REQUEST-FOR-INFORMATION - FOR - DURABLE MEDICAL EQUIPMENT and

TAG:  support hose 

Published Time: -

Filetype: pdf

Filesize: 117133

FORM NUMBER 1 [Carrier] [Address] [City, State, Zip] HMO Standard Conversion Plan [Carrier], [(hereinafter called XXXX)] agrees to provide the health care services described
under the provisions of this Conversion Plan to the Subscriber and the Subscriber’s eligible
Dependents who have transferred enrollment from a [Carrier], Group Contract. The
provision of services is subject to all of the terms on this page and those that follow,
including any limitations, restrictions or exclusions, as well as any amendments made a part
of this Plan. This Plan is issued in consideration of the submission of an application for conversion and
payment of subscription fees in advance at [Carrier]’s, home office. Any changes in this Plan must be approved by an officer of the company, and endorsed on
the certificate or attached to it. Any verbal promise made by an officer or employee of
[Carrier], or any other person, including an agent, will not be binding on the company
unless it is contained in writing in this certificate or an endorsement to it. This Plan is effective on the Effective Date shown on the Plan Information Page. The first
subscription fee covers the period starting on the Effective Date. Please call [(1-800-XXX-XXXX)] for assistance regarding claims and information about
coverage. [Carrier] [President] FORM NUMBER 2 PLAN INFORMATION PAGE Subscriber’s Name: Plan Number: Covered Dependents: Effective Date of Coverage: Plan Anniversary Date Subscription Fee Amount: Subscription Fee Payment Mode: FORM NUMBER 3 TABLE OF CONTENTS ADMINISTRATIVE PROVISION Responsibilities of [Carrier] Termination of the Plan by the Subscriber Termination of the Plan by [Carrier] Terms of Renewal Termination of Subscriber’s Coverage Termination of Dependent’s Coverage Termination of Coverage for Cause Subscription Fee Provisions General Plan Provisions Eligibility and Effective Date of Coverage Coordination of Benefits Grievance Procedures Coverage Provisions [Choosing a Primary Care Physician] Specialty Ca re Emergency Services and Care Within the Service Area Outside the Service Area Covered Person Copayments Reimbursement for Non-Participating Provider Services FORM NUMBER 4 Covered Services Hospital Services Outpatient Services Medical Services Special Services [Medical Payment Guidelines for Non-Participating Providers] Exclusions and Limitations Following Access Rules Pre-existing Condition Limitations Exclusions and Limitations Glossary Schedule of Benefits FORM NUMBER 5 ADMINISTRATIVE PROVISIONS RESPONSIBILITIES OF [CARRIER] In consideration of the payment of subscription fee by the Subscriber, [Carrier], shall
provide coverage for the Subscriber and their Covered Dependents on a direct service
basis. This means that [Carrier], arranges or contracts with physicians, hospitals, or
other providers of medical care and employs administrative personnel to directly
provide, organize and arrange for such service. [Carrier], agrees to use its best efforts
to assure that its providers render quality health care services in conformity with
accepted community medical standards. The physicians, hospitals and providers of
medical care are not our agents or employees, nor is [Carrier], their agent or employee. We agree to provide coverage without discrimination because of race, color, sex,
religion, national origin or any other basis prohibited by law. TERMINATION OF THIS PLAN BY THE SUBSCRIBER The Subscriber may terminate this Plan as of any subscription fee due date by giving
at least 45 days prior written notice. In such event, no benefits will be provided on or
after such termination date, except as specifically set forth in this Plan. TERMINATION OF THIS PLAN BY [CARRIER] [Carrier], may terminate this Plan as of any subscription fee due date if the Subscriber
has not paid the required subscription fee by the end of the grace period, as defined in
the Grace Period provision. However, if the Subscriber has given [Carrier], prior written
notice in advance of an earlier date of termination, this Plan will terminate as of that
earlier date. The Subscriber is liable to [Carrier] for any unpaid subscription fee for the
time the Plan was in force. TERMS OF RENEWAL [Carrier], guarantees the Subscriber the right to renew this Plan at the Subscriber’s
option. However, We may refuse to renew or discontinue this Plan, and all coverage
provided under this Plan, if one of the following circumstances has occurred: A. Failure to timely pay premiums or contributions in accordance with the terms of the Plan; FORM NUMBER 6 B. The carrier ceases offering the Plan to all Policyholders; C. The enrollee no longer, lives, or resides, or works in the service area of the carrier or in the area in which the carrier is authorized to do business; D. The enrollee has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the Plan. If, based on the occurrence of one or more of above circumstances (except for
nonpayment of premium), [Carrier], decides to non-renew or discontinue this Plan,
[Carrier], will give the Subscriber at least 90 days advance notice, in writing, of its intent
to non-renew or discontinue this Plan. TERMINATION OF SUBSCRIBER’S COVERAGE The coverage under this Plan for any Subscriber will end at 12:01 a.m., local standard time,
on the earliest of the date: A. The Plan between the Subscriber and [Carrier], ends. B. The Subscriber fails to pay the subscription fee due, or the Subscriber otherwise fails to continue to meet each of the eligibility requirements under this Plan. C. The Subscriber's coverage is terminated for cause. D. The Subscriber no longer lives or works in the Service Area. TERMINATION OF DEPENDENT’S COVERAGE The coverage under this Plan for any Covered Dependent will end automatically at 12:01
a.m., local standard time, on the earliest of the following dates: A. The Plan between the Subscriber and [Carrier], ends. B. The Subscriber's coverage ends for any reason. C. The dependent fails to continue to meet each of the dependent eligibility requirements under this Plan, except in the case of a handicapped child. D. The Covered dependent's coverage is terminated for cause. E. The Covered dependent no longer lives or works in the Service Area. FORM NUMBER 7 F. A court order, including a qualified medical child support order, covering a dependent child is no longer in effect, or a change in marital status that makes a
person ineligible under the terms of this Plan. However, a Subscriber’s dependents may if covered under this Plan, on their own, convert
to a conversion plan under one of these following conditions: A. If the Subscriber’s conversion plan terminates, Covered Dependents may convert as dependents under a new conversion plan. B. If the Subscriber dies, the Covered spouse may convert. C. If the Subscriber and the Covered spouse die simultaneously or upon the death of the last surviving parent, the covered children may convert if they are of contracting
age. D. If the covered spouse is no longer a qualified family Covered Person, the spouse may convert. E. If a Covered Dependent child is no longer an Eligible Dependent as defined in this Plan, such dependent may convert. The new conversion plan will be a benefit plan in use by [Carrier], on the date the request is
made. The new coverage will be issued at rates that apply to the person's class of risk and
age at the nearest birthday on the date coverage under this Plan stops. FORM NUMBER 8 TERMINATION OF COVERAGE FOR CAUSE Unless otherwise prohibited by law, if, in [Carrier]’s, opinion, any of the following events
occur, We may terminate a Covered Person for cause: A. Failure to comply with the treatment plan established by a Primary Care Physician or by a Participating Provider. B. Failure on a timely basis to pay any Copayments and/or financial contributions required under this Plan. C. Failure to provide any signed releases, consents, assignments, or other documents reasonably requested by [Carrier], or failure to otherwise cooperate with Us in the
administration of this Plan. D. Disruptive, unruly, abusive, or uncooperative behavior to the extent that such Covered Person's continued membership in [Carrier], impairs Our ability to
administer this Plan or to arrange for the delivery of health care services to such
Covered Person or to other Covered Persons. E. The knowing misrepresentation, or omission, or the giving of false information on the enrollment form or the enrollment change form, or other forms completed for
[Carrier], by or on behalf of the Covered Person. F. Fraud or material misrepresentation or omission in applying for membership or in requesting the receipt of coverage; G. Misuse of the Covered Person's I.D. Card; or H. The Subscriber no longer lives or works in the Service Area. Any termination made under this provision is subject to review in accordance with the
Grievance procedure described in this Plan. In relation to a misstatement in the application, after two (2) years from the issue date, only
fraudulent misstatements in the application may be used to void this agreement or deny
any claim for loss incurred or disability starting after the two (2) year period. FORM NUMBER 9 SUBSCRIPTION FEE PROVISIONS PAYMENT OF SUBSCRIPTION FEE The first subscription fee payment is due on the Effective Date shown on the Plan
Information Page. Each following subscription fee payment is due monthly unless the
Subscriber and [Carrier], agree on some other method and/or frequency of payment.
Subscription fee payments should be sent to [Carrier’s] [home office] [or may be given to an
authorized agent of [Carrier].] SUBSCRIPTION FEE DUE DATE After the Effective Date shown on the Plan Information Page, the subscription fee due date
will be [the day of the month with the same number as the anniversary date. If there is a
month with no day having the same number as the anniversary date, the subscription fee is
due on the last day of that month.] THE GRACE PERIOD This Plan has a 10 day grace period. A grace period means that if any required
subscription fee is not paid on or before the date it is due, it may be paid during the grace
period immediately following that subscription fee due date. During the grace period, the
Plan will stay in force. The grace period does not apply to the subscription fee due on the
Effective Date, or if the Subscriber has given [Carrier], written notice that the Plan is to be
terminated prior to the subscription fee due date. If the subscription fee is not paid by the
end of the grace period, the Plan may terminate as of the date the payment was due. Any
late payment penalties are subject to Department of Insurance approval. SUBSCRIPTION FEE The monthly subscription fee rate for each Subscriber is shown on the Plan Information
Page. The subscription fee is determined in accordance with subscription fee rates
applicable to the age and class of risk of each person to be covered under this plan and to
the type and amount of coverage provided. However, [Carrier], may change the subscription fee at any time if Our liability is altered
either because of a change in state or federal law or because of a revision in the coverage
provided under this Plan. Any such change in the subscription fee will take effect on the
later of the effective date of the change in law or change in coverage; or the date the
subscription fee change is approved by the Florida Department of Insurance, if such
approval is required. The Plan will give the Subscriber written notice of any changes in the subscription fee at
least 45 days in advance. FORM NUMBER 10 If an increase in the subscription fee takes place on other than a subscription fee due date,
a pro rata subscription fee increase will be applied from the date of the increase to the next
subscription fee due date. If a decrease in the subscription fee takes place on other than a
subscription fee due date, a pro rata credit will be granted. The pro rata credit will apply for
the decrease from the date of the decrease to the next subscription fee due date. INCORRECT SUBSCRIPTION FEE PAYMENT Any subscription fee adjustment made due to the correction of an error in the subscription
fee payment will be made without interest on the next subscription fee due date after the
facts are made known to [Carrier] FORM NUMBER 11 GENERAL PLAN PROVISIONS ENTIRE PLAN The entire agreement is made up of this Plan, the Subscriber’s application for this coverage
and any amendments or riders attached to the Plan. All statements made by the
Subscriber or by a Subscriber are considered to be representations, not warranties. This
means that the statements are considered to have been made in good faith. No such
statement will void this Plan, reduce the benefits it provides, or be used in defense to a
claim for coverage unless it is contained in a written application and a copy is furnished to
the person making such statement. TIME LIMIT FOR CERTAIN DEFENSES After two years from the effective date of this Plan, no misstatement made by the
Subscriber, except a fraudulent misstatement made in the Subscriber's application for this
Plan, may be used to void the Plan. After two years from a Covered Person's effective
date, no misstatement made by the Covered Person, except a fraudulent misstatement on
his or her application, may be used to deny a claim for any benefit which begins after the
end of the two-year period from the Covered Person's effective date. FINANCIAL RESPONSIBILITIES OF THE SUBSCRIBER [Carrier], reserves the right to recover any benefit payments made to or on behalf of any
individual whose coverage has been terminated. Recovery efforts will relate to benefit
payments made for services or supplies rendered subsequent to the Covered Person's
termination date and prior to the date notice of coverage termination by the Subscriber.
The Subscriber shall cooperate with and support such recovery efforts. In the event that the Subscriber does not comply with the notice requirements set forth in
the Subscription Fee Statement section, the Subscriber shall be solely liable to [Carrier], to
the extent of any payment made on behalf of such individual for services or supplies
rendered subsequent to the date notice of a Covered Person's termination was due. MISSTATEMENTS If information about a Covered Person is misstated, [Carrier], may adjust the subscription
fee to correctly reflect the true information. If the misstatement affects the amount of the
Covered Person's coverage, the true information may be used to determine the correct
amount of coverage. FORM NUMBER 12 CHANGES TO THIS PLAN No change to this Plan will be effective unless made by an amendment or rider that has
been signed by an officer of [Carrier] No agent may change this Plan or waive any of its
provisions. WORKERS' COMPENSATION This Plan does not affect or take the place of Workers’ Compensation. ASSIGNMENT Neither this Plan, nor the benefits provided under this Plan, may be assigned except as
otherwise specifically described in this Plan. FORM NUMBER 13 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE Eligibility After this Policy is in effect, the following Dependents are eligible for coverage: 1. the Subscriber’s lawful Spouse; or 2. an unmarried child of the Subscriber under the age of 25. Under this Policy, the following are considered children of the Subscriber until the
end of the calendar year in which the child reaches age 25, if the child is
dependent on the Subscriber for support and is either living in the
Subscriber’s household or is a full-time or part-time student: a. natural children, or legally adopted children, or step-children residing with You; or any child who lives with the Subscriber in a normal
parent-child relations[Carrier] if the child qualifies at all times for the
dependent exemption, as defined in the Internal Revenue Code and
the Federal Tax Regulations. [Carrier] has the right to request proof of
the child’s dependency status at any time. b. a newborn of You or Your Covered spouse, from the moment of birth; the newborn child of a covered family dependent child (e.g. the
newborn of a covered daughter or son) for a period of 18 months from
the moment of birth. c. a child You propose to adopt which is placed in compliance with Chapter 63, from the moment of placement in Your residence; a newly
born infant adopted by You, from the moment of birth if a written
agreement to adopt such child has been entered into prior to the birth
of the child, whether or not such agreement is enforceable. However,
coverage will not be provided in the event that the child is not
ultimately placed in Your residence in compliance with chapter 63; d. a child for whom You are the legal guardian, who is residing with You and who is chiefly Dependent upon You (in accordance with Internal
Revenue Service criteria) for support and maintenance; and e. An unmarried dependent handicapped child of the Subscriber or the Subscriber’s spouse, regardless of age who is incapable of self-
sustaining employment due to mental retardation or physical handicap
incurred prior to age twenty-five (25). FORM NUMBER 14 Enrolling for Coverage No person meeting eligibility requirements will be refused coverage under this Policy by
Us because of a health condition, a need for health services or a pre-existing physical
or mental condition, including pregnancy. A person who becomes eligible as a Dependent due to marriage, birth, adoption or
legal guardianship may apply for coverage by completing and submitting to [Carrier] a
signed application within thirty (30) days of becoming eligible. Newborn and adopted
children will be covered from the date of birth or date of placement. If you have family
coverage the addition of a Dependent will not change Your contract type, although You
must complete required forms within thirty (30) days of the event. If You have
individual or two-person coverage, Your contract type and associated premium will
change. You must submit any required additional premium payment. Except for a newborn or an adopted child, if an eligible Dependent does not apply for
coverage in the time frame specified herein, [Carrier] may at its own discretion either
deny coverage or allow the individual to make application for coverage. Based on the
current health status and health history of the individual, We may either issue coverage
under this Policy and subject the individual to a pre-existing condition waiting period, or
deny coverage. It is also Your responsibility to notify Us of any changes which will affect Your eligibility
or the eligibility of Your Dependents within thirty (30) days of the event. Effective Date of Coverage This Policy’s effective date is shown on the Policy Information Page. A newly eligible
Dependent’s coverage will begin as of the date of the event such as marriage, birth,
adoption, and guardianship, only if the Dependent’s application is received within thirty
(30) days of the event. Coverage will not be denied a newborn or an adopted child
for failure to notify within the time frame specified. The term Effective Date means to the entire Policy, and the Covered Persons covered when the Policy first becomes effective, 12:01 a.m. on the date specified on the Policy
Information Page; and with respect to a Covered Person who is subsequently covered,
12:01 a.m. on the date on which coverage will commence for that Covered Person as
specified in the Effective Date Section of this Policy. COVERAGE FOR NEWBORN CHILDREN All health coverage applicable for children under this Plan will be provided for the newborn
child of the Subscriber or to a Subscriber’s Covered Dependent from the moment of birth if
the Subscriber has dependent coverage. However, with respect to the newborn child of a FORM NUMBER 15 Covered Dependent of the Subscriber other than the Subscriber's spouse, the coverage for
the newborn child terminates eighteen (18) months after the birth of the newborn. The coverage for newborn children shall consist of coverage for injury or sickness,
including medically necessary care or treatment for medically diagnosed congenital
defects, birth abnormalities, or prematurity, and the transportation costs of the newborn to
and from the nearest available facility appropriately staffed and equipped to treat the
newborn's condition, when such transportation is certified by the attending physician as
necessary to protect the health and safety of the newborn child. The coverage for
transportation costs may not exceed allowed charges of $1,000. [Carrier], must be notified, in writing, within 30 days after the birth. If timely notice is given,
no additional subscription fee will be charged for coverage of the newborn child for the
duration of the notice period. If timely notice is not received, [Carrier], will charge the
applicable subscription fee from the date of birth. The applicable subscription fee for the
child will be charged after the initial 30-day period in either case. Coverage will not be
denied for a newborn child due to the Covered Person's failure to provide notice within the
30-day period of the birth of the child. COVERAGE FOR ADOPTED CHILDREN All health insurance benefits applicable to children will be payable with respect to a child
adopted by the Subscriber if the Subscriber has dependent coverage: A. When the child is placed in compliance with Florida Statutes, Chapter 63, prior to the child's 18th birthday, from the moment of placement in the Subscriber's
residence; and B. For a newborn child, from the moment of birth, if a written agreement to adopt such child has been entered into prior to the birth of the child, whether or not ultimately
placed in the Subscriber's residence. Notice of the birth or placement of the child must be given to [Carrier], in writing, no later
than 30 days after the occurrence. If timely notice is given, no additional subscription fee
will be charged for coverage of the adopted child for the duration of the notice period. If
timely notice is not received, [Carrier], will charge the applicable subscription fee from the
date of birth for the newborn and the date of placement for the adopted child. The
applicable subscription fee for the child will be charged after the initial 30-day period in
either case. Coverage will not be denied for a child due to the Covered Person's failure to
provide timely notice of birth or placement of the child. FORM NUMBER 16 COVERAGE FOR FOSTER CHILDREN Coverage for a foster child or a child otherwise placed in the Subscriber or the Subscriber’s
Covered spouse's custody by a court order, prior to the child's 18th birthday, will be
provided from the date of placement if on the date of placement the Subscriber has
dependent coverage. This coverage will be subject to the pre-existing condition waiting
period of 12 months for any conditions manifested or treated in the six month period prior to
the date of the court ordered custody. No coverage will be provided under this provision for
the child who is not ultimately placed in the Subscriber's home. For children in the
Subscriber's custody, coverage will terminate the date the Subscriber no longer has legal
custody. HANDICAPPED CHILDREN If a child attains the limiting age for a Covered Dependent (see the Eligibility provision),
coverage will not terminate while that person is, and continues to be, both: A. Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and B. Chiefly dependent on the Subscriber for support and maintenance. If a claim is denied for the stated reason that the child has reached the limiting age for
dependent coverage, the Subscriber has the burden of establishing that the child is and
has continued to be handicapped as defined above. The coverage of the handicapped child may be continued, but not beyond the termination
date of such incapacity or such dependence. This provision shall in no event limit the
application of any other provision of this Plan terminating such child's coverage for any
reason other than the attainment of the applicable limiting age. THIS PLAN AND OTHER PAYMENT ARRANGEMENTS COORDINATION OF BENEFITS When a Covered Person is covered under this Plan and another health coverage plan, We
reserve the right to coordinate the benefits of this Plan with the benefits of that other plan.
This provision explains how that coordination will take place. Coordination of benefits is designed to avoid the costly duplication of payment for health
care services and/or supplies under multiple health coverage plans. Because of this
provision, the sum of the benefits that would be payable under all plans, in the absence of
this coordination provision and similar provisions in the other plans, will not exceed 100% of
the total allowed expenses actually incurred. FORM NUMBER 17 PLANS AFFECTED If any of the other health coverage plans a Covered Person has, covers at least a portion of
a health care service or supply which is covered under this Plan, coordination may take
place. Not all health coverage plans will be considered in this coordination process. The
plans that will be considered are the following: A. Any group insurance, group-type self-insurance or HMO plan; including coverage under labor-management, trustee plans, union welfare plans, employer organization plans, or
employee benefit organization plans; B. Any service plan contracts, group practice, individual practice, or other prepayment coverage on a group basis; C. Any plan, program or insurance established pursuant to worker's compensation legislation or other legislation of similar purpose; or an insurance Plan, including an
automobile insurance Plan, provided any non-Plan contains a coordination of benefits
provision; D. Any coverage under governmental programs including Medicare, and any coverage required or provided by any statute. Each Plan or other arrangement for benefits or services that the Covered Person has will
be considered separately with respect to that portion of any such Plan, contract, or other
arrangement which reserves the right to take the benefits or services of other programs into
consideration in determining its benefits and that portion which does not. When a plan provides benefits in the form of services, the reasonable cash value of
each service rendered shall be deemed as a benefit paid. ORDER OF BENEFIT DETERMINATION If the health benefits of all of the health coverage plans the Covered Person is covered
under would have exceeded the actual cost of the services or supplies rendered in the
absence of this provision, this coordination process will reduce the payment by one or more
of the plans to eliminate the excess payment. To determine the order in which companies
will be considered and plan benefits reviewed to determine the appropriate benefit
payment, the following guidelines will be used: A. The first guideline is dependent status. The benefits of the plan which covers the
person on whose expense the claim is based as an employee shall be determined
before the benefits of the plan which covers the person as a dependent; B. The second guideline is parent birth date. Except for cases where the person for
whom claim is made as a dependent child whose parents are separated or divorced, the FORM NUMBER 18 benefits of the plan which cover the person on whose expenses the claim is based as a
dependent of a person whose date of birth, excluding year of birth, occurs earlier in the
calendar year shall be determined before the benefits of the plan which covers the
person as a dependent of a person whose date of birth, excluding year of birth, occurs
later in a calendar year. If either plan does not have a similar "birthday rule" provision
regarding dependents, which results either in each plan determining its benefits before
the other or in each plan determining its benefits after the other, the criteria shall not be
applied, and the rule set forth in the plan which does not have the "birthday rule"
provision shall determine the order of benefits. C. In the case of a person for whom claim is made as a dependent child, whose
parents are separated or divorced: 1. When the parents are separated or divorced and the parent with custody of the child has not remarried, the benefits of the plan which cover the child as a
dependent of the parent with custody of the child will be determined before the
benefits of the plan which cover the child as a dependent of the parent without
custody. 2. When the parents are divorced and the parent with custody of the child has remarried, the benefits of a program which cover that child as a dependent of the
parent with custody shall be determined before the benefits of a plan which cover
that child as a dependent of the step-parent; and the benefits of a plan which cover
that child as a dependent of a step-parent will be determined before the benefits of a
plan which covers the child as a dependent of the parent without custody. 3. If there is a court decree which would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to
the child, the benefits of a plan which cover the child as a dependent of the parent
with such financial responsibility shall be determined before the benefits of any other
program which cover the child as a dependent child. D. When rules A, B or C do not establish an order of benefit determination, the benefits
of a plan which has covered the person on whose expenses the claim is based for the
longer period shall be determined before the plan which has covered such person the
shorter period of time, provided that: 1. The benefits of a plan covering the person on whose expense claim is based as a laid-off or retired employee, or dependent of such person, shall be determined
after the benefits of any other plan covering such person as an employee, other than
a laid-off or retired employee or dependent of such person; and 2. If either program does not have a provision regarding laid-off or retired employees, which results in each program determining its benefits after the other,
then the provisions of 1. above shall not apply. FORM NUMBER 19 E. When this coordination process reduces the total amount of benefits otherwise
payable to a Covered Person under this Plan, each benefit that would be payable in the
absence of this provision will be reduced proportionately, and such reduced amount
shall be charged against any applicable benefit limit of this Plan. SUBROGATION Sometimes, the situations that cause a Covered Person to need the benefits and supplies
provided under this Plan also result in actions by the Covered Person to recover damages
related to that situation. Such actions may often result in duplicate payments for the
services and supplies that [Carrier], has already provided to the Covered Person. To protect Us from this type of duplicate payment, We reserve the right to get involved in
that recovery process. Our right to get involved is called " subrogation". A. If We have paid for services or supplies to a Covered Person under this Plan, the Covered Person will, to the extent of such services or supplies rendered, have
subrogated Us to all causes of action and rights of recovery that the Covered
Person may have or has against any persons and/or organizations that are related
to the incident that necessitated the rendering of the services or supplies. These
subrogation rights extend and apply to any settlement of a claim, irrespective of
whether litigation has been initiated. B. The Covered Person must promptly execute and deliver instruments and papers related to these subrogation rights as may be requested by Us. Further, the
Covered Person shall promptly notify [Carrier] of any settlement negotiations prior to
entering into a settlement agreement affecting Our subrogation rights. C. In no event should a Covered Person fail to take any action where action is appropriate, or take any action that may prejudice [Carrier]’s, subrogation rights. No
waiver, release of liability, settlement, or other documents executed by a Covered
Person without prior notice to and approval by Us shall be binding upon [Carrier] D. We retain the right to recover such payments and/or the reasonable value of the benefits provided from any person or organization to the fullest extent permitted by
law. FORM NUMBER 20 RIGHT TO RECEIVE AND RELEASE INFORMATION [Carrier], has the right to receive and release necessary information. By accepting
coverage under this Plan, the Subscriber gives permission for Us to obtain from or release
to any employee of [Carrier], or other organization or person any information necessary to
determine whether this provision or any similar provision in other plans applies to a claim
and to implement such provisions. We may obtain or release this information without
consent from or notice to anyone. Any person who claims benefits under this Plan agrees
to furnish to Us information that may be necessary to implement this provision. FACILITY OF PAYMENT Whenever payment which should have been made by Us is made to any other person,
plan, or organization, We shall have the right to pay to that other person, plan or
organization any amounts We determine to be necessary under this provision. Amounts
paid to another plan in this manner will be considered benefits paid under this Plan.
[Carrier], is discharged from liability under this Plan to the extent of any amounts so paid. RIGHT OF RECOVERY If [Carrier], makes larger payments than is required under this Plan, then We have the right
to recover any excess benefit payment from any person to or for whom such payments
were made, or any other person We may determine. NON-DUPLICATION OF GOVERNMENT PROGRAMS The benefits of this Plan shall not duplicate any benefits to which Covered Persons are
paid under governmental programs such as Medicare, Veterans Administration,
CHAMPUS, or any Workers' Compensation Act, to the extent allowed by law. In any event,
if this Plan has duplicated such benefits, all sums paid or payable under such programs
shall be paid or payable to [Carrier], to the extent of such duplication. NON-DUPLICATION OF OTHER COVERAGE The benefits under this Plan do not duplicate any benefits to which Covered Persons are
entitled by law, and/or for which they are eligible under any extension of benefits and/or
coverage provisions of any other plan, program, or contract. COOPERATION OF COVERED PERSONS Each Covered Person shall cooperate with [Carrier], and shall execute and submit to Us
such consents, releases, assignments, and other documents as may be requested by Us,
in order to administer and exercise its rights under the subrogation provision or to process
claims. Failure to do so may result in the reduction of benefit payments under this Plan. FORM NUMBER 21 REIMBURSEMENT FOR NON-PARTICIPATING PROVIDER SERVICES [Carrier], will provide or arrange for services to be received from Participating Providers on
a direct service basis. If a Covered Person receives services from a Participating Provider,
[Carrier], will pay the provider directly for all care received. The Covered Person will not
have to submit a claim for payment. In the event the Covered Person requires Emergency Services and Care from a Non-
Participating Provider while inside or outside the service area; or, if [Carrier], refers the
Covered Person to a Non-Participating Provider, the Covered Person will be reimbursed for
the cost of the services. Right To Require Medical Exams [Carrier], has the right to require medical exams be performed on any claimant for whom a
claim is pending as often as We may reasonably require. If We requires a medical exam, it
will be performed at Our expense. We also have the right to request an autopsy in the
case of death, if state law so permits. Unusual Circumstances If the rendering of services or benefits under this plan is delayed or impractical due to: (a)
complete or partial destruction of facilities; (b) war; (c) riot; (d) civil insurrection; (e) major
disaster; (f) disability of a significant part of participating hospital and practitioner network;
(g) epidemic; (h) labor dispute not involving employees of [Carrier], Participating hospitals
and other Participating Providers, Participating Providers will use their best efforts to
provide services and benefits within the limitations of available facilities and personnel.
However, neither [Carrier], nor any Participating Providers shall have any liability or
obligation because of a delay or failure to provide such services or benefits. If the
rendering of services or benefits under this plan is delayed due to a labor dispute involving
[Carrier], or Participating Providers, non-emergency care may be deferred until after the
resolution of the labor dispute. GRIEVANCE PROCEDURE Carrier should insert new grievance procedure submitted for approval to the Agency
for Health Care Administration in September, 1997. FORM NUMBER 22 COVERAGE PROVISIONS This section provides important information about the coverage provided under this
Plan, explaining: A. What rules the Covered Person must follow in accessing care; B. What services and supplies are covered; and C. What services and supplies are not covered. COVERAGE ACCESS RULES It is important that Covered Persons become familiar with the rules for accessing health
care services through Us The following sections explain the role of [Carrier], [and the
Primary Care Physician], how to access specialty care through [Carrier], [and the
Primary Care Physician,] and what to do if Emergency Services and Care is needed. CHOOSING A PRIMARY CARE PHYSICIAN The first and most important decision each Covered Person must make when joining a
health maintenance organization is the selection of a Primary Care Physician. This
decision is important since it is through this Physician that all other health services,
particularly those of specialists, are obtained. The Covered Person is free to choose any
Primary Care Physician listed in Our published list of Primary Care Physicians whose
practice is open to additional [Carrier], Covered Persons. This choice should be made
when the Covered Person enrolls. If the Covered Person fails to choose a Primary Care
Physician when enrolling, We will assign one to the Covered Person and notify the
Covered Person of that assignment. Some important rules apply to the Covered Person's
Primary Care Physician relationship: A. The Primary Care Physician selected by the Covered Person will maintain a Physician-patient relationship with the Covered Person, and will be solely
responsible for providing, authorizing and coordinating all medical services for the
Covered Person.] B. The Covered Person must look to the Primary Care Physician to direct his/her care, and should accept procedures and/or treatment recommended by the Primary Care
Physician. C. A Covered Person does not need to obtain a referral or prior authorization for dermatologic office visits or minor procedures and testing performed by a
Participating dermatologist. A Covered Person is limited to five (5) visits every
twelve (12) months with a Participating dermatologist. FORM NUMBER 23 D. Except for Emergency Medical Conditions, all services must be received from the Covered Person's Primary Care Physician, from Participating Providers on referral
from the Primary Care Physician, or through another Health Care Provider
designated by [Carrier], or the Covered Person's Primary Care Physician. E. [Carrier], wants the Covered Person and the Primary Care Physician to have a good relationship. To be certain this relationship is conducive to effective health care,
both the Covered Person and the Primary Care Physician may request a change in
the Primary Care Physician assignment:. 1. The Covered Person may request transfer of his or her health care to another Primary Care Physician whose practice is open to enrollment of
additional [Carrier], Covered Persons. The Covered Person shall be
limited to not less than four (4) transfer requests within a calendar year.
The transfer of care to the newly selected Primary Care Physician shall
be effective [the first day of the calendar month following the date of
receipt by [Carrier], of the request.] 2. Instances may occur where the Primary Care Physician, for good cause, finds it impossible to establish an appropriate and viable Physician-
patient relationship with the Covered Person. In such a circumstance, the
Primary Care Physician may request that [Carrier], assist the Covered
Person in the selection of another Primary Care Physician. F. If for any reason the Primary Care Physician or other contracting Health Care Provider fails to or is unable to provide the Covered Person with services they have
agreed to provide, [Carrier], agrees to provide, arrange or pay for services
equivalent to those described in the Covered Services section up to the date for
which payment has been made by the Covered Person. G. If the Primary Care Physician selected by the Covered Person terminates his or her agreement with [Carrier], or is unable to perform his or her duties or is on a leave of
absence, We may assist the Covered Person in selecting another Primary Care
Physician whose practice is open to new Covered Persons . H. If a Participating Provider terminates his contract with Us or is terminated by Us for any reason other than for cause, the treating Provider must provide continuous care
for no less than sixty (60) days to a Subscriber with a life-threatening or a disabling
or degenerative condition. If a Subscriber is in the third trimester of pregnancy, care
must be continued through postpartum care. I. When payment is provided for surgical first assisting benefits or services, payment will also be provided for the services of a registered nurse first assistant or
employers of a physician assistant or nurse first assistant who performs such FORM NUMBER 24 services that are within the scope of their professional license and only when their
services are used as a substitute. If such services are provided by a registered
nurse first assistant, the Plan will only pay the reimbursement for such provider and
will not also pay for the supervising physician.] SPECIALTY CARE The Primary Care Physician selected by the Covered Person will with [Carrier]’s
authorization, refer the Covered Person to Participating specialists or facilities when
Medically Necessary, using a referral form authorized by [Carrier] The referral form will
identify a course of treatment or specify the number of visits authorized for the diagnosis or
treatment of the Covered Person's Condition. Once the approved referral form has been obtained, the Covered Person may make an
appointment with the specialist at his/her convenience provided it is within sixty (60) days
from the date of issue of the referral. When additional services or visits are suggested by the specialist, Covered Persons should
first consult with their Primary Care Physician to obtain additional authorization/referrals. The Covered Person's Primary Care Physician will consult with [Carrier], and the specialist
and coordinate the Covered Person's care. This procedure provides the Covered Person
with continuity of treatment by the Physician who is most familiar with the Covered Person's
medical history and who understands the Covered Person's total health profile. If a specialist beyond those participating with [Carrier], is required, the Primary Care
Physician will authorize such treatment only if authorized by [Carrier] An agreed upon
treatment plan will then be implemented.] EMERGENCY SERVICES AND CARE The procedure the Covered Person should follow for Emergency Services and Care, as
defined in this Plan, depends on whether the treatment is rendered inside or outside the
Service Area. WITHIN THE SERVICE AREA If Emergency Services and Care are required within the Service Area, the Covered Person
should notify [Carrier], or his/her Primary Care Physician prior to receiving care. Prior
approval is not required for an Emergency Medical Condition. The Covered Person should,
in the instance of an Emergency Medical Condition, seek Emergency Services and Care. If
a Covered Person is admitted to a Hospital for an Emergency Medical Condition by a
Physician other than the Covered Person's Primary Care Physician, the Covered Person, a
member of a Covered Person's family or the attending Physician should notify [Carrier], or FORM NUMBER 25 his/her Primary Care Physician at the earliest time reasonably possible to allow the Primary
Care Physician to coordinate any necessary follow up care. Any Emergency room services provided without prior approval of [Carrier], or the Primary
Care Physician are the Covered Person's responsibility, except where an Emergency
Medical Condition is present. The Primary Care Physician cannot make a referral after
non-emergency treatment is provided. OUTSIDE THE SERVICE AREA Emergency Services and Care provided outside the Service Area will be covered if the
Covered Person sustains an accidental injury or becomes ill while temporarily away from
the Service Area. If the Covered Person requires treatment for an Emergency Medical Condition while
outside the Service Area, Emergency Services and Care may be sought without first
contacting [Carrier], or his/her Primary Care Physician. Initial treatment only is covered
without [Carrier]’s, or the Primary Care Physician's approval. The Covered Person should
notify [Carrier], or his/her Primary Care Physician within 24 hours of provision of such
treatment, or as soon thereafter as is practical, so that the Primary Care Physician and
[Carrier], may initiate necessary follow up care. If the Covered Person is admitted to a Hospital for an Emergency Medical Condition by a
Physician other than the Covered Person's Primary Care Physician, the Covered Person, a
member of the Covered Person's family, or the attending Physician should notify [Carrier],
or his/her Primary Care Physician at the earliest time reasonably possible to allow the
Primary Care Physician to coordinate any necessary follow up care. In the event the Covered Person requires Emergency Services and Care for an Emergency
Medical Condition from a Non-Participating Provider while inside or outside the service
area; or, if [Carrier], refers the Covered Person to a Non-Participating Provider, the
Covered Person will be reimbursed for the cost of the services. COVERED PERSON COPAYMENTS For some services, the Covered Person is responsible for paying a portion of the cost of
Covered Services. Usually, this portion is a flat dollar amount referred to as a Copayment.
The Copayment requirements for this Plan are shown in the Schedule of Covered Person
Copayments. The total Copayments the Covered Person is responsible for in any single calendar year
will be limited to an annual maximum of $1500 for an individual and $3000 for a family.
When the Covered Person has paid Copayments which total the annual maximum, no
further Copayments will be required by that Covered Person for the remainder of the
Calendar Year. The Covered Person is responsible for demonstration of the amount of FORM NUMBER 26 Copayments made. The Covered Person may call [Carrier], Customer Service Department
for information on Copayment limits. LIFETIME MAXIMUM COVERAGE LIMIT Coverage under this Plan for each Covered Person for all Covered Services is unlimited as
shown in the Schedule of Benefits. REIMBURSEMENT FOR NON-PARTICIPATING PROVIDER SERVICES [Carrier], will provide or arrange for services to be received from Participating Providers on
a direct service basis. If a Covered Person receives services from a Participating Provider,
[Carrier], will pay the provider directly for all care received. The Covered Person will not
have to submit a claim for payment. In the event the Covered Person requires Emergency Services and Care from a Non-
Participating provider while inside or outside the service area; or, if [Carrier], refers the
Covered Person to a Non-Participating Provider, the Covered Person will be reimbursed for
the cost of the services. DISCRETIONARY AUTHORITY [Carrier], has the discretionary authority to determine eligibility, to construe terms of this
Plan, and to make decisions concerning claims for benefits under the terms of this Plan. FORM NUMBER 27 COVERED SERVICES This section describes the services that are covered under this Standard Conversion Plan
and those that are not covered. It is important that this whole section be reviewed to be
sure both Covered Service details and the limitations and exclusions are understood. Also,
important information is contained in the Schedule of Covered Person Copayments. ALL
OF THESE PROVISIONS SHOULD BE READ CAREFULLY TO UNDERSTAND THE
BENEFITS PROVIDED UNDER THIS PLAN. The services and supplies listed below will be considered Covered Services under this Plan
if the service is: A. Required for a Condition; B. Received from or provided under the orders, direction or authorized approval of the Covered Person's Primary Care Physician and approved by [Carrier], except for
Emergency Services and Care; C. Rendered while coverage under this Plan is in force; and D. Not specifically limited or excluded under this Plan. The Copayment Amounts for which the Covered Person is responsible for the Covered
Services listed below are shown in the Schedule of Benefits. If services are received from Non-Participating Providers, the payment of costs for Covered
Services is subject to [Carrier’s], Non-Participating Provider Allowance Guidelines (See the
definition of Allowance in the Glossary). HOSPITAL SERVICES The services and supplies listed below shall be considered Covered Services when
furnished to a Covered Person at a Hospital on an inpatient or outpatient basis, if the
service or supply is ordered or authorized by [Carrier], and the Covered Person's Primary
Care Physician: A. Room and board for semi-private accommodations, unless [Carrier], has determined that private accommodations are Medically Necessary; B. Confinement in an intensive care unit, cardiac care unit or a neonatal care unit;
C. Miscellaneous hospital services;
D. Services provided by a birthing center licensed pursuant to Florida Statutes, chapter 383.30-383.335.; E. Routine nursery care for a newborn child;
F. Drugs and medicines administered by the Hospital;
G. Respiratory therapy (e.g., oxygen); FORM NUMBER 28 H. Rehabilitative services, when hospitalization is not primarily for rehabilitation.
I. Use of operating room and recovery rooms; J. Use of emergency rooms;
K. Intravenous solutions;
L. Dressings, including ordinary casts, splints and trusses;
M. Anesthetics and their administration;
N. Transfusion supplies and equipment;
O. Diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., electrocardiogram (EKG)); P. Chemotherapy treatment for proven malignant disease; and
Q. Other Medically Necessary services and supplies. AMBULATORY SURGICAL CENTER SERVICES AND OTHER OUTPATIENT MEDICAL
TREATMENT FACILITIES The services and supplies listed below will be considered Covered Services when
furnished to a Covered Person at a Participating Provider ambulatory surgical center or
other outpatient medical treatment facility, if authorized by [Carrier], and the Covered
Person's Primary Care Physician: A. Use of operating room and recovery rooms;
B. Respiratory therapy (e.g., oxygen);
C. Administered drugs and medicines;
D. Intravenous solutions;
E. Dressings, including ordinary casts, splints or trusses;
F. Anesthetics and their administration;
G. Transfusion supplies and equipment;
H. Diagnostic services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., electrocardiogram (EKG)); I. Chemotherapy treatment for proven malignant disease; and J. Other Medically Necessary services and supplies. MEDICAL SERVICES The medical services and supplies listed below will be considered Covered Services if
authorized by [Carrier], and provided or authorized by the Covered Person's Primary Care
Physician: Allergy treatment, [subject to the applicable Medical Payment Guidelines] including allergy
testing, desensitization therapy and allergy immunotherapy, including hyposensitization
serum. Ambulance services, when needed to transport a Covered Person from: FORM NUMBER 29 A. A Hospital which is unable to provide proper care to the nearest Hospital that can provide proper care; B. A Hospital to a Covered Person's nearest home or Skilled Nursing Facility; or C. The place an Emergency Medical Condition occurs to the nearest Hospital that can provide proper care. Ambulance services by boat, airplane, or helicopter will be reimbursed at the Allowance
level for a ground vehicle unless: A. The pick-up point is inaccessible by ground transportation; B. Speed in excess of ground vehicle speed is critical; or C. The travel distance involved in getting the Covered Person to the nearest Hospital that can provide proper care is too far for medical safety, as determined by [Carrier],
and the Covered Person's Primary Care Physician. Anesthesia services, when administered by a Health Care Provider when necessary for a
surgical procedure. Blood, including whole blood, blood plasma, blood components, and blood derivatives,
unless replaced. Breast Cancer Treatment is defined as routine follow-up care to determine whether a
breast cancer has recurred in a Covered Person who has been previously determined
to be free of breast cancer and is not considered medical advice, diagnosis, care, or
treatment for purposes of determining pre-existing conditions unless evidence of breast
cancer is found during or as a result of the follow-up care. Coverage for breast cancer treatment includes inpatient hospital care and outpatient
post-surgical follow-up care for mastectomies when medically necessary in accordance
with prevailing medical standards. Coverage for outpatient post-surgical care is
provided in the most medically appropriate setting which may include the hospital,
treating physician’s office, outpatient center, or the Covered Person’s home. Inpatient
hospital treatment for mastectomies will not be limited to any period that is less than
that determined by the Participating Physician. Coverage for mastectomies includes coverage for prosthetic devices and breast
reconstructive surgery incident to the mastectomy which reestablishes symmetry
between the two breasts due to the removal of all or part of the breast for medically
necessary reasons. The coverage for breast cancer treatment is subject to applicable
Copayment provisions specified in the Schedule of Benefits. FORM NUMBER 30 Cancer diagnosis and treatment, unless otherwise excluded, on an inpatient or outpatient
basis, including chemotherapy treatment, x-ray, cobalt, and other acceptable forms of
radiation therapy, microscopic tests or any lab tests or analysis made for diagnosis or
treatment. Casts, splints, and trusses, when part of treatment in a health care provider facility or
office or in a Hospital emergency room. This does not include the replacement of any of
these items, or dental splints. Child health supervision services when ordered and performed by a Provider for
health maintenance and preventive care. Services include physician-delivered or
physician-supervised visits from birth to 16 years which include a history, a physical
examination, developmental assessment and anticipatory guidance, and appropriate
immunizations and laboratory tests. Services and periodic visits are provided in
accordance with prevailing medical standards consistent with the Recommendations for
Preventive Pediatric Health Care of the American Academy of Pediatrics. Concurrent Physician Care, including surgical assistance, provided a) the care is
authorized by [Carrier] and the Covered Person's Primary Care Physician; b) the additional
Physician actively participates in the Covered Person's treatment; c) the Condition involves
more than one body system or is so severe or complex that one Physician cannot provide
the care unassisted; and d) the Physicians have different specialties or have the same
specialty with different sub-specialties. Congenital or developmental abnormality treatment, provided the treatment, or plastic
and reconstructive surgery is for the restoration of bodily function, or the correction of a
deformity resulting from disease, injury or congenital or developmental abnormalities. Consultations, provided the Covered Person's Primary Care Physician requests the
consultation and the consulting Physician prepares a written report. Dental services for the treatment of an Accidental Dental Injury to sound natural teeth if the
Injury occurs, and the services are rendered, while the Covered Person's covered and the
treatment is received within six (6) months of the accident (Note: This Benefit does not
include coverage for expenses for services related to an injury occurring while, and as a
result, of biting or chewing). Diabetes including all medically appropriate and necessary equipment, supplies and
diabetes outpatient self-management training and educational services used to treat
diabetes, when the Covered Person’s physician that specializes in the treatment of
diabetes certifies that such services are necessary and [Carrier], or his/her Primary Care
Physician approves the service in writing. We may require that diabetes outpatient self-
management training and educational services be provided under the direct supervision of
a certified diabetes instructor or a board-certified endocrinologist. We may require that
nutrition counseling be provided by a licensed dietitian. FORM NUMBER 31 Diagnostic procedures, lab tests or x-ray exams, including their interpretation, for the
treatment of a Condition. Durable medical equipment that is specifically listed below and when determined by
[Carrier], and the Covered Person's Primary Care Physician to be Medically Necessary for
the care and treatment of a Condition covered under this Plan. The specified durable
medical equipment will not, in whole or in part, serve as a comfort or convenience item for
the Covered Person. Supplies and services to repair medical equipment may be a
Covered Benefit only if the Covered Person owns the equipment or is purchasing the
equipment. [Carrier]’s allowance for durable medical equipment is based on the most cost
effective durable medical equipment which meets the Covered Person's needs, as
determined by Us. At [Carrier]’s or his/her Primary Care Physician's option, the cost of
either renting or purchasing will be covered. If the cost of renting is more than its purchase
price, only the cost of the purchase is considered a Covered Service. The only equipment
that is covered is as follows: Canes/crutches, walkers, Hospital beds, commode chairs, bedpans/urinals, decubitus care
equipment, ostomy and urinary products, LSO and TLSO braces, traction equipment, and
standard wheelchairs. Eye care, limited to the following: A. Aphakic patients and soft lenses or sclera shells intended for use in the treatment of a Condition, B. Initial glasses or contact lenses following cataract surgery, and C. Following an Injury to a Covered Person's eyes, while a Covered Person. Hemodialysis for renal disease, including the equipment, training and medical supplies
required for effective home dialysis. Immunizations, when Medically Necessary, including flu shots, or which are necessary in
the course of other medical treatments of a covered condition. Insulin, including the needles and syringes needed for insulin administration when
dispensed by a Participating Pharmacist. However, the Covered Person must have a
Physician's authorization for such supplies on record with the pharmacy where the supplies
are purchased. FORM NUMBER 32 Mammograms performed for breast cancer screening, but limited to the following: A. A baseline mammogram for women age 35 through 39; B. A mammogram for women age 40 through 49, every two years or more frequently based upon a Physician's recommendation; C. A mammogram every year for women age 50 and over. D. One or more mammograms per year, based on the Covered Person’s Physician’s recommendation, for any woman who is at risk for breast cancer due to: a. a personal or family history of breast cancer;
b. a history of biopsy-proven benign breast disease;
c. having a mother, sister or daughter who has had breast cancer; or
d. a woman not having given birth before the age of thirty (30) [Mammograms performed pursuant to the above are covered in full, with no Copayment.] Newborn child care services received on an inpatient or outpatient basis following birth.
These services include post-delivery care which includes newborn assessments, physical
assessments, and the performance of any medically necessary clinical tests and
immunizations in keeping with prevailing medical standards. Post-delivery care may be
provided at the hospital, at the attending physician’s office, at an outpatient maternity
center, or in the home by a qualified licensed health care professional trained in mother and
baby care. Coverage include the services provided in a licensed birthing center and the
services of certified nurse-midwives and midwives licensed pursuant to Florida Statutes,
chapter 467. Obstetrical and maternity care received on an inpatient or outpatient basis including
medically necessary prenatal and postnatal care of the mother. This also includes post
delivery care including a postpartum assessment of the mother, and the performance of any
medically necessary clinical tests and immunizations in keeping with prevailing medical
standards and may be provided at the hospital, at the attending physician’s office, at an
outpatient maternity center, or in the home by a qualified licensed health care professional
trained in mother and baby care. Coverage include the services provided in a licensed
birthing center and the services of certified nurse-midwives and midwives licensed pursuant
to chapter 467. Oxygen, including the use of equipment for its administration. However, [Carrier], reserves
the right to monitor a Covered Person's use of oxygen to assure its safe and medically
appropriate use. FORM NUMBER 33 Pap smears, when Medically Necessary. Pap smears that are provided as a preventive
service are covered as part of a periodic health assessment exam in the Preventive and
Reproductive Care Services Benefit below. Pathologist services on an inpatient or outpatient basis. Prosthetic or orthotic devices, if Medically Necessary, including the initial placement of
the most cost effective prosthetic or orthotic device, fitting, adjustments, and repair. We will
also cover the replacement of such prosthetic or orthotic devices if it is determined by the
Covered Person's Primary Care Physician to be necessary because of growth or change. Radiologist services on an inpatient or outpatient basis. Surgical procedures performed on an inpatient or outpatient basis. SPECIAL SERVICES The special services and supplies listed below will be considered Covered Services if
authorized by [Carrier], and provided by or authorized by the Covered Person's Primary
Care Physician, subject to the service limitations described below or in the Schedule of
Benefits: Home health care services are covered when provided by a home health agency, through
a licensed nurse registry or by an independent nurse licensed under Florida Statutes
Chapter 464, if: A. The Covered Person is confined at home and requires Home Health Care Visits; B. The treating Physician sends [Carrier], and the Covered Person's Primary Care Physician a home health care plan of treatment; and C. [Carrier], and the Covered Person's Primary Care Physician approves the plan of treatment in writing as being Medically Necessary and that the services are being
provided in lieu of hospitalization or continued hospitalization. [Carrier], and the Covered Person's Primary Care Physician will review the Covered
Person's Condition to determine the medical necessity for home health care services. If the
Covered Person's Condition does not warrant the services provided by a home health
agency, nurse registry or independent nurse, services will be denied. At such time as
documentation is provided for and services are found to be Medically Necessary and in lieu
of hospitalization or continued hospitalization, services will be covered. FORM NUMBER 34 Home health services include: A. Part-time or intermittent nursing care by a registered nurse or licensed practical nurse; B. Physical therapy, by a registered physical therapist; occupational therapy, by an occupational therapist; and speech therapy, by a speech-language pathologist. C. Medical appliances, equipment, laboratory services, supplies, drugs, and medicines prescribed by a Physician or other Health Care Provider and other services provided
by or for a home health care agency, through a licensed nurse registry or by an
independent nurse licensed under Florida Chapter 464, to the extent that they would
have been covered if the Covered Person had been confined in a Hospital; The covered home health care services under this Benefit do not include any service that
would not have been covered had the Covered Person been confined in a Hospital. Hospice services, when hospice services are the most appropriate and cost effective
treatment, as determined by [Carrier], and the Covered Person's Primary Care Physician.
Covered Persons who are diagnosed as having a terminal illness with a life expectancy of
one year or less may elect hospice care for such illness instead of the traditional services
covered under this Plan. To qualify for coverage, the attending Physician must (1) certify that the patient is not
expected to live more than one year; (2) submit a written hospice care plan or program and
(3) submit a life expectancy certification. All hospice care expenses must be approved in
writing by [Carrier]. Covered Persons who elect hospice care under this provision are not
entitled to any other services under this plan for the terminal illness while the hospice
election is in effect. Under these circumstances, the following services are covered. A. Home hospice care, comprised of: 1. Physician services and part-time or intermittent nursing care by a registered nurse or licensed practical nurse; 2. Home health aides;
3. Inhalation (respiratory) therapy;
4. Medical social services;
5. Medical supplies, drugs and appliances;
6. Medical counseling for the terminally ill Covered Person; and
7. Physical, Occupational and Speech Therapy, if approved by [Carrier], as appropriate for special circumstances. B. Inpatient hospice care in a hospice facility, Hospital or Skilled Nursing Facility, if approved in writing by [Carrier], including care for pain control or acute chronic
symptom management. However, the Allowance for such inpatient care will not FORM NUMBER 35 exceed the Allowance for the same or similar care when administered on an
outpatient basis. Covered hospice services do not include bereavement counseling, pastoral counseling,
financial or legal counseling, or custodial care. The hospice treatment program must: A. Meet the standards outlined by the National Hospice Association; and B. Be recognized as an approved hospice program by [Carrier], and the Covered Person's Primary Care Physician; and C. Be licensed, certified, and registered as required by Florida law, and D. Be directed by a Physician in consultation with the Covered Person's Primary Care Physician and coordinated by a registered nurse, with a treatment plan that provides
an organized system of hospice facility care; uses a hospice team; and has around-
the-clock care available. Mental and Nervous Disorders Treatment Expenses for the services and supplies listed below for the treatment of Mental and
Nervous Disorders will be considered Covered Services if provided to the Covered Person
by a Participating Provider: A. Inpatient confinement in a Hospital or a psychiatric facility for the treatment of a Mental and Nervous Disorder, if authorized by [Carrier], Coverage is limited as
shown in the Schedule of Benefits. Coverage includes visits from a psychiatrist or
other Physician during confinement. B. Outpatient treatment provided by a licensed psychiatrist, psychologist, clinical social worker, marriage and family therapist, or mental health counselor, for a Mental and
Nervous Disorder, including diagnostic evaluation and psychiatric treatment,
individual therapy, and group therapy. Coverage is limited as shown in the
Schedule of Benefits. Pre-admission tests, if Medically Necessary and when ordered or authorized by [Carrier],
and the Covered Person's Primary Care Physician. However, the following conditions must
be met:: A. The admission to the Hospital or the scheduled outpatient surgery must be confirmed in writing by [Carrier], or the Covered Person's Primary Care Physician
before the testing occurs. FORM NUMBER 36 B. The tests must be performed within 7 days before admission to the Hospital or the outpatient surgery. C. The tests must be ordered by [Carrier], and or authorized by the Covered Person's Primary Care Physician. D. The tests are performed in a facility accepted by the Hospital in place of the same tests which would normally be done while Hospital confined. E. The tests are not duplicated in the Hospital to confirm diagnosis. F. The Covered Person is subsequently admitted to the Hospital or the outpatient surgery is performed, except if a Hospital bed is unavailable or because there is a
change in the Covered Person's Condition which would preclude the procedure. Prescription drugs are covered when prescribed by a Physician or other Health Care
Provider authorized to prescribe drugs within the scope of their license, and are received by
the Covered Person. Prescription drugs purchased from a Participating Pharmacy are
subject to the following provisions: The prescription drug Copayments are shown in the Schedule of Benefits, and is printed on
the Covered Person's ID card. The Covered Person's ID card must be presented to a
Participating Pharmacy each time a prescription is filled or refilled. The Copayment must
be paid by the Covered Person each time a prescription is filled or refilled at a Participating
Pharmacy. The Copayment covers only generic drugs if a generic is available. If a generic drug is
not available, and the Covered Person is dispensed a brand name prescription drug, the
Covered Person is only responsible for the Copayment amount for a generic prescription
drug. If a generic drug is available and a more expensive brand name prescription drug is
dispensed at the request of the Covered Person or the prescribing Health Care Provider,
the Covered Person must pay the Copayment amount for a brand name drug plus pay the Pharmacist 100% of the additional cost for the more expensive brand name prescription
drug. Covered prescription drugs: A. Any drug, medicine, medication, or oral contraceptives that, under Federal or state law, may be dispensed only by prescription from a prescribing Health Care Provider
or any compounded prescription containing such drug, medicine or medication; B. Must be prescribed by a Physician or Health Care Provider authorized to prescribe drugs within the scope of their license for the treatment of a Condition. FORM NUMBER 37 C. Must be dispensed by a Pharmacist; D. Must be a generic medication when both a generic and a more expensive brand name drug are available and equally effective; E. Are limited to the lesser of a 31 day or 100 unit dose supply per prescription; F. Include prescription refills, but will not be covered until at least 75% of the previous prescription has been used by the Covered Person, (based on the dosage schedule
prescribed by the Physician); and G. Must be included in the Formulary approved by [Carrier]; and] H. Injectable drugs and biologicals only if: 1. Such injectables cannot be self-administered and are furnished incidental to a Health Care Provider's covered professional services; 2. They are reasonable and necessary for the diagnosis or treatment of the Covered Illness or Injury for which they are administered according to accepted
standards of [Carrier]; 3. They have not been determined by the FDA to be "less-than-effective"; 4. The injection is considered the indicated effective method of administration according to the accepted standards of medical practice for the Covered
Condition; 5. The frequency, amount, and duration of the course of injectable drug or biological meets accepted standards of medical practice as an appropriate level
of care for a specific condition, unless there are extenuating circumstances
which justify the need for additional injections; 6. They are a cost-effective alternative for an otherwise Covered Service as determined by [Carrier], and the Covered Person’s Primary Care Physician; 7. [They are included in a Formulary approved by [Carrier]] "Incidental to a Health Care Provider's professional service" means that the injectable is
furnished as an effective integral, although incidental, part of the Health Care Provider's
personal professional services in the course of diagnosis or treatment of a specific injury or
illness. In addition, the injection must be given by the Physician or under the Physician's
supervision. This does not mean, however, that to be considered "incidental to", each
injection must always be at the occasion of the actual rendition of a personal professional FORM NUMBER 38 service of the Health Care Provider. Such injections could be considered to be "incidental
to" when furnished during a course of treatment where the Health Care Provider performs
the initial service and subsequent services of a frequency which reflect his active
participation in and the management of the course of treatment. Infusions of cancer
chemotherapy drugs are considered to be procedures and not injections. When a Health Care Provider gives the Covered Person a subcutaneous, intramuscular,
intravenous or intraarterial injection, no additional payment will be made for the
administration of the injection. Payment is made separately for the drug or biological
injected, but the cost of the other supplies and the administration of the drug or biological is
included in the payment for the visit or other services rendered. I. Home administered and self-injectable drugs and biologicals only if: 1. Injection is considered the indicated effective method of administration for which the drug or biological is prescribed according to accepted standards of [Carrier],
for the covered condition; 2. The drug or biological can be safely self-administered based upon accepted standards of medical practice; 3. They are not immunizing agents; 4. They are reasonable and necessary for the specific or effective treatment of the Covered Condition according to accepted standards of medical practice; 5. They have not been determined by the FDA to be "less-than-effective"; 6. The frequency, amount and duration of the prescribed course of injectable drug or biologicals meets accepted standards of medical practice as an appropriate
level of care for a specific condition, unless there are extenuating circumstances
which justify the need for additional injections; and 7. They are a cost-effective alternative for an otherwise Covered Service as determined by [Carrier], and the Covered Person's Primary Care Physician. 8. [They are included in a Formulary approved by [Carrier].] No coverage is provided for: A. Any drug, medicine or medication that is consumed at the place where the prescription is given or that is dispensed by a Health Care Provider; B. Any portion of a prescription or refill that exceeds a 31-day supply or a 100 unit dose, whichever is less; FORM NUMBER 39 C. Prescription refills in excess of the number specified by the prescribing Health Care Provider or dispensed more than 6 months from the date of the original order; D. The administration of covered medication unless otherwise covered herein; E. Prescriptions that are to be taken by or administered to the Covered Person, in whole or in part, while he or she is a patient in a Hospital, Skilled Nursing Facility,
convalescent Hospital, inpatient hospice facility or other facility where drugs are
ordinarily provided by the facility on an inpatient basis; F. Prescriptions that may be properly received without charge under local, state, or federal programs, including Worker's Compensation; G. Prescriptions ordered or received in excess of any maximums covered under this benefit, and not covered under any other provision in this Plan; H. Any drug, medicine or medication labeled "Caution-Limited by Federal Law to Investigational Use." Any experimental drug or drug used for non-FDA approved
indication or prescribed for use by a route of administration that is not approved by
the FDA even though a charge is made to the Covered Person; I. Immunizing agents, biological serums or allergy serums, unless otherwise
covered herein; J. Any drug or medicine that is lawfully obtainable without a prescription; K. Therapeutic devices or appliances, including hypodermic needles/syringes unless otherwise covered herein; support garments, and other non-medical substances,
regardless of intended use; [L. Prescriptions filled at a Non-Participating Pharmacy, except for prescriptions required for an Emergency Medical Condition;] M. Any costs related to the mailing, sending or delivery of prescription drugs. Preventive medical and reproductive care services, limited to the services listed below.
Coverage is subject to the Calendar Year Preventive Medical and Reproductive Care
Services Maximum shown in the Schedule of Benefits and your responsibility will be based
on the Copayment amount or the Allowance, whichever is less: A. A periodic health assessment examination performed or authorized by the Covered Person's Primary Care Physician, which includes 1. A health history; FORM NUMBER 40 2. A physical examination; 3. Laboratory tests which include urinalysis for blood, sugar, and acetone, and hemoglobin and hematocrit tests; 4. A stool for occult blood; 5. A tuberculin skin test; 6. Tests for sexually transmitted diseases; 7. Vision screening; and 8. Hearing screening For women, this examination may be a gynecological exam that also includes a manual
breast exam, a pelvic exam, and a pap smear. This does not include exams required for travel, or those needed for school,
employment, insurance, or governmental licensing, unless the service is within the
scope of, and coinciding with, the periodic health assessment exam. Only one exam
per Calendar Year is allowed. B. Injectable contraceptives which are subject to the per prescription Copayment shown in the Schedule of Benefits in addition to the Copayment for a Provider Office
Visit. C. Contraceptive appliances, including an IUD or diaphragm appliance and its insertion, and norplant insertion and removal which are subject to the Copayment
shown in the Schedule of Benefits. However, this Plan will not cover any related
reconstructive surgery if needed. Rehabilitative Services, limited to the therapy categories listed below. [Carrier], and the
Covered Person's Primary Care Physician must specifically approve a written plan of
treatment submitted by the Covered Person's Physician and agree that the Covered
Person's Condition will improve significantly within 60 days of the date therapy begins. A. Services of a licensed speech-language pathologist to aid in the restoration of speech loss or an impairment resulting from Injury, stroke or a surgical procedure
while this coverage was in force. B. Services of a licensed audiologist to determine and measure the hearing function loss and aid in the restoration of hearing function loss, if such loss has occurred
while this coverage was in force. FORM NUMBER 41 C. Services of a licensed physical therapist, occupational therapist, or respiratory or inhalation therapist for the purpose of aiding in the restoration of normal physical
function lost due to Injury, stroke or a surgical procedure while this coverage was in
force. Rehabilitative services provided while the Covered Person is Hospital confined will be
covered for the duration of the Hospital confinement, subject to the conditions listed above.
Outpatient rehabilitative services are limited as shown in the Schedule of Benefits. Rehabilitative services do not include other therapy types, or any service or supply: A. Provided to a Covered Person as an inpatient in a Hospital or other facility, where the admission is primarily to provide rehabilitative services. B. Services that maintain rather than improve a level of physical function, or where it has been determined that the services will not result in significant improvement in
the Covered Person's Condition within a 60 day period. [Second surgical opinions from a Physician who is listed in [Carrier]’s, directory or any
Physician located in the same geographical service area after a Covered Person has
received a recommendation to have surgery. This consultation includes the physical
examination, laboratory work and x-rays not previously performed by the original Physician.
The consulting Physician must not be affiliated in practice with the surgeon who first
recommended surgery. [Carrier], will cover the second surgical opinion services for a Covered Person in obtaining
a second surgical opinion, after he or she has received a recommendation to have elective
surgery which is covered under this Plan, if the following conditions are met: A. The consulting Physician must personally examine the Covered Person and [Carrier], and the Covered Person's Primary Care Physician must receive a copy of
the written opinion; and B. The consulting Physician must not perform the surgery to correct the Condition for which the original recommendation was given. If the second opinion does not confirm the original recommendation, the Covered Person
shall consult another Physician for a third opinion. The third opinion must be obtained, and
the service will be covered in the same manner as the second opinion.] Skilled nursing facility services expenses are covered only if [Carrier], and the Covered
Person's Primary Care Physician approves a written plan of treatment submitted by a
Physician; and only if [Carrier], and the Covered Person's Primary Care Physician agrees
that such skilled level services are being provided in lieu of hospitalization or continued FORM NUMBER 42 hospitalization. If provided in the Skilled Nursing Facility, covered expenses include room
and board; respiratory therapy (e.g., oxygen); drugs and medicines administered while an
inpatient; intravenous solutions; dressings, including ordinary casts; anesthetics and their
administration; transfusion supplies and equipment; diagnostic services, including
radiology, ultrasound, laboratory, pathology and approved machine testing (e.g.,
electrocardiogram (EKG)); chemotherapy treatment for proven malignant disease; and
other Medically Necessary services and supplies. Services must be skilled level services,
and must be ordered by and provided under the direction of a Physician. Spine and Back Disorder Treatment, consisting of Medically Necessary non-surgical
spine and back disorder treatments, subject to all plan provisions and limited as shown in
the Schedule of Benefits. Transplantation of a covered tissue and organ transplant, as defined below, if approved
by Us and if performed at a facility approved by [Carrier], and the Covered Person's
Primary Care Physician, subject to those conditions and limitations described below. Transplantation includes pre-transplant, transplant and post-discharge services, and
treatment of complications after transplantation. We will pay benefits only for services, care
and treatment received for or in connection with the approved transplantation of the
following human tissues or organs: A. Cornea;
B. Heart;
C. Liver, but only for Covered Persons through age 17 with biliary atresia;
D. Kidney;
E. Bone marrow, but only for acute lymphocytic leukemia, acute non-lymphocytic leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, or Stage II, III, or IV breast
cancer. [Carrier], will not cover bone marrow transplants for treatment of cancers or
diseases of any other organ or system. As used in this Plan, the term "bone marrow transplant" means human blood precursor
cells which are administered to a patient following ablative or myelosuppressive therapy.
Such cells may be derived from bone marrow, circulating blood, or a combination of bone
marrow and circulating blood obtained from the patient in an autologous transplant or from
a matched related or unrelated donor. If chemotherapy is an integral part of the treatment
involving bone marrow transplantation, the term "bone marrow transplant" includes the
harvesting, the transplantation and the chemotherapy components. [For a transplant procedure to be considered approved for this transplant benefit, prior
approval from Our Medical Affairs Department is required in advance of the procedure.
Corneal transplants are considered to be tissue transplants and do not require prior
approval. The Covered Person or the Covered Person's Physician must notify Us in
advance of the Covered Person's initial evaluation for the procedure in order for Us to
determine if the transplant services will be covered. For approval of the transplant itself, FORM NUMBER 43 Our Medical Affairs Department must be given the opportunity to evaluate the clinical
results of the evaluation. Such evaluation and approval will be based on written criteria and
procedures established by Our Medical Affairs Department. If approval is not given,
benefits will not be provided for the transplant procedure.] No benefit is payable for or in connection with a transplant if: A. The organ or diagnosis involved is not listed above. B. [Carrier]’s, Medical Affairs Department is not contacted for authorization prior to referral for transplant evaluation of the procedure. C. [Carrier]’s, Medical Affairs Department does not approve coverage for the procedure. D. The transplant procedure is performed in a facility that has not been designated by [Carrier]’s, Medical Affairs Department as an approved transplant facility. E. The cost of the services are eligible to be paid under any private or public research fund, government program, or other funding program, whether or not such funding
was applied for or received. F. The service relates to the transplantation of any non-human organ or tissue. G. The service relates to the donation or acquisition of an organ for a recipient who is not covered by [Carrier] H. A denied transplant is performed; this includes follow up care, immunosuppressive drugs, and complications of such transplant. The following services and supplies are also not covered: A. Artificial heart devices used as a bridge to transplant. B. Drugs used in connection with diagnosis or treatment leading to a transplant when such drugs have not received FDA approval for such use. C. Transplant service costs that exceed the Lifetime Transplant Services Maximum. Once the transplant procedure is approved, Our Medical Affairs Department will advise the
Covered Person's Primary Care Physician of those facilities that have been approved for
the type of transplant procedure involved. Benefits are payable only if the pre-transplant
services, the transplant procedure and post-discharge services are performed in an
approved facility. FORM NUMBER 44 For approved transplant procedures, and all related complications, [Carrier], will cover only
the following services, up to a Transplant Services Maximum for all transplant procedures
as shown in the Schedule of Benefits: A. Hospital services and medical services will be paid under the Hospital Services and Medical Services provisions in this Plan, in accordance with the same terms and
conditions as [Carrier], will pay benefits for care and treatment of any other Covered
Condition. B. Transportation costs for the Covered Person to and from the approved facility where the transplant is to be performed if the facility is more than 100 miles from the
Covered Person's home. C. Direct, non-medical costs for one member of the Covered Person's immediate family (two Covered Persons if the patient is under age 18) for (a) transportation to and
from the approved facility where the transplant is performed, but no more than one
round trip per person per transplant and (b) temporary lodging at a prearranged
location during the Covered Person's confinement in the approved transplant facility,
not to exceed $75 per day. Direct, non-medical costs are only payable if the
Covered Person lives more than 100 miles from the approved transplant facility.
There is a $5,000 maximum for these direct, non-medical expenses, subject to the
maximum stated above. D. Organ acquisition and donor costs. However, donor costs are not payable under this Plan if they are payable in whole or in part by any other insurance carrier
organization or person other than the donor's family or estate. [MEDICAL PAYMENT GUIDELINES FOR NON-PARTICIPATING PROVIDER CARE] [If the Covered Person requires care from a Non-Participating Provider, and such care has
been authorized by [Carrier], and the Covered Person's Primary Care Physician, Our
payment for Covered Services will be limited by Our medical payment guidelines then in
effect. These guidelines apply to Covered Services only and are not in addition to all of the
other provisions, limitations and exclusions contained in this Plan. These guidelines
include, but are not limited to, the following:] [A. The payment of expenses for Covered Services received from Non-Participating Providers is limited to payment for services and supplies which, in the opinion of
[Carrier], are the most cost-effective setting, procedure, treatment, supply or service.
For example, services are limited to the most cost-effective prosthetic device,
orthotic device, or durable medical equipment which, in Our opinion, will restore to
the Covered Person the function lost due to the Condition.] [B. Multiple surgical procedures are more than one surgical procedure performed on the same or different areas of the body during the same operative session. This FORM NUMBER 45 includes bilateral procedures and all surgical procedures performed on the same
date of service. The Allowance for all such procedures, other than the primary
procedure, will be 50% of the Allowance for that procedure(s).] [C. Incidental surgical procedures are one or more than one surgical procedure performed through the same incision or operative approach as the primary surgical
procedure which, in Our opinion are not clearly identified and/or do not add
significant time or complexity to the surgical session. [Carrier]’s, payment is limited
to the Allowance for the primary surgical procedure, and there is no additional
Allowance for any incidental procedure.] [D. The Allowance for services rendered by a Physician acting in a surgical assistant role is limited to 16% of the Allowance for the surgical procedure; provided no intern,
resident, or other staff Physician is available. Surgical assistant services must be
rendered by a Physician to be eligible for payment.] [E. The Allowance for allergy testing is based upon the type and number of tests performed by the Physician or other medical Health Care Provider. The Allowance
for allergy immunotherapy is based upon the type and number of doses per vial.] [F. [Carrier]’s, payment for many services and/or supplies is included within the Allowance for the primary procedure and therefore no additional amount is payable
by Us or the Covered Person for any services and/or supplies. Examples include,
but are not limited to: 1. Payment for Physician or Health Care Provider services (e.g., Physician office and Hospital visits) is included in the Allowance for the procedure
with which the service is associated. Examples include but are not limited
to surgical procedures; obstetrical care; electric shock therapy; dialysis,
and therapeutic/diagnostic radiology services. 2. When multiple visits are provided by the same Physician on the same date, payment is limited to one visit which was the highest allowance.] 3. Payment for debridement, wound repair, splinting, strapping, unna boot, cast application and removal, and other related services is included in the
Allowance for fracture care, dislocation treatment, or other surgical
services. 4. Payment for a pathology consultant provided during surgery is included in the Allowance for a frozen section examination. 5. [Carrier]’s, payment for a service includes all components of the service when the service can be described by a single procedure code, or when
the service is an essential part of the associated therapeutic/diagnostic FORM NUMBER 46 service. For example, an RBC is part of a complete blood count, and a
KUB is part of a barium enema.] [G. [Carrier]’s, payment is based on the Allowance for the actual service rendered (for example, not based on the Allowance for a service which is more complex than the
service actually rendered), and is not based on the method utilized to perform the
service nor the day of the work or time of day the procedure is performed.] [H. Payment for psychological testing is limited to 50% of the Allowance for each hour of testing after the first two hours of testing, not to exceed 8 hours during a 12 month
period.] [I. For services rendered by a Physician during Hospital Critical Care, after the first hour of such care, is limited to 16.6% of the critical care Allowance for each
additional 1/2 hour, and further limited to 4 1/2 hours of critical care.] FORM NUMBER 47 EXCLUSIONS AND LIMITATIONS FOLLOWING ACCESS RULES If Covered Persons do not follow the Access Rules described in this section, the Covered
Person risks having services and supplies received not covered by this Plan. In such
circumstances, the Covered Person would be responsible for reimbursing the Plan for the
reasonable cost of the services rendered. Covered Persons must remember that services that are provided or received without
having been prescribed, directed or authorized in advance by [Carrier]’s, Medical Director
or his or her designee and by the Covered Person's Primary Care Physician, or if the
service is beyond the scope of practice authorized for that Health Care Provider under state
law, except in cases of Emergency Services and Care as described in this Plan, are not
covered unless such services otherwise have been expressly authorized under the terms of
this Plan. Except for Emergency Services and Care, all services must be received from
Participating Providers on referral from [Carrier], or the Primary Care Physician. Also, Covered Persons must understand that services that, in [Carrier]'s opinion, are not
Medically Necessary will not be covered. The ordering of a service by a Physician, whether
Participating or Non-Participating, other than the Covered Person's Primary Care Physician
or when expressly authorized by the Primary Care Physician, does not in itself make such
service Medically Necessary or a Covered Service. PRE-EXISTING CONDITION LIMITATIONS A Pre-existing Condition is a condition, or symptoms thereof, which was diagnosed,
and for which an individual received medical advice or treatment from a physician
within a twenty-four month period preceding the effective date of coverage of this Plan..
Coverage will not be excluded for a period beyond twenty-four (24) months following
the individual’s effective date of coverage. If an individual eligible for this Plan applies for coverage in a timely manner (See
Eligibility Section), credit will be given for the partial satisfaction of a pre-existing condition
limitation waiting period if that person was subject to a pre-existing condition limitation
under previous coverage and had not satisfied a 12 month pre-existing condition waiting
period. FORM NUMBER 48 EXCLUSIONS AND LIMITATIONS In addition to Access Rule Conditions and the Pre-existing Condition limitations noted
above, the following services and/or supplies are excluded from coverage, and are not
Covered Services under this Plan: Abortion, including any service or supply related to an elective abortion. However,
spontaneous abortions are not excluded. Also, abortions performed for reasons when
Medically Necessary for the pregnant Covered Person or when the pregnancy would result
in the birth of an infant with grave malformation, are not excluded. Alcoholism or substance abuse services in conjunction with the abuse of or addiction to
alcohol and drugs (including detoxification services, long-term rehabilitation services for
treatment of alcoholism and drug addiction, and including prolonged rehabilitation in a
specialized inpatient or residential facility). Ambulance services other than those specifically provided for in the Covered Services
section. Arch supports, orthopedic shoes, sneakers, or support hose, or similar type
devices/appliances regardless of intended use. Autopsy or postmortem examination services, unless specifically requested by Us. Biofeedback services and other forms of self-care or self-help training and any related
diagnostic testing, hypnosis, meditation, and pain control. Complications of Non-Covered Services, including the diagnosis or treatment of any
Condition which arises as a complication of a non-covered service (e.g., services or
supplies to treat a complication of a pre-existing condition or cosmetic surgery are not
covered under this Plan). Contraceptive appliances, except as specifically provided for in the Preventive Medical
and Reproductive Care Services Benefit or Prescription Drug Benefit. Cosmetic surgery (plastic and reconstructive surgery) and other service and supply to
improve the Covered Person's appearance or self-perception, such as procedures or
supplies to correct baldness or the appearance of skin (wrinkling). The restoration of bodily
function, or the correction of a deformity resulting from disease, Injury, or congenital or
developmental abnormalities, is covered. FORM NUMBER 49 Costs incurred by [Carrier], related to the following: A. Health care services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent such services are payable under any medical expense
provision of any automobile insurance Plan. B. Telephone consultations, failure to keep a scheduled appointment, or completion of any form and /or medical information. Custodial care, including any service or supply of a custodial nature primarily intended to
assist the Covered Person in the activities of daily living. This includes rest homes, home
health aides (sitters), home mothers, domestic maid services, and respite care. Dental care; routine dental procedures including, but not limited to: extraction of teeth,
restoration of teeth with fillings, crowns or other materials, bridges, cleaning of teeth, dental
implants, dentures, periodontal or endodontic procedures, orthodontic treatment including
palatal expansion devices, bruxism appliances, dental x-rays and routine intra-oral surgical
procedures are not covered, except as otherwise covered under the Accidental Dental
Injury provision or the Congenital or Developmental Abnormality provision. Likewise, all procedures, expenses, services, and supplies related to the treatment of
malocclusion or malposition of the teeth or jaws (orthognathic treatment), as well as
temporomandibular joint (TMJ) syndrome or craniomandibular jaw (CMJ) disorders are
excluded unless determined to be Medically Necessary by Us. Dietary regimens or treatments for reducing or controlling weight Durable Medical Equipment, other than the equipment specifically listed in the Covered
Services section. This exclusion includes, but is not limited to, electric wheelchairs,
modifications to motor vehicles and or homes such as wheelchair lifts or ramps; water
therapy devices such as jacuzzis or hot tubs; and exercise equipment. Experimental and Investigational treatment as defined in this Plan. Eye care, including: A. The purchase, examination, or fitting of eyeglasses or contact lenses, except as specifically provided for in the Covered Services section. B. Radial keratotomy, myopic keratomileusis, and any surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or
stigmatic error. C. Training or orthoptics, including eye exercises. FORM NUMBER 50 unless otherwise covered by a rider or endorsement attached to this coverage document. Family planning services, other than those services specifically described in the Covered
Services section. Foot care (routine), including any service or supply in connection with foot care in the
absence of disease. This exclusion includes, but is not limited to, treatment of bunions, flat
feet, fallen arches, and chronic foot strain, removal of warts, corns, or calluses, unless
determined by Us to be Medically Necessary. Hearing aids (external or implantable) and services related to the fitting or provision of
hearing aids, including tinnitus maskers. Home infusion therapy; except for prescription drugs. Hospice services, except as described in the Covered Services section. Hypnotism or hypnotic anesthesia. Immunizations and physical examinations, when required for travel, or when needed for
school, employment, insurance, or governmental licensing, except insofar as such
examinations are within the scope of, and coincide with, the periodic health assessment
examination and/or state law requirements; or immunizations necessary in the course of
other medical treatments of a Covered Sickness or Injury. Infertility treatment, services and supplies, including infertility testing, treatment of
infertility, diagnostic procedures and artificial insemination, to determine or correct the
cause or reason for infertility or inability to achieve conception. This includes in-vitro
fertilization, ovum or embryo placement or transfer, gamete intra-fallopian tube transfer, or
cryogenic or other preservation techniques used in such or similar procedures. Mental health services and supplies which are (a) rendered in connection with a
Condition not classified in the Diagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association, (b) extended beyond the period necessary for evaluation
and diagnosis of learning and behavioral disabilities or for mental retardation, (c) for
marriage and juvenile counseling, (d) court ordered care or testing or required as a
condition of parole or probation; (e) testing for aptitude, ability, intelligence or interest, or (f)
cognitive remediation. Military service-connected medical care for which the Covered Person is legally entitled
to service from military or government facilities, and for which such facilities are reasonably
accessible to the Covered Person. FORM NUMBER 51 Non-prescription drugs, including any non-prescription medicine, remedy, vaccine,
biological product, pharmaceuticals or chemical compounds, vitamin, mineral supplements,
fluoride products, or health foods. Obesity treatment, including surgical operations and medical procedures for the treatment
of morbid obesity, unless determined to be Medically Necessary by Us. Orthomolecular therapy, including nutrients, vitamins, and food supplements. Personal comfort, hygiene or convenience items, including services and supplies
deemed to be not Medically Necessary by Us and not directly related to the care of the
Covered Person, including, but not limited to, beauty and barber services, radio and
television, guest meals and accommodations, telephone charges, take-home supplies,
massages, travel expenses other than Medically Necessary ambulance services or other
transportation services that are specifically provided for in the Covered Services section,
motel/hotel accommodations, air conditioning humidifiers or physical fitness equipment. Private duty nursing care, except as related to covered home health care services. Rehabilitative therapy services, including speech, occupational and physical therapy,
except as described in the Covered Services section. This exclusion includes any services
or supplies: A. Provided to a Covered Person as an inpatient in a hospital or other facility, where the admission is primarily to provide rehabilitative services. B. Services that maintain rather than improve a level of physical function, or where it has been determined that the services will not result in significant improvement in
the Covered Person's Condition within a 60 day period. Reversal of voluntary, surgically-induced sterility, including the reversal of tubal
ligations and vasectomies. Services or supplies that are: A. Determined not to be Medically Necessary; B. Not specifically listed in Covered Services section unless such services are specifically required to be covered by state or federal law. This Plan will provide
coverage on a primary or secondary basis as required by state or federal law. C. Court ordered care or treatment, unless otherwise covered in this Plan. D. For the treatment of a Condition resulting from: FORM NUMBER 52 1. War or an act of war, whether declared or not; 2. Participation in any act which would constitute a riot or rebellion, or a crime punishable as a felony; 3. Engaging in an illegal occupation; 4. Services in the armed forces; 5. Intentionally self-inflicted injuries, suicide or attempted suicide, without regard to the mental state of the Covered Person; or 6. Being under the influence of alcohol or any narcotic unless taken on the specific advice of a Physician. E. Received on or after the date a Covered Person's coverage terminates under this Plan. F. Provided by a Physician or other Health Care Provider related to the Covered Person by blood or marriage. G. Rendered from a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group. H. Non-medical conditions related to hyperkinetic syndromes, learning disabilities, mental retardation, or inpatient confinement for environmental change. I. Supplied at no charge when insurance coverage is not present. Sexual reassignment or modification services, including any service or supply related to
such treatment, including psychiatric services. Skilled nursing facility services not provided in lieu of hospitalization. Smoking cessation programs, including any service or supply to eliminate or reduce the
dependency on or addiction to tobacco, including but not limited to nicotine withdrawal
programs and nicorette gum. Training and educational programs, including programs primarily for pain management,
or vocational rehabilitation. Transplantation or implantation services and supplies, including the transplant or
implant, other than those specifically listed in the Covered Services section. This exclusion
includes: FORM NUMBER 53 A. Any service or supply in connection with the implant of an artificial organ, including the implant of the artificial organ. B. Any organ which is sold rather than donated to the Covered Person. C. Any service or supply relating to any evaluation, treatment, or therapy involving the use of high dose chemotherapy and autologous bone marrow transplantation,
autologous peripheral stem cell rescue, or autologous stem rescue for the treatment
of any Condition other than acute lymphocytic leukemia, acute non-lymphocytic
leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, or Stage II, III, or IV breast
cancer. D. Any service or supply in connection with identification of a donor from a local, state or national listing. Transportation service that is non-emergency transportation between institutional care
facilities, or to and from the Covered Person's residence. Volunteer services or services which would normally be provided free of charge to a
Covered Person. Voluntary sterilization, including tubal ligations and vasectomies, unless Medically
Necessary. Weight control/loss programs, including but not limited to, food supplements, appetite
suppressants, dietary regimens or treatments, exercise programs, or equipment. Wigs or cranial prosthesis, except when related to restoration after cancer or brain tumor
treatment. Work related condition services to the extent the Covered Person is covered or required
to be covered by a workers' compensation law. If the Covered Person enters into a
settlement giving up rights to recover past or future medical Benefits under a workers'
compensation law, this plan will not cover past or future medical services that are the
subject of or related to that settlement. In addition, if the Covered Person is covered by a
workers' compensation program that limits Benefits if other than specified Health Care
Providers are used and the Covered Person receives care or services from a Health Care
Provider not specified by the program, this Plan will not cover the balance of any costs
remaining after the program has paid. FORM NUMBER 54 GLOSSARY This section defines many of the terms used in this Plan. Defined terms are capitalized and
have the meanings set forth in this section. Additionally, certain important terms and
phrases, not appearing in this section, which describe aspects of this plan, may be
capitalized. ACCIDENTAL DENTAL INJURY is an injury to the mouth or structures within the oral
cavity, including teeth, caused by a sudden unintentional, and unexpected event or force. It
does not include injuries to natural teeth caused by biting or chewing. ALLOWANCE means [Carrier to insert specific payment methodology used to pay benefits
(including inside and outside the network, if applicable).] AMBULATORY SURGICAL CENTER is a facility properly licensed pursuant to Chapter
395 of the Florida Statutes, or other state's applicable law, the primary purpose of which is
to provide elective surgical care to a patient, admitted to and discharged from such facility
within the same working day, and which is not part of a Hospital. CALENDAR YEAR is a period of one year which starts on January 1 and ends December
31. CONDITION means any sickness, injury, bodily dysfunction or pregnancy of a Covered
Person. For any preventive care benefits provided in this Plan, Condition includes the
prevention of sickness. CONFINEMENT is an approved Medically Necessary covered stay as an inpatient in a
Hospital that is: A. Due to a Condition; and
B. Authorized by a licensed medical Health Care Provider with admission privileges. Each "day" of confinement includes an overnight stay for which a charge is customarily
made. COPAYMENT means those amounts payable by the Covered Person, at the time of
service, as specifically set forth in the Schedule of Benefits. The Copayment is expressed
as a dollar amount rather than as a percentage. COVERED BENEFITS means those Medically Necessary services and supplies described
in the Covered Benefits section of this Plan and any rider or endorsement attached to it. COVERED OR COVERAGE means inclusion of an individual for payment of expenses
related to Covered Benefits expenses under this Plan. FORM NUMBER 55 COVERED PERSON means the Subscriber and any Eligible Dependents included for
coverage under this Plan. Eligibility requirements for Subscribers and dependents are
specified in the Eligibility provisions. EMERGENCY MEDICAL CONDITION means: A. A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that
the absence of immediate medical attention could reasonably be expected to
result in any of the following: 1. Serious jeopardy to the health of a patient, including a pregnant woman or fetus. 2. Serious impairment of bodily functions.
3. Serious dysfunction of any bodily organ or part. B. With respect to a pregnant woman: 1. That there is inadequate time to effect safe transfer