Common use of Observation Services Clause in Contracts

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Health Care Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited a bariatric surgery Center of Excellence by the American Society of Metabolic Centers for Medicare and Bariatric Surgery/American College of SurgeonsMedicaid Services (CMS). Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • · Evaluate an outpatient’s condition • · Determine the need for a possible admission to the Hospital • · When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • · Emergency Ambulance Services • · High-Risk Ambulance Services • · Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • · Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • · Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • · We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • · In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • · Non-emergency • · Medically Necessary for transporting a high-risk patient • · Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • · Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • · Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • · Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • · Medically Necessary • · Prescribed by your Practitioner/Provider • · Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.personnel

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexicothe 5-county area, to the nearest In-network facility where Emergency Healthcare Health Care Services and treatment can be rendered, or to an OutXxx-ofxx-network xxxxxxx (xxxxxxx xx xxx 0- xxxxxx xxxx) facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexicothe 5-county area, to the nearest appropriate facility where Emergency Healthcare Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (traumaTrauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Biomarker Testing Biomarker Testing for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of a member’s disease or condition is covered if the test is supported by medical and scientific evidence such as FDA approval, CMS national or local coverage determinations, or nationally recognized clinical practice guidelines. Biomarker testing may be subject to cost sharing consistent with that imposed on testing benefits. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring healthcare professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency medical Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency medical Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexicothe 5-county area, to the nearest In-network facility where Emergency Healthcare Health Care Services and treatment can be rendered, or to an Out-of-network (outside of the 5- county area) facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexicothe 5-county area, to the nearest appropriate facility where Emergency Healthcare Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • · Evaluate an outpatient’s condition • · Determine the need for a possible admission to the Hospital • · When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • · Emergency Ambulance Services • · High-Risk Ambulance Services • · Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • · Within New Mexicothe 5-county area, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network (outside of the 5-county area) facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • · Outside of New Mexicothe 5-county area, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • · We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • · In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • · Non-emergency • · Medically Necessary for transporting a high-risk patient • · Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • · Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • · Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • · Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • · Medically Necessary • · Prescribed by your Practitioner/Provider • · Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring healthcare professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency medical Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- co-morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. ‌ Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: are:‌ • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring healthcare professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel personnel‌ Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency Healthcare medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at an In-network a facility that is designated by Presbyterian Health PlanInsurance Company, Inc., and designated as an accredited a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the American Society bariatric surgical Center of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trialExcellence chosen.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (traumaTrauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, Covered unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required required, and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Biomarker Testing Biomarker Testing for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of a member’s disease or condition is covered if the test is supported by medical and scientific evidence such as FDA approval, CMS national or local coverage determinations, or nationally recognized clinical practice guidelines. Biomarker testing may be subject to cost sharing consistent with that imposed on testing benefits. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency medical Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- co-morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, For transportation to the nearest appropriate facility where Emergency Healthcare medical Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Maternity/Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when is limited to: o The medically high-risk pregnant woman with an impeding delivery of a potentially viable infant. o When necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- co-morbid medical conditions; and Prior Authorization is required for both In-network and Out-of- network facilities and services must be performed at an In-network a facility that is designated by Presbyterian Health PlanInsurance Company, Inc., and designated as an accredited a bariatric surgery Center of Excellence by Centers for Medicare and Medicaid Services (CMS). Out-of-network Benefits may apply depending upon the American Society bariatric surgical Center of Metabolic and Bariatric Surgery/American College of SurgeonsExcellence chosen. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (traumaTrauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- co-morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Biomarker Testing Biomarker Testing for the purposes of diagnosis, treatment, appropriate management or ongoing monitoring of a member’s disease or condition is covered if the test is supported by medical and scientific evidence such as FDA approval, CMS national or local coverage determinations, or nationally recognized clinical practice guidelines. Biomarker testing may be subject to cost sharing consistent with that imposed on testing benefits. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexico, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexico, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery Surgery‌ This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexicothe 5-county area, to the nearest In-network facility where Emergency Healthcare Services and treatment can be rendered, or to an Out-of-network (outside of the 5-county area) facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexicothe 5-county area, to the nearest appropriate facility where Emergency Healthcare Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited bariatric surgery Center by the American Society of Metabolic and Bariatric Surgery/American College of Surgeons. Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring healthcare professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is:

Observation Services. Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the patient’s condition is anticipated or occurs When a Hospital places a patient under Outpatient Observation, it is based upon the Practitioner’s/Provider’s written order. To transition from Observation to an Inpatient admission, our level of care criteria must be met. The length of time spent in the Hospital is not the sole factor determining Observation versus Inpatient stays. Medical criteria will also be considered. Observation Services for greater than 24 hours will require Prior Authorization. It is the responsibility of the facility to notify us. All Accidental Injury (trauma), Urgent Care, Emergency Healthcare Health Care Services, and Observation Services whether provided within or outside of our Service Area are subject to the Limitations listed in the Limitations Section and the Exclusions listed in the Exclusions Section. Ambulance Services This benefit has one or more exclusions as specified in the Exclusions Section. The following types of Ambulance Services are Covered: • Emergency Ambulance Services • High-Risk Ambulance Services • Inter-facility Transfer services Emergency Ambulance Services are defined as ground or air Ambulance Services delivered to a Member who requires Emergency Healthcare Health Care Services under circumstances that would lead a Reasonable/Prudent Layperson acting in good faith to believe that transportation in any other vehicle would endanger your health. Emergency Ambulance Services are Covered only under the following circumstances: • Within New Mexicothe 5-county area, to the nearest In-network facility where Emergency Healthcare Health Care Services and treatment can be rendered, or to an Out-of-network (outside of the 5- county area) facility if an In-network facility is not reasonably accessible. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • Outside of New Mexicothe 5-county area, to the nearest appropriate facility where Emergency Healthcare Health Care Services and treatment can be rendered. Such services must be provided by a licensed Ambulance Service, in a vehicle that is equipped and staffed with life-sustaining equipment and personnel. • We will not pay more for air Ambulance Services than we would have paid for ground Ambulance Services over the same distance unless your condition renders the utilization of such ground transportation services medically inappropriate. • In determining whether you acted in good faith as a Reasonable/Prudent Layperson when obtaining Emergency Ambulance Services, we will take the following factors into consideration: o Whether you required Emergency Healthcare Health Care Services, as defined above o The presenting symptoms o Whether a Reasonable/Prudent Layperson who possesses average knowledge of health and medicine would have believed that transportation in any other vehicle would have endangered your health o Whether you were advised to seek an Ambulance Service by your Practitioner/Provider or by our staff. Any such advice will result in reimbursement for all Medically Necessary services rendered, unless otherwise limited or excluded under this Agreement o Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols Ambulance Service (ground or air) to the coroner’s office or to a mortuary is not Covered, unless the Ambulance had been dispatched prior to the pronouncement of death by an individual authorized under state law to make such pronouncements. High-Risk Ambulance Services are defined as Ambulance Services that are: • Non-emergency • Medically Necessary for transporting a high-risk patient • Prescribed by your Practitioner/Provider Coverage for High-Risk Ambulance Services is limited to: • Air Ambulance Service when Medically Necessary. However, we will not pay more for air Ambulance Service than we would have paid for transportation over the same distance by ground Ambulance Services, unless your condition renders the utilization of such ground Ambulance Services medically inappropriate. • Neonatal Ambulance Services, including ground or air Ambulance Service to the nearest Tertiary Care Facility when necessary to protect the life of a newborn. • Ground or air Ambulance Services to any Level I or II or other appropriately designated trauma/burn center according to established emergency medical services triage and treatment protocols. Inter-facility Transfer Ambulance Services are defined as ground or air Ambulance Service between Hospitals, Skilled Nursing Facilities or diagnostic facilities. Inter-facility transfer services are Covered only if they are: • Medically Necessary • Prescribed by your Practitioner/Provider • Provided by a licensed Ambulance Service in a vehicle which is equipped and staffed with life-sustaining equipment and personnel Bariatric Surgery This benefit has one or more exclusions as specified in the Exclusions Section. Surgical treatment of morbid obesity (bariatric surgery) is Covered only if it is Medically Necessary as defined in this Agreement. Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related co- morbid medical conditions; and Prior Authorization is required and services must be performed at an In-network facility that is designated by Presbyterian Health Plan, and designated as an accredited a bariatric surgery Center of Excellence by the American Society of Metabolic Centers for Medicare and Bariatric Surgery/American College of SurgeonsMedicaid Services (CMS). Clinical Trials This benefit has one or more exclusions as specified in the Exclusions Section. If you are a qualified individual participating in an approved Clinical Trial, you may receive coverage for certain routine patient care costs incurred in the trial.. A qualified individual is someone who is eligible to participate in an approved Clinical Trial according to the trial protocol with respect the treatment of cancer or another life-threatening disease or condition; and either (1) the referring health care professional is a participating provider and has concluded that participation in the clinical trial would be appropriate; or (2) the participant or beneficiary provides medical and scientific information establishing that the individual's participation would be appropriate. An approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or another life- threatening disease or condition and is: