail: xxxx.xxxxxxxxx@xxxxx.xx.xx This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These items replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Welcome 13 Welcome to Presbyterian Health Plan! 13 Our Agreement with You 13 Understanding This Agreement 14 Customer Assistance 15 Member Rights and Responsibilities 17 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 17 Additional Member Rights and Responsibilities 18 Consumer Advisory Board 20 How the Plan Works 21 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 22 Obtaining Healthcare 22 How to Obtain a PCP 22 Women’s Healthcare Provider/Practitioner 22 23 Specialist Care 23 Obtaining Care after Normal Provider Office Hours 23 24 In-Network Practitioners/Providers 23 24 Out-of-Network Practitioners/Providers 24 Restrictions on Services Received Outside of the PHP Service Area 26 25 Out-Of-Network Care And Bills 26 If you pay an Out-of-network Provider more than we determine you owe: 27 Restrictions on Services Received Outside of the PHP Service Xxxx 00 National PPO Providers 28 Restrictions on Services Received Outside of the PHP Service Area 27 28 National Health Care Practitioner/Provider Network 28 29 Cost sharing Sharing – Your Out-of-Pocket Costs 28 29 Annual Contract Year Deductible 28 29 Coinsurance 29 30 Annual Out-of-Pocket Maximum 29 30 Office Visit Copayment 30 31 Utilization Management and Quality 30 31 Technology Assessment Committee 30 31 Transition of Care 31 32 Advance Directives 31 32 Prior Authorization 32 33 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 32 33 Prior Authorization Is Required 32 33 Prior Authorization when In-Network 33 34 Prior Authorization when Out-of-Network 33 34 Services That Require Prior Authorization In In- or Out-of-Network 34 35 Authorizing Inpatient Hospital Admission following an Emergency 36 37 Prescription drug Prior Authorization protocols 36 37 Prior Authorization and Your Coverage 36 37 Prior Authorization Decisions – Non-Emergency 36 37 Prior Authorization Decision – Expedited (Accelerated) 37 38 Prior Authorization Review – Initial Adverse Determination 37 38 Prior Authorization 37 38 Benefits 40 41 This Health Care Benefit Plan offers Coverage for a wide range of Healthcare Service. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 40 41 Medical Necessity 40 41 Care Coordination and Case Management 41 42 PresRN 41 42 Health Management Programs 41 42 Covered Benefits 43 44 Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 43 44 Ambulance Services 45 46 Bariatric Surgery 47 48 Clinical Trials 47 48 Certified Hospice Care 49 50 Clinical Preventive Health Services 50 51 Complementary Therapies 54 COVID-19 55 Dental Services (Limited) 55 56 Diabetes Services 57 Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) 58 59 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 59 60 Electroconvulsive Therapy (ECT) 61 62 Employee Assistance Program 61 62 Family, Infant and Toddler (FIT) Program 62 Genetic Inborn Errors of Metabolism Disorders (IEM) 62 63 Genetic/Genomic Testing 63 Habilitative Services 63 64 Heart Artery Calcification Scan 64 Home Health Care Services/Home Intravenous Services and Supplies 64 65 Hospital Services – Inpatient 65 66 Hyperbaric Oxygen Therapy 65 66 Infertility 66 Mental Health Services and Alcohol and Substance Use Disorder Services 66 No Cost Sharing For Behavioral Health Services 66 67 Nutritional Support and Supplements 67 68 Orthotics 68 Outpatient Medical Services 68 69 Positron Emissions Emission Tomography (PET) Scans in an Outpatient Setting 69 70 Practitioner/Provider Services 69 70 Prescription Drugs/Medications 70 Benefit Limitations 79 71 Covered Prescription Drugs/Medications 71 Proton Beam Irradiation 81 82 Reconstructive Surgery 82 Rehabilitation and Therapy 82 Selected Surgical/Diagnostic Procedures 83 Skilled Nursing Facility Care 84 Smoking Cessation Counseling/Program 84 Telemedicine Services 85 Transplants 85 Women’s Healthcare 86 87 General Limitations 90 91 This Section explains the general limitations that apply to your Covered Benefits and other Sections of this Agreement Agreement. Benefit Limitations 90 91 Major Disasters 90 91 Prior Authorization 90 91 Exclusions 91 92 This Section lists services that are not Covered for certain Benefits in your Health Benefits 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. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 91 92 Ambulance Services 91 92 Autopsies 91 92 Before or After the Effective Date of Coverage 91 92 Clinical Trials 91 92 Care for Military Service Connected Disabilities 92 93 Certified Hospice Care Benefits 92 93 Charges in Excess of Medicare Allowable Unreasonable 93 94 Clothing or Other Protective Devices 93 94 Clinical Preventive Health Services 93 94 Complementary Therapies 93 94 Cosmetic Surgery 93 94 Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications ...........................................................................................................................94 95 Costs for Extended Warranties and Premiums for Other Insurance Coverage 94 95 Dental Services 94 95 Diabetes Services 94 95 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 94 96 Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices 96 97 Extracorporeal Shock Wave Therapy 97 98 Foot Care 97 98 Genetic Testing 97 98 Genetic Inborn Errors of Metabolism Coverage 98 99 Hair-loss (or baldness) 98 99 Home Health Care Services/Home Intravenous Services and Supplies 98 99 Hospital Services 98 99 Mental Health and Alcohol and Substance Use Disorder 98 99 Nutritional Support and Supplements 99 100 Out-of-State Surcharges 99 100 Palliative Care 99 100 Practitioner/Provider Services 99 100 Prescription Drugs/Medications 100 101 Radiation 101 102 Reconstructive Surgery for Cosmetic Purposes 101 102 Rehabilitation and Therapy 101 102 Services for Which You or Your Dependent are Eligible under Any Governmental Program 102 103 Services Requiring Prior Authorization When Out-of-network 102 103 Sexual Dysfunction Treatment 102 103 Skilled Nursing Facility Care 102 103 Smoking Cessation Services 103 104 Thermography 103 104 Transplant Services 103 104 Treatment While Incarcerated 103 104 War 103 104 Women’s Healthcare 103 104 Work-related Illnesses or Injuries 104 105 Claims 105 106 Your Healthcare Benefits are paid according to the conditions outlined in the Section. If you paid Practitioners/Providers for services, this Section also outlines the process you should follow if you need to be reimbursed. Notice of Claim 105 106 Claim Forms 105 106 In-Network Practitioners/Providers 105 106 Out-of-Network Practitioners/Providers 106 107 Procedure for Reimbursement 106 107 Services Received Outside the United States 107 108 Claim Fraud 107 108 Effects of Other Coverage 108 109 This Section explains how we will coordinate benefits hsould you have medical coverage through another group Health Benefits Plan. Coordination of Benefits 108 109 Medicare 110 111 Medicaid 110 111 Subrogation (Recovering Healthcare Expenses from Others) 110 111 Summary of Health Insurance Grievance Procedures 112 113 This Section explains how to file a Complaint, Grievance and Appeal. What types of decisions can be reviewed? 112 113 Review of an Adverse Determination 112 113 Review of an Administrative Decision 118 119 General Information 119 120 Records 121 122 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 121 122 Accuracy of Information 121 122 Consent for Use and Disclosure of Medical Records 121 122 Professional Review 121 122 Confidentiality of Protected Health Information/Medical Records 122 123 Eligibility, Enrollment, Effective Dates, Termination and Continuation 128 Your medical records are important documents needed in order to administer your Health Benefits Plan. This 129 The Section explains how we ensure the confidentiality eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of these records Coverage and how these records are used to administer your plancontinuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 128 129 Residence of a Dependent Child 130 131 Enrollment and Effective Dates 131 132 Full, Accurate and Complete Information 138 140 Change in Address, Family Status and Employment 139 140 Termination of Coverage 139 140 Continuation of Coverage of Your Group Plan 142 143 Discontinuance of Your Plan 145 146 General Provisions 150 151 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments (Group) 150 151 Assignment 150 151 Entire Contract 150 151 Execution of Contract - Application for Coverage 150 151 Federal and State Healthcare Health Care Reform 150 151 Fraud 151 152 Practitioner/Provider Activity 151 152 Member Activity 151 152 Governing Law 152 153 HSA Note: Health Savings Account Information 153 Identification Cards 152 153 Legal Actions 152 153 Misrepresentation of Information 152 153 Misstatements 152 154 Notice 153 154 Policies and Procedures 153 154 Reinstatements 153 154 Right to Examine 153 154 Waiver by Agents 153 154 Workers' Compensation Insurance 153 155 Glossary of Terms 155 156 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Statement of ERISA Rights 177 Welcome‌‌ 178 Welcome Welcome to Presbyterian Health Plan! Welcome and thank you for joining Presbyterian Health Plan. We are a Healthcare Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico healthcare system. When we use the words “Presbyterian Health Plan”, “PHP”, “we”, “us”, and “our” in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your,” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community services to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your healthcare Practitioners and Providers to provide a quality, affordable healthcare plan. Our Agreement with You This is your Group Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Healthcare Benefits and plan features that you and your eligible Dependents may receive when you enroll. This policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurance company and unless such approval and countersignature be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Information you will find in this Agreement includes: • · Your rights and responsibilities as a Member • · Covered Benefits available through this Plan • · How to access services from physicians, Practitioners, Providers, and Pharmacies • · Services that require Prior Authorization • · Limitations and Exclusions for certain Covered Benefits • · Coverage for your Dependents who are outside of New Mexico • · A Glossary of Terms used in this Agreement • · What to do when you need assistance

Expedited Review. If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB) of the Office of Superintendent of Insurance at: Telephone: 0-000-000-0000 Office of Superintendent of Insurance-MHCB X.X. Xxx P.O. Box 1689, 0000 Xxxxx xx Xxxxxxx Xxxxx Fe, NM 87504-1689 E-mail: xxxx.xxxxxxxxx@xxxxx.xx.xx This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These items replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply. Table of Contents Welcome 13 Welcome to Presbyterian Health Plan! 13 Our Agreement with You 13 Understanding This Agreement 14 Customer Assistance 15 Member Rights and Responsibilities 17 This Section explains your rights and responsibilities under this Agreement and how you can participate on our Consumer Advisory Board. Member Rights 17 Additional Member Rights and Responsibilities 18 Consumer Advisory Board 20 How the Plan Works 21 This section explains how to find Practitioners/Providers who are in our Network (In- network), get Healthcare Services both In-network and Out-of-network, requirements you must follow when getting care and how to receive Covered Benefits under this Agreement. Provider Directory 22 Obtaining Healthcare 22 How to Obtain a PCP 22 Women’s Healthcare Provider/Practitioner 22 23 Specialist Care 23 Obtaining Care after Normal Provider Office Hours 23 In-Network Practitioners/Providers 23 24 Out-of-Network network (outside of the 5-county area) Practitioners/Providers 24 Restrictions on Services Received Outside of the PHP Service Area 26 Out-Of-Network Care And Bills 26 If you pay an Out-of-network Provider more than we determine you owe: 27 Restrictions on Services Received Outside of the PHP Service Area 27 National Health Care Practitioner/Provider Network 28 27 Cost sharing Sharing – Your Out-of-Pocket Costs 28 Annual Contract Year Deductible 28 Coinsurance 29 Annual Out-of-Pocket pocket Maximum 29 Office Visit Copayment 30 29 Utilization Management and Quality 30 Technology Assessment Committee 30 Transition of Care 31 Advance Directives 31 Prior Authorization 32 This Section explains what Covered Healthcare Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. What is Prior Authorization? 32 Prior Authorization Is Required 32 Prior Authorization when In-Network network 33 Prior Authorization when Out-of-Network network (outside of the 5-county area) 33 Services That Require Prior Authorization In or Out-of-Network network (outside of the 5-county area) 34 Authorizing Inpatient Hospital Admission following an Emergency 36 Prescription drug Prior Authorization protocols 36 Prior Authorization and Your Coverage 36 Prior Authorization Decisions – Non-Emergency 36 Prior Authorization Decision – Expedited (Accelerated) 37 Prior Authorization Review – Initial Adverse Determination 37 Prior Authorization 37 Benefits 40 This Health Care Benefit Plan offers Coverage for a wide range of Healthcare Service. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 40 Medical Necessity 40 Care Coordination and Case Management 41 PresRN 41 Health Management Programs 41 Covered Benefits 43 Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 43 Ambulance Services 45 Bariatric Surgery 47 Clinical Trials 47 Certified Hospice Care 49 Clinical Preventive Health Services 50 Complementary Therapies 54 COVID-19 55 Dental Services (Limited) 55 Diabetes Services 57 56 Diagnostic and Imaging Services (tests performed to determine if you have a medical problem or to determine the status of any existing medical conditions) 58 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 59 Electroconvulsive Therapy (ECT) 61 Employee Assistance Program 61 Family, Infant and Toddler (FIT) Program 62 61 Genetic Inborn Errors of Metabolism Disorders (IEM) 62 Genetic/Genomic Testing 63 Habilitative Services 63 Heart Artery Calcification Scan 64 63 Home Health Care Services/Home Intravenous Services and Supplies 64 Hospital Services – Inpatient 65 Hyperbaric Oxygen Therapy 65 Infertility 66 65 Mental Health Services and Alcohol and Substance Use Disorder Services 66 No Cost Sharing For Behavioral Health Services 66 Nutritional Support and Supplements 67 Orthotics 68 Outpatient Medical Services 68 Positron Emissions Tomography (PET) Scans in an Outpatient Setting 69 Practitioner/Provider Services 69 Prescription Drugs/Medications 70 Benefit Limitations 79 Proton Beam Irradiation 81 Reconstructive Surgery 82 Rehabilitation and Therapy 82 Selected Surgical/Diagnostic Procedures 83 Skilled Nursing Facility Care 84 Smoking Cessation Counseling/Program 84 Telemedicine Services 85 Transplants 85 Women’s Healthcare 86 General Limitations 90 This Section explains the general limitations that apply to your Covered Benefits and other Sections of this Agreement Agreement. Benefit Limitations 90 Major Disasters 90 Prior Authorization 90 Exclusions 91 This Section lists services that are not Covered for certain Benefits in your Health Benefits 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. Accidental Injury (Trauma), Urgent Care, Emergency Healthcare Services, and Observation Services 91 Ambulance Services 91 Autopsies 91 Before or After the Effective Date of Coverage 91 Clinical Trials 91 Care for Military Service Connected Disabilities 92 Certified Hospice Care Benefits 92 Charges in Excess of Medicare Allowable Unreasonable 93 Clothing or Other Protective Devices 93 Clinical Preventive Health Services 93 Complementary Therapies 93 Cosmetic Surgery 93 Cosmetic Treatments, Devices, Orthotics, and Prescription Drugs/Medications ...........................................................................................................................94 Costs for Extended Warranties and Premiums for Other Insurance Coverage 94 Dental Services 94 Diabetes Services 94 Durable Medical Equipment, Orthotic Appliances, Prosthetic Devices, Repair and Replacement of Durable Medical Equipment, Prosthetics and Orthotic Devices, Surgical Dressing Benefit, Eyeglasses/Contact Lenses and Hearing Aids 94 95 Experimental or Investigational drugs, Diagnostic Genetic Testing, Medicines, Treatments, Procedures, or Devices 96 Extracorporeal Shock Wave Therapy 97 Foot Care 97 Genetic Testing 97 Genetic Inborn Errors of Metabolism Coverage 98 Hair-Hair loss (or baldness) 98 Home Health Care Services/Home Intravenous Services and Supplies 98 Hospital Services 98 Mental Health and Alcohol and Substance Use Disorder 98 Nutritional Support and Supplements 99 Out-of-State Surcharges 99 Palliative Care 99 Practitioner/Provider Services 99 Palliative Care 100 Prescription Drugs/Medications 100 Radiation 101 Reconstructive Surgery for Cosmetic Purposes 101 Rehabilitation and Therapy 101 Services for Which You or Your Dependent are Eligible under Any Governmental Program 102 Services Requiring Prior Authorization When Out-of-network (outside of the 5-county area) 102 Sexual Dysfunction Treatment 102 Skilled Nursing Facility Care 102 103 Smoking Cessation Services 103 Thermography 103 Transplant Services 103 Treatment While Incarcerated 103 War 103 Women’s Healthcare 103 Work-related Illnesses or Injuries 104 Claims 105 Your Healthcare Benefits are paid according to the conditions outlined in the Section. If you paid Practitioners/Providers for services, this Section also outlines the process you should follow if you need to be reimbursed. Notice of Claim 105 Claim Forms 105 In-Network network Practitioners/Providers 105 Out-of-Network network (outside of the 5-county area) Practitioners/Providers 106 Procedure for Reimbursement 106 Services Received Outside the United States 107 Claim Fraud 107 Effects of Other Coverage 108 This Section explains how we will coordinate benefits hsould you have medical coverage through another group Health Benefits Plan. Coordination of Benefits 108 Medicare 110 Medicaid 110 Subrogation (Recovering Healthcare Expenses from Others) 110 Summary of Health Insurance Grievance Procedures 112 This Section explains how to file a Complaint, Grievance and Appeal. What types of decisions can be reviewed? 112 Review of an Adverse Determination 112 Review of an Administrative Decision 118 General Information 119 Records 121 Your medical records are important documents needed in order to administer your Health Benefits Plan. This Section explains how we ensure the confidentiality of these records and how these records are used to administer your plan. Creation of Non-Medical Records 121 Accuracy of Information 121 Consent for Use and Disclosure of Medical Records 121 Professional Review 121 Confidentiality of Protected Health Information/Medical Records 122 Eligibility, Enrollment, Effective Dates, Termination and Continuation 128 Your medical records are important documents needed in order to administer your Health Benefits Plan. This The Section explains how we ensure the confidentiality eligibility requirements for Subscribers and/or their Dependents, important effective dates, conditions for Termination of these records Coverage and how these records are used to administer your plancontinuing Coverage for Members who become ineligible for this Plan. How You Can Enroll as a Member 128 Residence of a Dependent Child 130 Enrollment and Effective Dates 131 Full, Accurate and Complete Information 138 Change in Address, Family Status and Employment 139 138 Termination of Coverage 139 138 Continuation of Coverage of Your Group Plan 142 141 Discontinuance of Your Plan 145 144 General Provisions 150 149 This Section explains important information and provisions not covered in other Sections of this Agreement. Amendments (Group) 150 149 Assignment 150 149 Entire Contract 150 149 Execution of Contract - Application for Coverage 150 149 Federal and State Healthcare Reform 149 Fraud 150 Fraud 151 Practitioner/Provider Activity 151 150 Member Activity 151 150 Governing Law 152 151 Identification Cards 152 151 Legal Actions 152 151 Misrepresentation of Information 151 Misstatements 151 Notice 152 Misstatements 152 Notice 153 Policies and Procedures 153 152 Reinstatements 153 152 Right to Examine 153 152 Waiver by Agents 153 152 Workers' Compensation Insurance 153 152 Glossary of Terms 155 154 This Section defines some of the important terms used in this Agreement. Terms defined in this Section will be capitalized throughout the Agreement. Exhibit A – Statement of ERISA Rights 177 Welcome‌‌ 175 Welcome Welcome to Presbyterian Health Plan! Welcome and thank you for joining Presbyterian Health Plan. We are a Healthcare Insurer operated as a division of Presbyterian Healthcare Services, a locally owned New Mexico healthcare system. When we use the words “Presbyterian Health Plan”, ,” “PHP”, ,” “we”, ,” “us”, ,” and “our” in this document, we are referring to Presbyterian Health Plan. When we use the words “you” and “your,” we are referring to each Member. As part of Presbyterian Healthcare Services, the health plan represents an organization with over 100 years of community services to New Mexicans. Our priority has been and will continue to be improving the health of individuals, families and communities. We are working to make sure that you receive quality care and service. We are pleased to provide you with access to a comprehensive network of Physicians, Hospitals, and outpatient medical Providers, who provide services for your Covered Benefits. We provide utilization management and quality improvement oversight programs with our commitment to Member service. We work closely with you, your Covered Dependents and your healthcare Practitioners and Providers to provide a quality, affordable healthcare plan. Our Agreement with You This is your Group Subscriber Agreement (Agreement) and it is a legal document. This Agreement, along with the Summary of Benefits and Coverage, describes the Covered Healthcare Benefits and plan features that you and your eligible Dependents may receive when you enroll. This policy, including the endorsements and attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurance company and unless such approval and countersignature be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. Information you will find in this Agreement includes: • · Your rights and responsibilities as a Member • · Covered Benefits available through this Plan • · How to access services from physicians, Practitioners, Providers, and Pharmacies • · Services that require Prior Authorization • · Limitations and Exclusions for certain Covered Benefits • · Coverage for your Dependents who are outside of New Mexico • the 5-county area · A Glossary of Of Terms used in this Agreement • · What to do when you need assistance