id' 1 s ,z_l®Wolters Kluwer CT Corporation 

Service of Process Notification 

11/18/2022 

CT Log Number 542707397 

Service of Process Transmittal Summary 

TO: Gail Callanan 

HUMANA INC. 

500 West Main St., 27th Flr. 

Louisville, KY 40202- 

RE: Process Served in Florida 

FOR: Humana Inc. (Domestic State: DE) 

ENCLOSED ARE COPIES OF LEGAL PROCESS RECEIVED BY THE STATUTORY AGENT OF THE ABOVE COMPANY AS FOLLOWS: 

TITLE OF ACTION: ERICA WHITE vs. HUMANA, INC. 

CASE #: 2022021292CA01 

NATURE OF ACTION: Insurance Litigation 

PROCESS SERVED ON: CT Corporation System, Plantation, FL 

DATE/METHOD OF SERVICE: By Process Server on 11/18/2022 at 16:05 

JURISDICTION SERVED: Florida 

ACTION ITEMS: CT will retain the current log 

Image SOP 

Email Notification, Jasmine Anand janand@humana.com 

Email Notification, Robert Croft rcroft3@humana.com 

Email Notification, Patrick Doheny pdoheny1@humana.com 

Email Notification, MELISSA DONOVAN mdonovan5@humana.com 

Email Notification, Wendy Enfors wenfors@humana.com 

Email Notification, Eric Holdridge eholdridge@humana.com 

Email Notification, Christina Isbell cisbell@humana.com 

Email Notification, Katelyn Justice kjustice1@humana.com 

Email Notification, Faith Kennedy fkennedy2@humana.com 

Email Notification, Joyce King jking@humana.com 

Email Notification, MARY MCGUIRE mmcguire1@humana.com 

Email Notification, Bri Sons bsons1@humana.com 

Email Notification, Kara Wort kwort@humana.com 

Email Notification, Gail Callanan gcallanan@humana.com 

REGISTERED AGENT CONTACT: CT Corporation System 

1200 South Pine Island Road 

Plantation, FL 33324 

800-448-5350 

MajorAccountTeam1@wolterskluwer.com 

Page 1 of 2 

A-0001

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 1 of 172
IAI is ,z_l®Wolters Kluwer CT Corporation 

Service of Process Notification 

11/18/2022 

CT Log Number 542707397 

The information contained in this Transmittal is provided by CT for quick reference only. It does not constitute a legal opinion, 

and should not otherwise be relied on, as to the nature of action, the amount of damages, the answer date, or any other 

information contained in the included documents. The recipient(s) of this form is responsible for reviewing and interpreting the 

included documents and taking appropriate action, including consulting with its legal and other advisors as necessary. CT 

disclaims all liability for the information contained in this form, including for any omissions or inaccuracies that may be 

contained therein. 

Page 2 of 2 

A-0002

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 2 of 172
Wolters Kluwer 

PROCESS SERVER DELIVERY DETAILS 

Date: Fri, Nov 18, 2022 

Server Name: Luz Gonzalez 

Entity Served HUMANA INC. 

Case Number 2022-021292-CA-01 

Jurisdiction FL 

Inserts 

A-0003

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 3 of 172
DATE 1 TIME L i

1 

.1AL BADGE# L17. 

By: 32_937 

Filing # 160812585 E-Filed 11/07/2022 08:07:47 P1\4,_ 

IN THE CIRCUIT COURT OF THE 11TH 

JUDICIAL CIRCUIT IN AND FOR MIAMIDADE COUNTY, FLORIDA 

CIVIL DIVISION 

CASE NO.: 2022-021292-CA-01 

ERICA WHITE, 

Plaintiff, 

vs. 

HUMANA, INC., 

Defendant. 

THE STATE OF FLORIDA: 

To Each Sheriff of Said State: 

YOU ARE HEREBY COMMANDED to serve this summons and a copy of 

the complaint or petition in this action on Defendant: 

HUMANA, INC. 

C/O C T CORPORATION SYSTEM 

1200 SOUTH PM ISLAND ROAD 

PLANTATION, FL 33324 

Each defendant is required to serve written defenses to the complaint or petition on 

Plaintiff' s attorney, Leonard Desir, Jr., Esq., THE DESHILAW FIRM, PA., whose 

mailing address is: 1580 Sawgrass Corporate Parkway, Suite 130, Sunrise, FL 

33323, Tel: 954-848-2912 within 20 days after service of this summons on that Defendant, 

exclusive of the day of service, and to file the original of the defenses with the Clerk of this 

Court either before service on Plaintiff's attorney or immediately thereafter. Ifa defendant 

fails to do so, a default will be entered against that Defendant for the reliefdemanded in the 

complaint or petition. 

11/8/2022 DATED ON ,2022. 

Clerk of Said Court 

A-0004

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 4 of 172
IN THE CIRCUIT COURT OF THE 11Th 

JUDICIAL CIRCUIT IN AND FOR MIAMIDADE COUNTY, FLORIDA 

CIVIL DIVISION 

ERICA WHITE, 

Plaintiff, 

vs. 

HUMANA, INC., 

Defendant. 

COMPLAINT 

Plaintiff, ERICA WHITE, by and through undersigned counsel, hereby sues the Defendant, 

HUMANA, INC., and states as follows: 

1. This is an action for breach of contract wherein Plaintiff seeks damages for more than 

$30,000. 

2. Plaintiff, ERICA WHITE, is sui juris and is a resident of Miami-Dade County, 

Florida. 

3. Defendant is, upon information and belief, a corporation duly authorized to conduct 

business in the State of Florida, and which does, in fact, issue policies of insurance in Miami-Dade 

County, Florida. 

4 Defendant issued a health insurance policy to Plaintiff. A copy of the policy is attached 

as Exhibit A. 

5. On or about September 15, 2021, while the subject policy was in full force and effect, 

A-0005

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 5 of 172
Plaintiff suffered from diabetic ketoacidosis with elevated beta-hydroxybutyrate levels that resulted 

in vomiting, nausea, and diarrhea. As a result of Plaintiff's health condition, it was determined that 

it was medically necessary to admit her into a hospital. These damages are covered under the subject 

policy. 

6. As such, Plaintiff submitted a claim with Defendant and said claim was assigned 

Claim No.: 202112178325524. 

7. Plaintiff received a bill from the hospital in the amount of $30,457.49. See 

Exhibit B. 

8. Plaintiff complied with and performed all conditions precedent under the subject 

policy for the recovery of benefits and/or said conditions were waived by Defendant. 

9. However, Defendant, by word, conduct and deed, has refused to pay for the benefits 

due for the covered loss due to Plaintiffs hospitalization due to medical necessity based on her 

health at the time of her admission. 

10. Plaintiff attempted to appeal the denial. 

11. On June 7, 2022, Defendant denied Plaintiffs appeal. See Exhibit C. 

12. Defendant, therefore, has breached the terms of the subject contract of insurance by 

failing to pay the benefits which became due and owing to Plaintiff as a result of her health 

condition. 

13. As a result of Defendant's breach, Plaintiff have suffered damages in the amount of 

insurance benefits due and owing to her under the subject policy. 

14. Defendant's conduct has caused Plaintiff to retain the services of the undersigned 

attorney to represent her in this action, and Defendant is, therefore, also liable for reasonable 

attorney's fees pursuant to Fla. Stat. § 627.6698 for such services. 

A-0006

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 6 of 172
WHEREFORE, Plaintiff, ERICA WHITE, demands judgment against the Defendant, 

HUMANA, INC., for(i) damages and interest thereon, (ii) attorney's fees and costs pursuant to Fla. 

Stat. § 627.6698 and (iii) such other and further relief as this court deems just and proper. 

DEMAND FOR JURY TRIAL 

Plaintiff demands a trial by jury of all issues so triable as of right by jury. 

Dated this 7thday of November, 2022. 

The Desir Law Firm, P.A. 

Attorney for Plaintiff 

1580 Sawgrass Corporate Parkway 

Suite 130 

Sunrise, FL 33323 

Office: 954-848-2912 

Fax: 888-616-7608 

Email: ldesir@thedesirlawfirm.com 

Email: paralegal@thedesirlawfirm.com 

Email: casemanager@thedesirlawfirm.com 

Email: assistant@thedesirlawfirm.com 

By: /s/ Leonard Desir, Jr. 

Leonard R. Desir, Jr., Esq. 

Florida Bar No.: 98928 

A-0007

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 7 of 172
Important! 

At Humana, it is important you are treated fairly. 

Humana Inc. and its subsidiaries do not discriminate or exclude people because of their 

race, color, national origin, age, disability, sex, sexual orientation, gender, gender identity, 

ancestry, marital status or religion. Discrimination is against the law. Humana and its 

subsidiaries comply with applicable Federal Civil Rights laws. If you believe that you have 

been discriminated against by Humana or its subsidiaries, there are ways to get help. 

• You may file a complaint, also known as a grievance: 

Discrimination Grievances, P.O. Box 14618, 

Lexington, KY 40512-4618 

If you need help filing a grievance, call the number on your ID card or if you use a TTY, 

call 711. 

• You can also file a civil rights complaint with the U.S. Department of Health and Human 

Services, Office for Civil Rights electronically through their complaint portal, available at 

https://ocrportal.hhs.gov/ocr/portaUlobbyjsf, or by at U.S. Department of Health and 

Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, 

DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at 

https://www.hhs.gov/ocr/office/file/index.html. 

• California residents: You may also call California Department of Insurance toll-free hotline 

number: 1-800-927-HELP (4357), to file a grievance. 

Auxiliary aids and services, free of charge, are available to you. 

Call the number on your ID card (TTY: 711) 

Humana provides free auxiliary aids and services, such as qualified sign language 

interpreters, video remote interpretation, and written information in other formats 

to people with disabilities when such auxiliary aids and services are necessary to 

ensure an equal opportunity to participate. 

GCHK9X2EN 0220 

A-0008

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 8 of 172
Language assistance services, free of charge, are available to you. 

Call the number on your ID card (TTY: 711) 

ATTENTION: If you do not speak English, language assistance services, free of charge, are 

available to you. Call the number on your ID card (TTY: 711)... ATENCION: Si habla espariol, 

tiene a su disposicion servicios gratuitos de asistencia IinguIstica. Llame al nOmero que figura 

en su tarjeta de identificacion (TTY: 711)... Ark, : PORITIMEIM214:13Z, 21-511gtaMig 

• ft gEft 0 (TTY: 711)... CHO Ngu ban no' Ting Viet, 

co cac clIch %Ai h6 try non ngir.mien phi clanh cho ban. GO so" din thoai ghi tren the ID dm 

quct vi (TTY: 711)...'421: -6J-01--2AFFAI A1E1 12_—E- 01§-61-N 

▪ 21g1-1E1- . ID 51-12ii JFH-T-I1.1Al2. /4 (Try: 711)... PAUNAWA: Kung 

nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang 

walang bayad. Tawagan ang numero na nasa iyong ID card (TTY: 711)... BHMMAHVIE: EC/111 

Bbl roBopwre Ha pycckonn 513bIKB, TO BM AOCTIMHbl 6ecnnamble ycnynn nepeao,qa. Ha6epinTe 

Honnep, YKa3aHHb11.1 Ha Bawe ri KapToLme-yAocToaepeHmin trenerarin: ATANSYON: Si 

w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou ou. Rele nimewo ki sou 

kat idantite manm ou (TTY: 711)... ATTENTION: Si vous parlez frangais, des services d'aide 

linguistique vous sont proposes gratuitement. Appelez le numero figurant sur votre carte 

de membre (ATS: 711)...UWAGA: Jeieli mowisz po polsku, moiesz skorzysta6 z bezptatnej 

pomocy Azykowej. Proszq zadzwonie pod numer podany na karcie identyfikacyjnej 

(TTY: 711)... ATEKAO: Se fala portugues, encontram-se disponiveis servigos linguisticos, 

gratis. Ligue para o niimero presente em seu cartao de identificagao (TTY: 711)... ATTENZIONE: 

In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica 

gratuiti. Chiamare il numero che appare sulla tessera identificativa (TTY: 711)... ACHTUNG: 

Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur 

Verfugung. Wahlen Sie die Nummer, die sich auf Ihrer Versicherungskarte befindet (TTY: 

711)... ARVA : El*fifiVite..r41V4a. 

8fl4t 0) IDt — FiLiEnattl:COrdlitg---C:2Mtii<i"T...t \ (riY: 711)... 

bitazil..-L,114 1-0-1 j1-23 cl *4-La Lro L.T.J.U1-401-Ii 44 )51 :4"9:i 

...(TTY: 711) ..t.LA 

DII baa eke) ninizin: DII saad bee Or-lad/go Dine Bizaad, saad bee 

aka'anida'.iwo'dW, t'66 jiik'eh, éí ná hol(5, namboo ninaaltsoos yezhf, bee 

née ho'dolzin bikaa'igii bee hOlne'(TTY: 711)... 

L.63142,110.).? J.4,51 .01...,2,11.1 ,±11 j.61.gu3 lii LJl iL Bl j.S31 

•(TY: 711) 21,',i...01..i.J1a...L942,11 '4:41:14 

GCHK9X2EN 0220 

A-0009

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 9 of 172
Humana. 

Administrative Office: 

3501 SW 160th Avenue 

Miramar, FL 33027 

Certificate of Coverage 

Humana Medical Plan, Inc. 

Group Plan Sponsor: WHITE, WHITE & ASSOCIATES 

Group Plan Number: 665238 

Effective Date: 01/01/2021 

Product Name: FLDA0006 Copay Hybrid 

In accordance with the terms of the master group contract issued to the group plan sponsor, Humana 

Medical Plan, Inc. certifies that a covered person has coverage for the benefits described in this 

certificate. This certificate becomes the Certificate of Coverage and replaces any and all certificates and 

certificate riders previously issued. 

Bruce Broussard 

President 

This booklet, referred to as a Benefit Plan 

Document, is provided to describe your 

Humana coverage 

This certificate contains a Deductible 

Florida Compare Care resources from the Agency for Health Care Administration (AHCA) can be found 

at https://www.floridahealthfinder.gov/. The site includes helpful information about Florida healthcare, 

plans and facilities. 

CHMO 2004-C SG GF FP 21 3 

A-0010

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 10 of 172
TABLE OF CONTENTS 

Understanding your coverage 9 

Schedule of benefits 13 

Schedule of benefits - behavioral health 25 

Schedule of benefits - transplant services 28 

Covered expenses 30 

Covered expenses - behavioral health 45 

Covered expenses - transplant services 48 

Limitations and exclusions 50 

Eligibility and effective dates 56 

Replacement of coverage 62 

Termination provisions 63 

Extension of benefits 65 

Continuation 66 

Continuation of Coverage for active military service 68 

Coordination of benefits 69 

Coordination of benefits for medicare eligibles 74 

, 

CHMO 2004-C SG GF TC 20 4 

A-0011

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 11 of 172
TABLE OF CONTENTS (continued) 

Claims 75 

Complaint and appeals procedures 81 

Disclosure provisions 85 

Miscellaneous provisions 88 

Glossary 92 

Specialty drug benefit 113 

Prescription drug benefit 117 

CHMO 2004-C SG GF TC 20 5 

A-0012

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 12 of 172
PATIENT PROTECTION AND AFFORDABLE CARE ACT 

RIDER 

This rider is made part of the benefit plan document to which it is attached. 

All terms used in this rider have the same meaning given to them in the benefit plan document unless 

otherwise defined in this rider, by the Patient Protection and Affordable Care Act of 2010 (the 

Affordable Care Act), also known as federal health care reform, or by future federal regulations. Except 

as modified below, all conditions and limitations of the benefit plan document apply. State laws 

continue to apply except to the extent that the state law prevents application of federal health care 

reform. 

If your plan is effective prior to 09/23/2010, these requirements will apply to your current plan as of 

your plan renewal date on or after 09/23/2010. If your plan is effective 09/23/2010 or after, this rider is 

applicable to your current plan as of your plan's effective date. 

Definitions 

Essential health benefits mean the items and services in the following categories defined by the United 

States Health and Human Services (HHS) as set forth by the Affordable Care Act and future federal 

regulations: 

• Ambulatory patient services; 

• Emergency services; 

• Hospitalization; 

• Maternity and newborn care; 

• Mental and substance use disorder, including behavioral health treatment; 

• Prescription drugs; 

• Rehabilitative and habilitafive services and devices; 

• Laboratory services; 

• Preventive and wellness services and chronic disease management; 

• Pediatric services, including oral and vision care. 

Lifetime maximum - 

The lifetime maximum does not apply to essential health benefits. 

Annual limits - 

Annual dollar limits for essential health benefits are removed. 

Rescission - 

We will rescind coverage only due to fraud or an intentional misrepresentation of a material fact. 

HGN-HCR GNGF 06/10 6 

A-0013

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 13 of 172
PATIENT PROTECTION AND AFFORDABLE CARE ACT 

RIDER (continued) 

Dependent coverage - 

If your health plan includes coverage for dependent children, your child is covered to age 26 regardless 

if the child is: 

• Married; 

• A tax dependent; 

• A student; 

• Employed; 

• Eligible for other coverage through employment; or 

• Residing with or receives financial support from you. 

Pre-existing conditions - 

The pre-existing condition limitation does not apply to a covered person who is under the age of 19. 

Preventive care - 

Preventive care services to detect or prevent sickness that have an A or B rating in the current 

recommendations of the U.S. Preventive Services Task Force (USPSTF) are covered without cost sharing 

when provided by a network provider. The recommendations by the USPSTF for breast cancer 

screening, mammography and prevention issued prior to any recommendations issued in or around 

November 2009 will be considered current when applying this benefit. HHS will specify the 

recommendations for preventive services that apply for your plan year. You may be responsible for any 

preventive care services received, that are not specifically required by the Affordable Care Act. 

Internal appeals and external review - 

You have the right to an internal appeal and the right to request an external review of an adverse claim 

determination. If you have questions, you can call the Customer Care number on the back of your 

Humana ID card. We are available to help you Monday through Friday, 8 a.m. to 6 p.m. 

Primary care physicians - 

If your health plan requires you to select a primary care physician, a participating physician specializing 

in pediatrics is permitted to be selected as the primary care physician for a covered dependent child. 

HGN-HCR GNGF 06/10 7 

A-0014

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 14 of 172
PATIENT PROTECTION AND AFFORDABLE CARE ACT 

RIDER (continued) 

Gynecological and obstetrical services - 

If a primary care physician referral is required by your health plan, a female covered person is permitted 

to receive services for obstetrical or gynecological care from a participating health care professional 

specializing in obstetrics or gynecology without a referral from her primary care physician. Services 

received from, or ordered by a participating health care professional for obstetrical or gynecological 

services, are considered authorization from the primary care physician. 

Emergency care - 

Coverage will be provided for an emergency medical condition in a hospital's emergency department: 

• Without prior authorization; 

• With the same restrictions on coverage for non-network providers as those applied for network 

providers; 

• With the same cost-sharing requirements for non-network providers as those applied to network 

providers. In addition to the cost sharing requirements, you may be responsible for the difference 

between the allowed amount under your plan and what is billed by a non-network provider, as 

permitted by the Affordable Care Act; 

• Without regard to any other terms or conditions of the policy other than exclusion; coordination of 

benefits, affiliation or waiting periods, or cost-sharing requirements. 

Humana Medical Plan, Inc. 

Bruce Broussard 

President 

HGN-HCR GNGF 06/10 8 

A-0015

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 15 of 172
UNDERSTANDING YOUR COVERAGE 

As you read the certificate, you will see some words are printed in italics. Italicized words may have 

different meanings in the certificate than in general. Please check the "Glossary" sections for the 

meaning of the italicized words as they apply to your plan. 

The certificate gives you information about your plan. It tells you what is covered and what is not 

covered. It also tells you what you must do and how much you must pay for services. Your plan covers 

many services, but it is important to remember it has limits. Be sure to readyour certificate carefully 

before using your benefits. 

Covered and non-covered expenses 

We will provide coverage for services, equipment and supplies that are covered expenses. All 

requirements of the master group contract apply to covered expenses. 

The date used on the bill we receive for covered expenses or the date confirmed in your medical records 

is the date that will be used whenyour claim is processed to determine the benefit period. 

You must pay the health care provider any amount due that we do not pay. Not all services and supplies 

are a covered expense, even when they are ordered by a health care practitioner. 

Refer to the "Schedule of Benefits," the "Covered Expenses" and the "Limitations and Exclusions" 

sections and rider or amendment attached to the certificate to see when services or supplies are covered 

expenses or are non-covered expenses. 

How your master group contract works 

You may have to pay a deductible before we pay for certain covered expenses. If a deductible applies, 

and it is met, we will pay covered expenses at the coinsurance amount. Refer to the "Schedule of 

Benefits" to see when the deductible applies and the coinsurance amount we pay. You will be 

responsible for the coinsurance amount we do not pay. 

If an out-of-pocket limit applies and it is met, we will pay covered expenses at 100% the rest of the year, 

subject to the maximum allowable fee. 

Our payment for covered expenses is calculated by applying any deductible and coinsurance to what we 

allow. For a covered expense, we will allow the total amount billed by the qualified provider, less any 

amounts such as: 

• Those negotiated by contract, directly or indirectly, between us and the qualified provider; 

• Those in excess of the maximum allowable fee; or 

• Adjustments related to our claims processing procedures. 

The service and diagnostic information submitted on the qualified provider's bill will be used to 

determine which provision of the "Schedule of Benefits" applies. 

CHMO 2004-C SG GF UYC 21 9 

A-0016

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 16 of 172
UNDERSTANDING YOUR COVERAGE (continued) 

Your choice of providers affects your benefits 

We may appoint certain network providers for certain kinds of services. If you do not see the appointed 

network provider for these services, we may pay less. 

Some non-network providers work with network hospitals. We will pay non-network pathologists, 

anesthesiologists, radiologists, and emergency room physicians working with a network hospital at the 

network provider benefit, subject to the maximum allowable fee. Non-network providers have not 

signed an agreement with us to accept discounted or negotiated fees for services and may bill you for 

charges in excess of the maximum allowable fee. Unless balance billing is prohibited by applicable law, 

you may be required to pay any amount not paid by us in addition to any applicable copayment, 

deductible and coinsurance for services received. 

Refer to the "Schedule of Benefits" sections to see your benefits. 

How to find a network provider 

You may find a list of network providers at www.humana.com. This list is subject to change. Please 

check this list before receiving services from a qualified provider. You may also call our customer 

service department at the number listed on your ID card to determine if a qualified provider is a network 

provider, or we can send the list to you. A network provider can only be confirmed by us. 

How to use your health maintenance organization (HMO) plan 

You may receive services from a network provider with your HMO plan without a referral from your 

primary care physician. Refer to the "Schedule of Benefits" for any preauthorization requirements. 

Use of network providers 

In most cases, there are network providers for your health care. Network providers have agreed to 

provide covered expenses at lower costs. You must pay any cop ayment, deductible or coinsurance you 

owe to the network provider. The network provider will accept your copayment, deductible or 

coinsurance and the amount we pay as the full payment. You will not be billed for charges over the 

maximum allowable fee. 

Be sure to determine ifyour provider is a network provider before you receive services from them. We 

offer many health care plans, and a qualified provider who is a network provider for one plan may not 

be a network provider for this plan. 

We may designate certain network providers for certain kinds of services. 

CHMO 2004-C SG GF UYC 21 10 

A-0017

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 17 of 172
UNDERSTANDING YOUR COVERAGE (continued) 

Use of non-network providers 

If a network provider cannot provide the covered expenses you need or they cannot treat your condition, 

you must have a referral from your primary care physician that is approved by us to receive services 

from a non-network provider. Only the services approved by us will be a covered expense. 

Non-network providers have not signed an agreement with us and may bill you for charges in excess of 

any amount over the maximum allowable fee. Unless balance billing is prohibited by applicable law, 

you may be required to pay any amount not paid by us in addition to any applicable cop ayment, 

deductible and coinsurance for services received. Any amount over the maximum allowable fee will not 

apply to your deductible or any out-of-pocket limit. 

Continuity of care 

Continuity of care means the continuation of services from a terminated provider. A terminated provider 

is a network provider whose contract is terminated or not renewed for reasons other than for cause. 

A covered person who is actively under treatment may continue medically necessary treatment with the 

terminated provider until: 

• The covered person selects another provider; or 

• The next open enrollment period; 

whichever period is longer up to a maximum of 6 months following termination of the provider's 

contract. 

Continuity of care is also available for a covered person who is pregnant and has initiated prenatal care, 

regardless of the trimester in which care was initiated. The covered person may continue receiving care 

from a terminated provider until completion of their postpartum care. 

Seeking emergency care 

If you need emergency care: 

• Go to the nearest network hospital emergency room; or 

• Find the nearest hospital emergency room if your condition does not allow you to go to a network 

hospital. 

You, or someone on your behalf, must call us within 48 hours after your admission to a non-network 

hospital for emergency care. If your condition does not allow you to call us within 48 hours after your 

admission, contact us as soon as your condition allows. We may transfer you to a network hospital in 

the service area when your condition is stable. You must receive services from a network provider for 

any follow-up care. 

CHMO 2004-C SG GF UYC 21 11 

A-0018

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 18 of 172
UNDERSTANDING YOUR COVERAGE (continued) 

Seeking urgent care 

If you need urgent care, go to the nearest urgent care center or call an urgent care qualffied provider. 

You must receive urgent care services from a network provider for the network provider copayment, 

deductible or coinsurance to apply. 

Our relationship with qualified providers 

Qualified providers are not our agents, employees or partners. All providers are independent 

contractors. Qualified providers make their own clinical judgments or give their own treatment advice 

without decisions made by us. 

The master group contract will not change what is decided between you and qualffied providers 

regarding your medical condition or treatment options. Qualffied providers act on your behalf when 

they order services. You and your qualffied providers make all decisions about your health care, no 

matter what we cover. We are not responsible for anything said or written by a qualified provider about 

covered expenses and/or what is not covered under this certificate. Please call our customer service 

department at the telephone number listed on your ID card if you have any questions. 

Our financial arrangements with network providers 

We have agreements with network providers that may have different payment arrangements: 

• Many network providers are paid on a discounted fee-for-services basis. This means they have 

agreed to be paid a set amount for each covered expense; 

• Some network providers may have capitation agreements. This means the network provider is paid 

a set dollar amount each month to care for each covered person no matter how many services a 

covered person may receive from the network provider, such as a prima?), care physician or a 

specialty care physician; 

• Hospitals may be paid on a Diagnosis Related Group (DRG) basis or a flat fee per day basis for 

inpatient services. Outpatient services are usually paid on a flat fee per service or a procedure or 

discount from their normal charges. 

The certificate 

The certificate is part of the master group contract and tells you what is covered and not covered and 

the requirements of the master group contract. Nothing in the certificate takes the place of or changes 

the terms of the master group contract. The final interpretation of any provision in the certificate is 

governed by the master group contract. If the certificate is different than the master group contract, the 

provisions of the master group contract will apply. The benefits in the certificate apply if you are a 

covered person. 

CHMO 2004-C SG GF UYC 21 12 

A-0019

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 19 of 172
SCHEDULE OF BENEFITS 

Reading this "Schedule of Benefits" section will help you understand: 

• The level of benefits generally paid for covered expenses; 

• The amounts of copayments and/or coinsurance you are required to pay; 

• The services that require you to meet a deductible, if any, before benefits are paid; and 

• Preauthorization requirements. 

The benefits outlined in this "Schedule of Benefits" are a summary of coverage and limitations provided 

under the master group contract. A more detailed explanation of your coverage and its limitations and 

exclusions for these benefits is provided in the "Covered Expenses" and "Limitations and Exclusions" 

sections of this certificate. Please refer to any applicable riders for additional coverage and/or 

limitations. 

All services are subject to all of the terms, provisions, limitations and exclusions of the master group 

contract. 

The benefits outlined under the "Schedule of Benefits — Behavioral Health" and "Schedule of Benefits — 

Transplant Services" and "Specialty Drug Benefit" sections are not payable under any other Schedule of 

Benefits of the master group contract. However, all other terms and provisions of the master group 

contract, including the individual lifetime maximum benefit, preauthorization requirements, any annual 

deductible(s), and maximum out-of-pocket limit(s), unless otherwise stated, are applicable. 

HSCH1-1100 02/11 

Network provider verification 

This certificate contains multiple network provider benefit levels. The benefits are identified as primary 

care physician and specialty care physician or Concentra in the Schedules of Benefits. 

To know which benefit level is assigned to a network provider, please refer to the Online Physician 

Directory on our Website at www.humana.com. You may also contact our customer service department 

at the telephone number shown on your identification card. This list is subject to change. 

HSCH1-1200FL 04/10 

Individual lifetime maximum benefit 

The total amount of benefits payable for all covered expenses incurred by you will not exceed the 

individual lifetime maximum benefit as follows. 

Individual lifetime maximum benefit Maximum benefit amount 

Individual lifetime maximum benefit per covered 

person 

UNLIMITED 

HSCH1-1300 02/11 

CHMO 2004-C 13 

A-0020

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 20 of 172
SCHEDULE OF BENEFITS (continued) 

Preauthorization requirements 

Preauthorization by us is required for certain services and supplies. Visit our Website at 

www.humana.comor call the customer service telephone number on your identification card to obtain a 

list of services and supplies that require preauthorization. The list of services and supplies that require 

preauthorization is subject to change. Coverage provided in the past for services or supplies that did not 

receive or require preauthorization, is not a guarantee of future coverage of the same services or 

supplies. 

You are responsible for informing your health care practitioner of the preauthorization requirements. 

You or your health care practitioner must contact us by telephone, electronic mail, or in writing to 

request the appropriate authorization. Your identification card will show the health care practitioner the 

telephone number to call to request authorization. Benefits are not paid at all for services or supplies 

that are not covered expenses. 

HSCH1-1500FL 02/11 

Annual deductible 

An annual deductible is a specified dollar amount that you must pay for covered expenses per year 

before most benefits will be paid under the master group contract. There are individual and family 

network provider deductibles. The deductible amount(s) for each covered person and each covered 

family are as follows, and must be satisfied eachyear, either individually or combined as a covered 

family. Once the family deductible is met, any remaining deductible for a covered person in the family 

will be waived for thatyear. Copayments do not apply toward the annual deductible. 

Deductible Deductible amount 

Individual network provider deductible $2,500 

Family network provider deductible $5,000 

HSCH1-1600FL 02/11 

Out-of-pocket limit 

The out-of-pocket limit is the amount of covered expenses that must be paid by you, either individually 

or combined as a covered family, per year before a benefit percentage will be increased. There are 

individual and family network provider out-of-pocket limits. 

CHMO 2004-C 14 

A-0021

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 21 of 172
SCHEDULE OF BENEFITS (continued) 

After the individual network provider out-of-pocket limit has been satisfied in a year, the network 

provider benefit percentage for covered expenses for that covered person will be payable by us at the 

rate of 100% for the rest of the year, subject to any maximum benefit and all other terms, provisions, 

limitations and exclusions of the master group contract. After the family network provider 

out-of-pocket limit has been satisfied in a year, the network provider benefit percentage for covered 

expenses will be payable by us at the rate of 100% for the rest of the year, subject to any maximum 

benefit and all other terms, provisions, limitations and exclusions of the master group contract. 

If an out-of-pocket limit is shown to be unlimited, covered expenses will be paid at the levels indicated 

in this "Schedule of Benefits". You will be responsible for any out-of-pocket expenses. 

Deductibles and copayments do apply towards any out-of-pocket limit. Out-of-pocket expenses for 

specialty drugs do not apply towards any out-of-pocket limit. 

Out-of- ocket limit Out-of- ocket limit amount 

Individual network provider out-of-pocket limit $10,000 

Family network provider out-of-pocket limit $20,000 

HSCH1-1900 04/12 

CHMO 2004-C 15 

A-0022

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 22 of 172
SCHEDULE OF BENEFITS (continued) 

Preventive services 

Preventive services and prostate specific antigen (PSA) test 

Network provider Covered in full 

Health care practitioner office visit services 

Health care practitioner office visit 

Excludes diagnostic laboratory and radiology services, advanced imaging and outpatient surgery. 

Primary care physician $25 cop ayment per visit 

Specialty care physician $55 copayment per visit 

Diagnostic laboratory and radiology services when performed in the office and billed by 

the health care practitioner 

Excludes advanced imaging. 

Primary care physician Covered in full 

Specialty care physician Covered in full 

CHMO 2004-C 16 

A-0023

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 23 of 172
SCHEDULE OF BENEFITS (continued) 

Advanced imaging when performed in a health care practitioner's office 

Primary care physician $300 cop ayment per visit 

Specialty care physician $300 copayment per visit 

Allergy serum when received in a health care practitioner's office 

Primary care physician Covered in full 

Specialty care physician Covered in full 

Allergy injections when received in a health care practitioner's office 

Primary care physician Covered in full 

Specialty care physician Covered in full 

Injections other than allergy when received in a health care practitioner's office 

Primary care physician Covered in full 

Specialty care physician Covered in full 

CHMO 2004-C 17 

A-0024

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 24 of 172
SCHEDULE OF BENEFITS (continued) 

Surgery performed in the office and billed by the health care practitioner 

Primary care physician Covered in full 

Specialty care physician Covered in full 

Second medical opinion 

Primary care physician $25 copayment per visit 

Specialty care physician $55 copayment per visit 

Hospital services 

Hospital inpatient services 

Network hospital 50% coinsurance after network provider 

deductible 

CRIVIO 2004-C 18 

A-0025

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 25 of 172
SCHEDULE OF BENEFITS (continued) 

Health care practitioner inpatient services when provided in a hospital 

Primary care physician 50% coinsurance after network provider 

deductible 

Specialty care physician 50% coinsurance after network provider 

deductible 

Hospital outpatient surgical services 

Must be performed in a hospital's outpatient department. 

Network hospital 50% coinsurance after network provider 

deductible 

Health care practitioner outpatient services when provided in a hospital 

Includes outpatient surgery. 

Primary care physician 50% coinsurance after network provider 

deductible 

Specialty care physician 50% coinsurance after network provider 

deductible 

Hospital outpatient non-surgical services 

Must be performed in a hospital's outpatient department. Excludes advanced imaging. 

Network hospital 50% coinsurance after network provider 

deductible 

CHMO 2004-C 19 

A-0026

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 26 of 172
SCHEDULE OF BENEFITS (continued) 

Diagnostic radiology and laboratory services when provided in a hospital's outpatient 

department 

Excludes advanced imaging. 

Network hospital 50% coinsurance after network provider 

deductible 

Hospital outpatient advanced imaging 

Must be performed in a hospital's outpatient department. 

Network hospital $300 copayment per visit 

Pregnancy and newborn benefit 

Same as any other sickness based upon location of services and the type of provider. 

Emergency services 

Hospital emergency room services 

Excludes advanced imaging. 

Network hospital $350 copayment per visit. Copayment waived if 

admitted. 

Hospital emergency room advanced imaging 

Network hospital $300 copayment per visit 

cfrmo 2004-C 20 

A-0027

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 27 of 172
SCHEDULE OF BENEFITS (continued) 

Hospital emergency room health care practitioner services 

Network health care practitioner Covered in full 

Ambulance 

Network provider 50% coinsurance after network provider 

deductible 

Ambulatory surgical center services 

Ambulatory surgical center for outpatient surgery 

Network provider 50% coinsurance after network provider 

deductible 

Health care practitioner outpatient services provided in an ambulatory surgical center 

Includes outpatient surgery. 

Primary care physician 50% coinsurance after network provider 

deductible 

Specialty care physician 50% coinsurance after network provider 

deductible 

Durable medical equipment 

Network provider 50% coinsurance after network provider 

deductible 

CHMO 2004-C 21 

A-0028

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 28 of 172
SCHEDULE OF BENEFITS (continued) 

Diabetes equipment 

Network provider 50% coinsurance after network provider 

deductible 

Free-standing facility services 

Diagnostic radiology and laboratory services when provided in a free-standing facility 

Excludes advanced imaging. 

Network provider Covered in full 

Health care practitioner non-surgical services provided in a free-standing facility 

Primary care physician 50% coinsurance after network provider 

deductible 

Specialty care physician 50% coinsurance after network provider 

deductible 

Free-standing facility advanced imaging 

Network provider $300 copayment per visit 

CHMO 2004-C 22 

A-0029

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 29 of 172
SCHEDULE OF BENEFITS (continued) 

Home health care 

Limited to a maximum of 100 visits per year. 

Network provider 50% coinsurance after network provider 

deductible 

Hospice 

Network provider 50% coinsurance after network provider 

deductible 

Jaw joint benefit 

Same as any other sickness based upon location of services and type of provider. 

Physical medicine and rehabilitative services 

Physical therapy, occupational therapy, speech therapy, audiology, cognitive rehabilitation services, and 

spinal manipulations/adjustments are limited to a combined maximum of 30 visits per year. 

Network provider $55 copayment per visit 

Other therapy 

Network provider 50% coinsurance after network provider 

deductible 

CHMO 2004-C 23 

A-0030

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 30 of 172
SCHEDULE OF BENEFITS (continued) 

Skilled nursing facility 

Limited to a maximum of 60 days per year. 

Network provider 50% coinsurance after network provider 

deductible 

Urgent care services 

Concentra network provider $55 copayment per visit 

Network provider $100 copayment per visit 

Autism spectrum disorders 

Same deductible, coinsurance and copayment as any other sickness based upon location of services and 

the type of provider. 

Additional covered expenses 

Same as any other sickness based upon location of services and the type of provider. 

HSCH2FL 02/12 

CHMO 2004-C 24 

A-0031

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 31 of 172
SCHEDULE OF BENEFITS - BEHAVIORAL HEALTH 

Reading this "Schedule of Benefits — Behavioral Health" section will help you understand: 

• The level of benefits generally paid for mental health services and chemical dependency services 

under the master group contract, 

• The amounts of copayments and/or coinsurance you are required to pay; and 

• The services that require you to meet a deductible, if any, before benefits are paid. 

The benefits outlined in this "Schedule of Benefits — Behavioral Health" are a summary of coverage and 

limitations provided under the master group contract. A more detailed explanation of your coverage 

and its limitations and exclusions for these benefits is provided in the "Covered Expenses — Behavioral 

Health" and "Limitations and Exclusions" sections of this certificate. Please refer to this certificate and 

any applicable riders for additional coverage and/or limitations. 

All services are subject to all the terms and provisions, limitations and exclusions of the master group 

contract. 

Mental health services 

Acute inpatient services 

All acute inpatient services for mental health services are limited to a maximum of 30 days per year. 

Acute inpatient services 

Network provider 50% coinsurance after network provider 

deductible 

Health care practitioner services — inpatient 

Network health care practitioner 50% coinsurance after network provider 

deductible 

CHMO 2004-C 25 

A-0032

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 32 of 172
SCHEDULE OF BENEFITS - BEHAVIORAL HEALTH 

(continued) 

Partial hospitalization 

Covered expenses for partial hospitalization are limited to a maximum of 30 days per year. 

Network provider 50% coinsurance after network provider 

deductible 

Outpatient therapy and office therapy 

Outpatient therapy, including outpatient services provided as part of an intensive outpatient program, 

and office therapy for mental health services are limited to a combined maximum of 20 visits per year. 

Network provider $55 copayment per visit 

Outpatient care 

Network provider 50% coinsurance after network provider 

deductible 

CHMO 2004-C 26 

A-0033

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 33 of 172
SCHEDULE OF BENEFITS - BEHAVIORAL HEALTH 

(continued) 

Chemical dependency services 

Acute inpatient services 

All acute inpatient services for chemical dependency services are limited to a maximum of 10 days per 

year. 

Acute inpatient services 

Network provider 50% coinsurance after network provider 

deductible 

Health care practitioner services - inpatient 

Network health care practitioner 50% coinsurance after network provider 

deductible 

Outpatient therapy and office therapy 

Network provider $55 copayment per visit 

Outpatient care 

Network provider 50% coinsurance after network provider 

deductible 

HSCH-BHFL 02/11 

CHMO 2004-C 27 

A-0034

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 34 of 172
SCHEDULE OF BENEFITS - TRANSPLANT SERVICES 

Reading this "Schedule of Benefits — Transplant Services" section will help you understand: 

• The level of benefits generally paid for the transplant services covered under the master group 

contract, 

• The amounts of copayments and/or coinsurance you are required to pay; and 

• The services that require you to meet a deductible, if any, before benefits are paid. 

The benefits outlined in this "Schedule of Benefits — Transplant Services" are a summary of coverage 

and limitations provided under the master group contract. A more detailed explanation of your 

coverage and its limitations and exclusions for these benefits are provided in the "Covered Expenses — 

Transplant Services" and "Limitations and Exclusions" sections of this certificate. Please refer to this 

certificate and any applicable riders for additional coverage and/or limitations. 

All services are subject to all of the terms, provisions, limitations and exclusions of the master group 

contract. 

Organ transplant benefit 

Medical services 

• Hospital services 

Hospital benefits as shown in the "Schedule of Benefits" section under the "Hospital Services" 

provision of the certificate will be payable as follows: 

Network hospital designated by us as an approved 

transplant facility 

Same as any other sickness based on location of 

services and type of provider. 

• Health care practitioner services 

Health care practitioner benefits as shown in the "Schedule of Benefits" section under the "Health 

Care Practitioner Services" provision of the certificate will be payable as follows: 

Network health care practitioner designated by us 

as an approved transplant health care practitioner 

Same as any other sickness based on location of 

services and type of provider. 

CHMO 2004-C 28 

A-0035

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 35 of 172
SCHEDULE OF BENEFITS - TRANSPLANT SERVICES 

(continued) 

Direct, non-medical costs 

Limited to a combined maximum of $10,000 per covered organ transplant. 

• Transportation 

Network hospital designated by us as an approved 

transplant facility 

Covered in full 

• Temporary lodging 

Network hospital designated by us as an approved 

transplant facility 

Covered in full 

HSCHFL-OT 10/06 

CHMO 2004-C 29 

A-0036

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 36 of 172
COVERED EXPENSES 

This "Covered Expenses" section describes the services that will be considered covered expenses under 

the master group contract. Benefits will be paid for covered medical services for a bodily injury or 

sickness, or for specifiedpreventive services, on a maximum allowable fee basis and as shown on the 

"Schedules of Benefits" subject to any applicable: 

• Deductible; 

• Cop ayment, 

• Coinsurance percentage; and 

• Maximum benefit. 

Refer to the "Limitations and Exclusions" section listed in this certificate. All terms and provisions of 

the master group contract, including the preauthorization requirements specified in this certificate, are 

applicable to covered expenses. 

Preventive services 

Covered expenses include the preventive services recommended by the U.S. Department of Health and 

Human Services (HHS) for your plan year. Preventive services include: 

• Services with an A or B rating in the current recommendations of the U. S. Preventive Services Task 

Force (USPSTF). The recommendations by the USPSTF for breast cancer screenings, 

mammography and preventions issued prior to November 2009 will be considered current. 

• Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers 

for Disease Control and Prevention (CDC). 

• Preventive care for infants, children and adolescents provided in the comprehensive guidelines 

supported by the Health Resources and Services Administration (HRSA). 

• Preventive care for women provided in the comprehensive guidelines supported by HRSA. 

For the recommendedpreventive services that apply to your plan year, refer to the www.healthcare.gov 

website or call the customer service telephone number on your identification card. 

Health care practitioner office services 

We will pay the following benefits for covered expenses incurred by you for health care practitioner 

office visit services. You must incur the health care practitioner's services as the result of a sickness or 

bodily injury. 

Health care practitioner office visit 

Covered expenses include: 

• Office visits for the diagnosis and treatment of a sickness or bodily injury. 

• Office visits for prenatal and post-delivery care. 

• Office visits for diabetes self-management training. 

CHMO 2004-C BEN 16 30 

A-0037

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 37 of 172
COVERED EXPENSES (continued) 

• Diagnostic laboratory and radiology. 

• Allergy testing. 

• Allergy serum. 

• Allergy injections. 

• Injections other than allergy. 

• Surgery, including anesthesia. 

• Second surgical opinions by a health care practitioner of your choice. 

• Second medical opinions by a health care practitioner of your choice subject to the following 

conditions: 

The covered person feels that he/she is not responding to the current treatment plan in a 

satisfactory manner after a reasonable lapse of time for the condition being treated. The primary 

care physician must be so informed by the covered person, and a request for a consultation 

initiated. Such a consultation shall be provided upon authorization by the Medical Director. 

The covered person disagrees with our opinion or a health care practitioner's, regarding the 

reasonableness or necessity of a surgical procedure; or, the treatment is for a serious injury or 

illness. 

The health care practitioner chosen by the covered person for the second opinion is located in 

the master group contract service area. 

We retain the right to have any tests that may be required by a non-network health care 

practitioner administered by a network provider. 

Reimbursement for second opinions by non-network health care practitioners may be limited to 

a maximum of three in a year and is subject to maximum allowable fee applicable to the master 

group contract service area. 

The covered person is responsible for the copayment and/or coinsurance listed in the Schedule 

of Benefits which is a part of the master group contract. 

The covered person's network health care practitioner or our Medical Director's judgment 

concerning the treatment shall be controlling, after review of the second opinion, as to the 

obligations of Humana Medical Plan, Inc. 

Any treatment, including follow-up treatment pursuant to the second opinion is authorized by us. 

Hospital services 

We will pay benefits for covered expenses incurred by you while hospital confined or for outpatient 

services. A hospital confinement must be ordered by a health care practitioner. 

For emergency care benefits provided in a hospital, refer to the "Emergency services" provisions of this 

section. 

CHMO 2004-C BEN 16 31 

A-0038

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 38 of 172
COVERED EXPENSES (continued) 

Hospital inpatient services 

Covered expenses include: 

• Daily semi-private, ward, intensive care or coronary care room and board charges for each day of 

confinement. Benefits for a private or single-bed room are limited to the maximum allowable fee 

charged for a semi-private room in the hospital while confined. 

• Services and supplies, other than room and board, provided by a hospital while confined. 

Health care practitioner inpatient services when provided in a hospital 

Covered expenses include: 

• Medical services furnished by an attending health care practitioner to you while you are hospital 

confined. 

• Surgery performed on an inpatient basis. If several surgeries are performed during one operation, 

we will allow the maximum allowable fee for the most complex procedure. For each additional 

procedure we will allow: 

- 50% of maximum allowable fee for the secondary procedure; and 

- 25% of maximum allowable fee for the third and subsequent procedures. 

If two surgeons work together as primary surgeons performing distinct parts of a single reportable 

procedure, we will allow each surgeon 62.5% of the maximum allowable fee for the procedure. 

• Services of a surgical assistant and/or assistant surgeon. We will allow the surgical assistants and/or 

assistant surgeons 20% of the maximum allowable fee for the surgery. 

• Services of a physician assistant (P.A.), registered nurse (R.N.) or a certified operating room 

technician. We will allow the physician assistants, registered nurses and certified operating room 

technicians 10% of the maximum allowable fee for the surgery. 

• Anesthesia administered by a health care practitioner or certified registered anesthetist attendant for 

a surgery. 

• Consultation charges requested by the attending health care practitioner during a hospital 

confinement. The benefit is limited to one consultation by any one health care practitioner per 

specialty during a hospital confinement. 

• Services of a pathologist. 

CHMO 2004-C BEN 16 32 

A-0039

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 39 of 172
COVERED EXPENSES (continued) 

• Services of a radiologist. 

• Services performed on an emergency basis in a hospital if the sickness or bodily injury being treated 

results in a hospital confinement. 

Hospital outpatient services 

Covered expenses include outpatient services and supplies, as outlined in the following provisions, 

provided in a hospital's outpatient department. 

Covered expenses provided in a hospital's outpatient department will not exceed the average 

semi-private room rate when you are in observation status. 

Hospital outpatient surgical services 

Covered expenses include services provided in a hospital's outpatient department in connection with 

outpatient surgery. 

Health care practitioner outpatient services when provided in a hospital 

Covered expenses include: 

• Surgery performed on an outpatient basis. If several surgeries are performed during one operation, 

we will allow the maximum allowable fee for the most complex procedure. For each additional 

procedure we will allow: 

50% of maximum allowable fee for the secondary procedure; and 

25% of maximum allowable fee for the third and subsequent procedures. 

If two surgeons work together as primary surgeons performing distinct parts of a single reportable 

procedure, we will allow each surgeon 62.5% of the maximum allowable fee for the procedure. 

• Services of a surgical assistant and/or assistant surgeon. We will allow the surgical assistants and/or 

assistant surgeons 20% of the maximum allowable fee for the surgery. 

• Services of a physician assistant (P.A.), registered nurse (RN.) or a certified operating room 

technician. We will allow the physician assistants, registered nurses and certified operating room 

technicians 10% of the maximum allowable fee for the surgery. 

CHMO 2004-C BEN 16 33 

A-0040

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 40 of 172
COVERED EXPENSES (continued) 

• Anesthesia administered by a health care practitioner or certified registered anesthetist attendant for 

a surgery. 

• Services of a pathologist. 

• Services of a radiologist. 

• Post-delivery care including services rendered in an outpatient maternity center. 

Hospital outpatient non-surgical services 

Covered expenses include services provided in a hospital's outpatient department in connection with 

non-surgical services. 

Hospital outpatient advanced imaging 

We will pay benefits for covered expenses incurred by you for outpatient advanced imaging in a 

hospital's outpatient department. 

Pregnancy and newborn benefit 

We will pay benefits for covered expenses incurred by a covered person for a pregnancy. 

Covered expenses include: 

• A minimum stay of 48 hours following an uncomplicated vaginal delivery and 96 hours following 

an uncomplicated cesarean section. If an earlier discharge is consistent with the most current 

protocols and guidelines of the American College of Obstetricians and Gynecologists or the 

American Academy of Pediatrics and is consented to by the mother and the attending health care 

practitioner, a post-discharge office visit to the health care practitioner or a home health care visit 

within the first 48 hours after discharge is also covered, subject to the terms of this certificate. 

• For a newborn, hospital confinement during the first 48 hours or 96 hours following birth, as 

applicable and listed above for: 

Hospital charges for routine nursery care; 

The health care practitioner's charges for circumcision of the newborn child; and 

The health care practitioner's charges for routine examination of the newborn before release 

from the hospital. 

• If the covered newborn must remain in the hospital past the mother's confinement, services and 

supplies received for: 

A bodily injury or sickness; 

Care and treatment for premature birth; and 

Medically diagnosed birth defects and abnormalities. 

CI-IMO 2004-C BEN 16 34 

A-0041

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 41 of 172
COVERED EXPENSES (continued) 

Covered expenses also include cosmetic surgery specifically and solely for: 

• Reconstruction due to bodily injury, infection or other disease of the involved part; or 

• Congenital anomaly of a covered dependent child that resulted in a functional impairment. 

Covered expenses also include those services rendered in licensed birth centers. 

The newborn will not be required to satisfy a separate deductible and/or copayment for hospital facility 

charges for the confinement period immediately following birth. A deductible and/or copayment, if 

applicable, will be required for any subsequent hospital admission. 

Emergency services 

We will pay benefits for covered expenses incurred by you for emergency care, including the treatment 

and stabilization of an emergency medical condition. 

Emergency care provided by a non-network hospital or a non-network health care practitioner will be 

covered at the same benefit level as a network provider, subject to the maximum allowable fee. You are 

not responsible for paying the non-network hospital or non-network health care practitioner for charges 

in excess of the maximum allowable fee; however, you are responsible for any applicable deductible, 

coinsurance and/or copayment for services received. 

Covered expenses also include health care practitioner services for emergency care, including the 

treatment and stabilization of an emergency medical condition, provided in a hospital emergency 

facility. These services are subject to the terms, conditions, limitations, and exclusions of the master 

group contract. 

Ambulance services 

We will pay benefits for covered expenses incurred by you for licensed ambulance services to, from or 

between medical facilities for emergency care. We will also pay benefits for a newborn dependent's 

transportation to and from the nearest available facility staffed and equipped to treat the newborn's 

condition if the transportation is certified by the attending physician as necessary to protect the health 

and safety of the newborn dependent. 

Ambulance services for emergency care provided by a non-network provider will be covered at the same 

benefit level as a network provider, subject to the maximum allowable fee. You are not responsible for 

paying the non-network provider for charges in excess of the maximum allowable fee; however, you are 

responsible for any applicable deductible, coinsurance and/or copayment for services received. 

Ambulatory surgical center services 

We will pay benefits for covered expenses incurred by you for services provided in an ambulatory 

surgical center for the utilization of the facility and ancillary services in connection with outpatient 

surgery. 

CHMO 2004-C BEN 16 35 

A-0042

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 42 of 172
COVERED EXPENSES (continued) 

Health care practitioner outpatient services when provided in an ambulatory surgical 

center 

Covered expenses include: 

• Surgery performed on an outpatient basis. If several surgeries are performed during one operation, 

we will allow the maximum allowable fee for the most complex procedure. For each additional 

procedure we will allow: 

- 50% of maximum allowable fee for the secondary procedure; and 

- 25% of maximum allowable fee for the third and subsequent procedures. 

If two surgeons work together as primary surgeons performing distinct parts of a single reportable 

procedure, we will allow each surgeon 62.5% of the maximum allowable fee for the procedure. 

• Services of a surgical assistant and/or assistant surgeon. We will allow the surgical assistants and/or 

assistant surgeons 20% of the maximum allowable fee for the surgery. 

• Services of a physician assistant (P.A.), registered nurse (R.N.) or a certified operating room 

technician. We will allow the physician assistants, registered nurses and certified operating room 

technicians 10% of the maximum allowable fee for the surgery. 

• Anesthesia administered by a health care practitioner or certified registered anesthetist attendant for 

a surgery. 

• Services of a pathologist. 

• Services of a radiologist. 

Durable medical equipment and diabetes equipment 

We will pay benefits for covered expenses incurred by you for durable medical equipment and diabetes 

equipment. 

At our option, covered expense includes the purchase or rental of durable medical equipment or diabetes 

equipment. If the cost of renting the equipment is more thanyou would pay to buy it, only the cost of 

the purchase is considered to be a covered expense. In either case, total covered expenses for durable 

medical equipment or diabetes equipment shall not exceed its purchase price. In the event we determine 

to purchase the durable medical equipment or diabetes equipment, any amount paid as rent for such 

equipment will be credited toward the purchase price. 

CHMO 2004-C BEN 16 36 

A-0043

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 43 of 172
COVERED EXPENSES (continued) 

Repair and maintenance of purchased durable medical equipment and diabetes equipment is a covered 

expense if: 

• Manufacturer's warranty is expired; 

• Repair or maintenance is not a result of misuse or abuse; 

• Maintenance is not more frequent than every six months; and 

• Repair cost is less than replacement cost. 

Replacement of purchased durable medical equipment and diabetes equipment is a covered expense if: 

• Manufacturer's warranty is expired; 

• Replacement cost is less than repair cost; and 

• Replacement is not due to lost or stolen equipment, or misuse or abuse of the equipment; or 

• Replacement is required due to a change in your condition that makes the current equipment 

non-functional. 

Free-standing facility services 

Free-standing non-surgical services 

We will pay benefits for covered expenses for services provided in afree-standing facility. 

Health care practitioner non-surgical services when provided in a free-standing facility 

We will pay benefits for outpatient non-surgical services provided by a health care practitioner in a 

free-standing facility. 

Free-standing facility advanced imaging 

We will pay benefits for covered expenses incurred by you for outpatient advanced imaging in a 

free-standing facility. 

Home health care services 

We will pay benefits for covered expenses incurred by you in connection with a home health care plan. 

All home health care services and supplies must be provided on a part-time or intermittent basis to you 

in conjunction with the approved home health care plan. 

The "Schedule of Benefits" shows the maximum number of visits allowed by a representative of a home 

health care agency, if any. A visit by any representative of a home health care agency of two hours or 

less will be counted as one visit. 

CHMO 2004-C BEN 16 37 

A-0044

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 44 of 172
COVERED EXPENSES (continued) 

Home health care covered expenses include: 

• Care provided by a nurse; 

• Physical, occupational, respiratory or speech therapy; 

• Medical social work and nutrition services; and 

• Medical appliances, equipment and laboratory services. 

Home health care covered expenses do not include: 

• Charges for mileage or travel time to and from the covered person's home; 

• Wage or shift differentials for any representative of a home health care agency; 

• Charges for supervision of home health care agencies; 

• Charges for services of a home health aide; 

• Custodial care; or 

• The provision or administration of self-administered injectable drugs, unless otherwise determined 

by us. 

Hospice services 

We will pay benefits for covered expenses incurred by you for a hospice care program. A health care 

practitioner must certify that the covered person is terminally ill with a life expectancy of 18 months or 

less. 

If the above criteria is not met, no benefits will be payable under the master group contract. 

Hospice care benefits are payable as shown on the "Schedule of Benefits" for the following hospice 

services: 

• Room and board at a hospice, when it is for management of acute pain or for an acute phase of 

chronic symptom management; 

• Part-time nursing care provided by or supervised by a registered nurse (R.N.) for up to eight hours in 

any one day; 

• Counseling for the terminally ill covered person and his/her immediate covered family members by 

a licensed: 

Clinical social worker; or 

Pastoral counselor. 

• Medical social services provided to the terminally ill covered person or his/her immediate covered 

family members under the direction of a health care practitioner, including: 

Assessment of social, emotional and medical needs, and the home and family situation; and 

Identification of the community resources available; 

• Psychological and dietary counseling; 

• Physical therapy; 

• Part-time home health aid services for up to eight hours in any one day; and 

• Medical supplies, drugs, and medicines prescribed by a health care practitioner for palliative care. 

CHMO 2004-C BEN 16 38 

A-0045

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 45 of 172
COVERED EXPENSES (continued) 

Hospice care covered expenses do not include: 

• A confinement not required for acute pain control or other treatment for an acute phase of chronic 

symptom management; 

• Services by volunteers or persons who do not regularly charge for their services; 

• Services by a licensed pastoral counselor to a member of his or her congregation. These are services 

in the course of the duties to which he or she is called as a pastor or minister; and 

• Bereavement counseling services for family members not covered under the master group contract. 

Jaw joint benefit 

We will pay benefits for covered expenses incurred by you during a plan of treatment for any jaw joint 

problem, including temporomandibular joint disorder, craniomaxillary disorder, craniomandibular 

disorder, head and neck neuromuscular disorder or other conditions of the joint linking the jaw bone and 

the skull, subject to the maximum benefit shown on the "Schedule of Benefits", if any. Expenses 

covered under this jaw joint benefit are not covered under any other provision of this certificate. 

The following are covered expenses: 

• A single examination including a history, physical examination, muscle testing, range of motion 

measurements, and psychological evaluation; 

• Diagnostic x-rays; 

• Physical therapy of necessary frequency and duration, limited to a multiple modality benefit when 

more than one therapeutic treatment is rendered on the same date of service; 

• Therapeutic injections; 

• Appliance therapy utilizing an appliance that does not permanently alter tooth position, jaw position 

or bite. Benefits for reversible appliance therapy will be based on the maximum allowable fee for 

use of a single appliance, regardless of the number of appliances used in treatment. The benefit for 

the appliance therapy will include an allowance for all jaw relation and position diagnostic services, 

office visits, adjustments, training, repair, and replacement of the appliance; and 

• Surgical procedures. 

Covered expenses do not include charges for: 

• Computed Tomography (CT) scans or magnetic resonance imaging except in conjunction with 

surgical management; 

• Electronic diagnostic modalities; 

• Occlusal analysis; or 

• Any irreversible procedure, including, but not limited to: orthodontics, occlusal adjustment, crowns, 

onlays, fixed or removable partial dentures, and full dentures. 

CHMO 2004-C BEN 16 39 

A-0046

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 46 of 172
COVERED EXPENSES (continued) 

Physical medicine and rehabilitative services 

We will pay benefits for covered expenses incurred by you for the following physical medicine and/or 

rehabilitative services for a documentedfunctional impairment, pain, or developmental defect as ordered 

by a health care practitioner and performed by a health care practitioner: 

• Physical therapy services; 

• Occupational therapy services; 

• Spinal manipulations/adjustments performed in a health care practitioner's office, on an inpatient or 

outpatient basis or in a rehabilitation facility; 

• Speech therapy or speech pathology services; 

• Audiology services; 

• Cognitive rehabilitation services; 

• Respiratory or pulmonary rehabilitation services; and 

• Cardiac rehabilitation services. 

The "Schedule of Benefits" shows the maximum number of visits for physical medicine and/or 

rehabilitative services, if any. 

Skilled nursing facility services 

We will pay benefits for covered expenses incurred by you for charges made by a skilled nursing facility 

for room and board, and for services and supplies. Your confinement to a skilled nursing facility must 

be based upon a written recommendation of a health care practitioner. 

The "Schedule of Benefits" shows the maximum length of time for which we will pay benefits for 

charges made by a skilled nursing facility, if any. 

Health care practitioner services when provided in a skilled nursing facility 

Services that are payable as a skilled nursing facility charge are not payable as a health care practitioner 

charge. 

Covered expenses include: 

• Medical services furnished by an attending health care practitioner to you while you are confined in 

a skilled nursing facility. 

• Consultation charges requested by the attending health care practitioner during a confinement in a 

skilled nursing facility. 

• Services of a pathologist. 

• Services of a radiologist. 

Urgent care center 

We will pay benefits for covered expenses incurred by you for charges made by an urgent care center 

for urgent care services. Covered expense also includes health care practitioner services for urgent 

care provided at and billed by an urgent care center. 

CHMO 2004-C BEN 16 40 

A-0047

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 47 of 172
COVERED EXPENSES (continued) 

Autism spectrum disorders 

We will pay benefits for covered expenses incurred by covered dependents who have been diagnosed as 

having a developmental disability. 

Covered expenses include: 

• Well-baby and well-child screening to diagnose the presence of autism spectrum disorder; 

• Treatment of autism spectrum disorder through: 

Speech therapy; 

Occupational therapy; 

Physical therapy; and 

Applied behavior analysis provided by a certified behavior analyst, psychologist, 

psychotherapist, 

clinical social worker, marriage and family therapist, or mental health counselor. 

Autism spectrum disorders are payable as shown in the "Schedule of Benefits". 

Additional covered expenses 

We will pay benefits for covered expenses incurred by you based upon the location of the services and 

the type of provider for: 

• Blood and blood plasma which is not replaced by donation; administration of the blood and blood 

products including blood extracts or derivatives. 

• Oxygen and rental of equipment for its administration. 

• Prosthetic devices and supplies, including but not limited to limbs and eyes. Coverage will be 

provided for prosthetic devices to: 

Restore the previous level of function lost as a result of a bodily injury or sickness; or 

Improve function caused by a congenital anomaly. 

Covered expense for prosthetic devices includes repair or replacement, if not covered by the 

manufacturer and if due to: 

A change in the covered person's physical condition causing the device to become 

non-functional; or 

Normal wear and tear. 

• Cochlear implants, when approved by us, for a covered person: 

- 18 years of age or older with bilateral severe to profound sensorineural deafness; or 

- 12 months through 17 years of age with profound bilateral sensorineural deafness. 

CIIMO 2004-C BEN 16 41 

A-0048

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 48 of 172
COVERED EXPENSES (continued) 

Replacement or upgrade of a cochlear implant and its external components may be a covered 

expense if: 

The existing device malfunctions and cannot be repaired; 

Replacement is due to a change in the covered person's condition that makes the present device 

non-functional; or 

The replacement or upgrade is not for cosmetic purposes. 

• Orthotics used to support, align, prevent, or correct deformities. 

Covered expense does not include: 

Replacement orthotics; 

Dental braces; or 

Oral or dental splints and appliances, unless custom made for the treatment of documented 

obstructive sleep apnea. 

• The following special supplies, dispensed up to a 30-day supply, when prescribed by your attending 

health care practitioner: 

- Surgical dressings; 

Catheters; 

Colostomy bags, rings and belts; and 

Flotation pads. 

• The initial pair of eyeglasses or contacts needed due to cataract surgery or an accident if the 

eyeglasses or contacts were not needed prior to the accident. 

• Dental treatment only if: 

The charges are incurred for treatment of a dental injury to a sound natural tooth; 

The treatment begins within 90 days after the date of the dental injury; and 

The treatment is completed within 12 months after the date of the dental injury. 

However, benefits will be paid only for the least expensive service that will, in our opinion, produce 

a professionally adequate result. 

• Hospitalization services and general anesthesia for dental treatment or surgery when provided to a 

covered person who is under 8 years of age and who is determined by a licensed dentist and the 

child's physician to require necessary dental treatment in a hospital or ambulatory surgical center 

due to a significantly complex dental condition or a developmental disability in which patient 

management in the dental office has proven to be ineffective; or has one or more medical conditions 

that would create significant or undue medical risk in the course of treatment delivery if not 

rendered in a hospital or ambulatory surgical center. 

CHMO 2004-C BEN 16 42 

A-0049

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 49 of 172
COVERED EXPENSES (continued) 

• Certain oral surgical operations as follows: 

Excisions of tumors and cysts of the jaws, cheeks, lips, tongue, and roof and floor of the mouth 

when such conditions require pathological examinations; 

Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, and 

roof and floor of the mouth; 

Reduction of fractures and dislocation of the jaw; 

External incision and drainage of cellulitis; 

Incision of accessory sinuses, salivary glands or ducts; 

Frenectomy (the cutting of the tissue in the midline of the tongue); and 

Orthognathic surgery for a congenital anomaly, bodily injury or sickness causing a functional 

impairment. 

• For a covered person, who is receiving benefits in connection with a mastectomy, service for: 

Reconstructive surgery of the breast on which the mastectomy has been performed; 

- Surgery and reconstruction on the non-diseased breast to achieve symmetrical appearance; 

Prostheses and treatment of physical complications for all stages of mastectomy, including 

lymphedema; and 

Post-surgical follow-up care. 

• Reconstructive surgery resulting from: 

A bodily injury, infection or other disease of the involved part, when a functional impairment is 

present; or 

A congenital anomaly of a covered dependent child which resulted in afunctional impairment. 

Expenses for reconstructive surgery due to a psychological condition are not considered a covered 

expense, unless the condition(s) described above are also met. 

• Enteral formulas, nutritional supplements and low protein modified foods for use at home by a 

covered person that are prescribed or ordered by a health care practitioner and are for the treatment 

of an inherited metabolic disease, e.g. phenylketonuria (PKU). Coverage shall include food products 

modified to be low protein for a covered person through the age of 24. 

• Services for the medically necessary diagnosis and treatment of osteoporosis for high-risk 

individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for 

osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term 

glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals 

who have a family history of osteoporosis. 

• Covered expenses for the treatment of cleft lip and cleft palate for a covered dependent under the age 

of eighteen. This coverage includes medical, dental, speech therapy, audiology, and nutrition 

services when prescribed by the treating health care practitioner. The health care practitioner must 

certify that such services are medically necessary and consequent to treatment of the cleft lip or 

palate. This benefit is subject to all other terms and conditions applicable to other benefits. 

CI-IMO 2004-C BEN 16 43 

A-0050

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 50 of 172
COVERED EXPENSES (continued) 

• Nutritional counseling for the treatment of obesity, which includes morbid obesity, limited to 4 

visits per year. 

• Routine patient care costs for a covered person participating in an approved Phase I, II, III or IV 

clinical trial. 

Routine patient care costs include health care services that are otherwise a covered expense if the 

covered person were not participating in a clinical trial. 

Routine patient care costs do not include services or items that are: 

Experimental, investigational or for research purposes; 

Provided only for data collection and analysis that is not directly related to the clinical 

management of the covered person; or 

Inconsistent with widely accepted and established standards of care for a diagnosis. 

The covered person must be eligible to participate in a clinical trial according to the trial protocol 

and: 

Referred by a health care practitioner; or 

Provide medical and scientific information supporting their participation in the clinical trial is 

appropriate. 

For the routine patient care costs to be considered a covered expense, the approved clinical trial 

must be a Phase I, II, III or IV clinical trial for the treatment of cancer or a life threatening condition 

and is: 

Federally funded or approved by the appropriate federal agency; 

The study or investigation is conducted under an investigational new drug application reviewed 

by the Federal Food and Drug Administration; or 

The study or investigation is a drug trial that is exempt from having such an investigational new 

drug application. 

Cancer screenings and exams must be covered in compliance with the most recently published 

guidelines and recommendations established by any of the following: 

American Cancer Society; 

National Institutes of Health; 

National Cancer Institute; 

U.S. Public Health Service; 

Center for Disease Control; 

U.S. Preventive Services Task Force; 

National Comprehensive Cancer Network; or 

Other nationally recognized health care organizations. 

CHMO 2004-C BEN 16 44 

A-0051

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 51 of 172
COVERED EXPENSES - BEHAVIORAL HEALTH 

This "Covered Expenses — Behavioral Health" section describes the services that will be considered 

covered expenses for mental health services and chemical dependency services under the master group 

contract. Benefits for mental health services and chemical dependency services will be paid on a 

maximum allowable fee basis and as shown in the "Schedule of Benefits — Behavioral Health." Refer to 

the "Schedule of Benefits" for any service not specifically listed in the "Schedule of Benefits — 

Behavioral Health." Benefits are subject to any applicable: 

• Preauthorization requirements; 

• Deductible; 

• Copayment, 

• Coinsurance percentage; and 

• Maximum benefit. 

Refer to the "Limitations and Exclusions" section listed in this certzficate. All terms and provisions of 

the master group contract apply. 

CHMO 2004-C BEN 16 45 

A-0052

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 52 of 172
COVERED EXPENSES - BEHAVIORAL HEALTH (continued) 

Benefits under this "Emergency services" provision are not available if the services provided do not 

meet the definition of emergency care. 

Urgent care services 

We will pay benefits for urgent care covered expenses incurred by you for charges made by an urgent 

care center or an urgent care qualified provider for mental health services and chemical dependency 

services. 

CHMO 2004-C BEN 16 46 

A-0053

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 53 of 172
COVERED EXPENSES - BEHAVIORAL HEALTH (continued) 

• Charges for supervision of home health care agencies; 

• Charges for services of a home health aide; 

• Custodial care; or 

• The provision or administration of self-administered injectable drugs, unless otherwise determined 

by us. 

Specialty drugs in a medical place of service 

We will pay benefits for covered expenses incurred by you for behavioral health specialty drugs that are 

administered in the following medical places of service: 

• Health care practitioner's office; 

• Free-standing facility; 

• Urgent care center, 

• Home health care; 

• Hospital; 

• Skilled nursing facility, 

• Ambulance; and 

• Emergency room. 

Benefits for specialty drugs may be subject to preauthorization requirements, if any. Please refer to the 

"Schedule of Benefits" in this certificate for preauthorization requirements and contact us prior to 

receiving specialty drugs. 

Benefits for specialty drugs do not include the charge for the actual administration of the specialty drug. 

Payment for the administration of specialty drugs is addressed in the "Schedule of Benefits" section of 

this certificate. 

Residential treatment facility services 

We will pay benefits for covered expenses incurred by you for mental health services and chemical 

dependency services provided while inpatient or outpatient in a residential treatment facility. 

Autism spectrum disorders 

We will pay benefits for covered expenses incurred by you, based upon the location of the services and 

the type of provider for: 

• Well-baby and well-child screening to diagnose the presence of autism spectrum disorder, and 

• Treatment of autism spectrum disorder through: 

Speech therapy; 

- Occupational therapy; 

Physical therapy; and 

Applied behavior analysis provided by a certified behavior analyst, psychologist, 

psychotherapist, clinical social worker, marriage and family therapist, or mental health 

counselor. 

CHMO 2004-C BEN 16 47 

A-0054

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 54 of 172
COVERED EXPENSES - TRANSPLANT SERVICES 

This "Covered Expenses — Transplant Services" section describes the services that will be considered 

covered expenses for transplant services under the master group contract. Benefits for transplant 

services will be paid on a maximum allowable fee basis and as shown in the "Schedule of Benefits — 

Transplant Services" subject to any applicable: 

• Deductible; 

• Copayment; and 

• Coinsurance percentage. 

Refer to the "Limitations and Exclusions" section listed in this certificate for transplant services not 

covered by the master group contract. All terms and provisions of the master group contract are 

applicable to covered expenses. 

Transplant covered expenses 

We will pay benefits for covered expenses incurred by you for a transplant that is preauthorized and 

approved by us. We must be notified of the initial transplant evaluation and given a reasonable 

opportunity to review the clinical results to determine if the transplant will be covered. You or your 

health care practitioner must contact our Transplant Management Department by calling the Customer 

Service number on your ID card when in need of a transplant. We will advise your health care 

practitioner once coverage of the requested transplant is approved by us. Benefits are payable only if 

the transplant is approved by us. 

Covered expense for a transplant includes pre-transplant services, transplant inclusive of any integral 

chemotherapy and associated services, post-discharge services, and treatment of complications after 

transplantation for or in connection with only the following procedures: 

• Heart; 

• Lung(s); 

• Liver; 

• Kidney; 

• Bone marrow; 

• Intestine; 

• Pancreas; 

• Auto islet cell; 

• Any combination of the above listed transplants; and 

• Any transplant not listed above required by state or federal law. 

Multiple transplantations performed simultaneously are considered one transplant surgery. 

Corneal transplants and porcine heart valve implants are tissues, which are considered part of regular 

plan benefits and are subject to other applicable provisions of the master group contract. 

The following are covered expenses for an approved transplant and all related complications: 

• Hospital and health care practitioner services. 

ClEv10 2004-C BEN 16 48 

A-0055

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 55 of 172
COVERED EXPENSES - TRANSPLANT SERVICES (continued) 

• Acquisition for transplants and associated donor costs, including pre-transplant services, the 

acquisition procedure, and any complications resulting from the acquisition. Donor costs for 

post-discharge services and treatment of complications for or in connection with acquisition for an 

approved transplant will not exceed the transplant treatment period of 365 days from the date of 

hospital discharge following acquisition. 

• Direct, non-medical costs for: 

The covered person receiving the transplant, if he or she lives more than 100 miles from the 

transplant facility; and 

One designated caregiver or support person (two, if the covered person receiving the transplant 

is under 18 years of age), if they live more than 100 miles from the transplant facility. 

• Direct, non-medical costs include: 

Transportation to and from the hospital where the transplant is performed; and 

Temporary lodging at a prearranged location when requested by the hospital and approved by 

us. 

All direct, non-medical costs for the covered person receiving the transplant and the designated 

caregiver(s) or support person(s) are limited to a combined maximum coverage per transplant, as 

specified in the "Schedule of Benefits — Transplant Services" section in this certificate. 

Covered expenses for post-discharge services and treatment of complications for or in connection with 

an approved transplant are limited to the transplant treatment period of 365 days from the date of 

hospital discharge following transplantation of an approved transplant received while you were covered 

by us. After this transplant treatment period, regular plan benefits and other provisions of the master 

group contract are applicable. 

CHMO 2004-C BEN 16 49 

A-0056

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 56 of 172
LIMITATIONS AND EXCLUSIONS 

These limitations and exclusions apply even if a health care practitioner has performed or prescribed a 

medically appropriate procedure, treatment or supply. This does not preventyour health care 

practitioner from providing or performing the procedure, treatment or supply. However, the procedure, 

treatment or supply will not be a covered expense. 

Unless specifically stated otherwise, no benefits will be provided for, or on account of, the following 

items: 

• Treatments, services, supplies or surgeries that are not medically necessary, except preventive 

services. 

• A sickness or bodily injury for which benefits are paid or received under any Workers' 

Compensation or similar law. 

• Care and treatment given in a hospital owned, or run, by any government entity, unless you are 

legally required to pay for such care and treatment. However, care and treatment provided by 

military hospitals to covered persons who are armed services retirees and their dependents are not 

excluded. 

• Any service furnished while you are confined in a hospital or institution owned or operated by the 

United States government or any of its agencies for any military service-connected sickness or bodily 

injury. 

• Services, or any portion of a service, for which no charge is made. 

• Services, or any portion of a service you would not be required to pay for, or would not have been 

charged for, in the absence of this coverage. 

• Any portion of the amount we determineyou owe for a services that the provider waives, rebates or 

discounts, includingyour copayment, deductible or coinsurance. 

• Sickness or bodily injury for which you are in any way paid or entitled to payment or care and 

treatment by or through a government program. 

• Any service not ordered by a health care practitioner. 

• Services provided to you, if you do not comply with the master group contract's requirements. 

These include services received in an emergency room, unless the services are emergency care. 

• Private duty nursing. 

• Services rendered by a standby physician, surgical assistant or assistant surgeon unless medically 

necessary. 

• Any service not rendered by the billing provider. 

• Any service not substantiated in the medical records of the billing provider. 

CHMO 2004-C SG GF LE 21 50 

A-0057

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 57 of 172
LIMITATIONS AND EXCLUSIONS (continued) 

• Education, or training, except for diabetes self-management training. 

• Educational or vocational, therapy, testing, services or schools, including therapeutic boarding 

schools and other therapeutic environments. Educational or vocational videos, tapes, books and 

similar materials are also excluded. 

• Services provided by a covered person's family member. 

• Ambulance services for routine transportation to, from or between medical facilities and/or a health 

care practitioner's office. 

• Any drug, biological product, device, medical treatment, or procedure which is experimental, 

investigational or for research purposes. 

• Vitamins, except for preventive services with a prescription from a health care practitioner, dietary 

supplements, and dietary formulas, except enteral formulas, nutritional supplements or low protein 

modified food products for the treatment of an inherited metabolic disease, e.g. phenylketonuria 

(PKU). 

• Over-the-counter, non-prescription medications, unless for drugs, medicines or medications or 

supplies on the Preventive Medication Coverage drug list with a prescription from a health care 

practitioner. 

• Over-the-counter medical items or supplies that can be provided or prescribed by a health care 

practitioner but are also available without a written order or prescription, except for preventive 

services. 

• Immuni7ations required for foreign travel for a covered person of any age. 

• Growth hormones (medications, drugs or hormones to stimulate growth) unless there is a laboratory 

confirmed diagnosis of growth hormone deficiency, or as otherwise determined by us. 

• Prescription drugs and self-administered injectable drugs unless administered to you: 

While an inpatient in a hospital, skilled nursing facility, health care treatment facility or 

residential treatment facility; 

- By the following, when deemed appropriate by us: 

A health care practitioner: 

- During an office visit; or 

- While an outpatient, or 

A home health care agency as part of a covered home health care plan. 

• Hearing aids, the fitting of hearing aids or advice on their care; implantable hearing devices, except 

for cochlear implants as otherwise stated in this certificate. 

• Services received in an emergency room, unless the services are emergency care. 

CHMO 2004-C SG GF LE 21 51 

A-0058

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 58 of 172
LIMITATIONS AND EXCLUSIONS (continued) 

• Weekend non-emergency hospital admissions, specifically admissions to a hospital on a Friday or 

Saturday at the convenience of the covered person or his or her health care practitioner when there 

is no cause for an emergency admission and the covered person receives no surgery or therapeutic 

treatment until the following Monday. 

• Hospital inpatient services when you are in observation status. 

• Infertility services; or reversal of elective sterilization. 

• In vitro fertilization regardless of the reason for treatment. 

• Services for or in connection with a transplant if: 

The expense relates to storage of cord blood and stem cells, unless it is an integral part of a 

transplant approved by us. 

Not approved by us based on our established criteria. 

Expenses are eligible to be paid under any private or public research fund, government program 

except Medicaid, or another funding program, whether or not such funding was applied for or 

received. 

The expense relates to the transplantation of any non-human organ or tissue, unless otherwise 

stated in the master group contract. 

The expense relates to the donation or acquisition of an organ or tissue for a recipient who is not 

covered by us. 

The expense relates to a transplant performed outside of the United States and any care resulting 

from that transplant. This exclusion applies even if the employee and dependents live outside 

the United States and the employee is in active status with the employer sponsoring the master 

group contract. 

• Services provided for: 

Immunotherapy for recurrent abortion; 

Chemonucleolysis; 

Sleep therapy; 

Light treatments for Seasonal Affective Disorder (S.A.D.); 

Immunotherapy for food allergy; 

Prolotherapy; or 

Sensory integration therapy. 

• Cosmetic surgery and cosmetic services or devices. 

• Hair prosthesis, hair transplants or implants and wigs. 

• Dental services, appliances or supplies for treatment of the teeth, gums, jaws, or alveolar processes, 

including any oral surgery or periodontics, implants and related procedures, orthodontic procedures, 

and any dental services related to a bodily injury or sickness unless otherwise stated in this 

certificate. 

CHMO 2004-C SG GF LE 21 52 

A-0059

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 59 of 172
LIMITATIONS AND EXCLUSIONS (continued) 

• The following types of care of the feet: 

Shock wave therapy of the feet; 

The treatment of weak, strained, flat, unstable or unbalanced feet; 

Hygienic care, and the treatment of superficial lesions of the feet, such as corns, calluses, or 

hyperkeratosis; 

The treatment of tarsalgia, metatarsalgia, or bunion, except surgically; 

The cutting of toenails, except the removal of the nail matrix; 

Heel wedges, lifts, or shoe inserts; and 

Arch supports (foot orthofics) or orthopedic shoes, except for diabetes or hammer toe. 

• Custodial care and maintenance care. 

• Any loss contributed to, or caused by: 

War or any act of war, whether declared or not; 

Insurrection; or 

Any conflict involving armed forces of any authority. 

• Services relating to a sickness or bodily injury as a result of: 

- Engagement in an illegal profession or occupation; or 

- Commission of or an attempt to commit a criminal act. 

This exclusion does not apply to any sickness or bodily injury resulting from an act of domestic 

violence or a medical condition (including both physical and mental health conditions). 

• Expenses for any membership fees or program fees paid by you, including health clubs, health spas, 

aerobic and strength conditioning, work-hardening programs, and weight loss or surgical programs 

and any materials or products related to these programs. 

• Surgical procedures for the removal of excess skin and/or fat in conjunction with or resulting from 

weight loss or a weight loss surgery. 

• Expenses for services that are primarily and customarily used for environmental control or 

enhancement (whether or not prescribed by a health care practitioner) and certain medical devices 

including: 

Common household items including air conditioners, air purifiers, water purifiers, vacuum 

cleaners, waterbeds, hypoallergenic mattresses or pillows or exercise equipment; 

Motorized transportation equipment (e.g. scooters), escalators, elevators, ramps or modifications 

or additions to living/working quarters or transportation vehicles; 

Personal hygiene equipment including bath/shower chairs, transfer equipment or supplies or bed 

side commodes; 

Personal comfort items including cervical pillows, gravity lumbar reduction chairs, swimming 

pools, whirlpools, spas or saunas; 

CHMO 2004-C SG GF LE 21 53 

A-0060

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 60 of 172
LIMITATIONS AND EXCLUSIONS (continued) 

Medical equipment including: 

Blood pressure monitoring devices, unless prescribed by a health care practitioner for 

preventive services and ambulatory blood pressure monitoring is not available to confirm 

diagnosis of hypertension; 

PUVA lights; and 

Stethoscopes; 

Communication systems, telephone, television or computer systems and related equipment or 

similar items or equipment; 

Communication devices, except after surgical removal of the larynx or a diagnosis of permanent 

lack of function of the larynx. 

• Duplicate or similar rentals or purchases of durable medical equipment or diabetes equipment. 

• Therapy and testing for treatment of allergies, including services related to clinical ecology, 

environmental allergy and allergic immune system dysregulation and sublingual antigen(s), extracts, 

neutralization tests and/or treatment unless such therapy or testing is approved by: 

The American Academy of Allergy and Immunology; or 

The Department of Health and Human Services or any of its offices or agencies. 

• Lodging accommodations or transportation. 

• Communications or travel time. 

• Bariatric surgery, any services or complications related to bariatric surgery, and other weight loss 

products or services. 

• Sickness or bodily injury for which no-fault medical payment or expense coverage benefits are paid 

or payable under any automobile, homeowners, premises or any other similar coverage. 

• Elective medical or surgical abortion unless: 

- The pregnancy would endanger the life of the mother; 

- The pregnancy is a result of rape or incest; or 

- The fetus has been diagnosed with a lethal or otherwise significant abnormality. 

CHNIO 2004-C SG GF LE 21 54 

A-0061

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 61 of 172
LIMITATIONS AND EXCLUSIONS (continued) 

• Alternative medicine. 

• Acupuncture, unless: 

The treatment is medically necessary, appropriate and is provided within the scope of the 

acupuncturist's license; and 

You are directed to the acupuncturist for treatment by a licensed physician. 

• Services rendered in a premenstrual syndrome clinic or holistic medicine clinic. 

• Services of a midwife, unless provided by a Licensed Midwife or a Certified Nurse Midwife. 

• Vision examinations or testing for the purposes of prescribing corrective lenses. 

• Orthoptic/vision training (eye exercises). 

• Radial keratotomy, refractive keratoplasty or any other surgery or procedure to correct myopia, 

hyperopia or stigmatic error. 

• The purchase or fitting of eyeglasses or contact lenses, except as the result of an accident or 

following cataract surgery .as stated in this certificate. 

• Services and supplies which are: 

Rendered in connection with mental illnesses not classified in the International Classification of 

Diseases of the U.S. Department of Health and Human Services; or 

Extended beyond the period necessary for evaluation and diagnosis of learning and behavioral 

disabilities or for mental retardation. 

• Marriage counseling. 

• Expenses for employment, school, sport or camp physical examinations or for the purposes of 

obtaining insurance. 

• Expenses for care and treatment of non-covered procedures or services. 

• Expenses for treatment of complications of non-covered procedures or services. 

• Expenses incurred for services prior to the effective date or after the termination date ofyour 

coverage under the master group contract. Coverage will be extended as described in the 

"Extension of Benefits" section, as required by state law. 

• Any care, treatment, services, equipment or supplies received outside of the service area: 

If you could have reasonably foreseen or anticipated their need prior to departure from the 

service area; and 

Which are not authorized by us or to the extent they exceed the maximum allowable fee. 

• Pre-surgical/procedural testing duplicated during a hospital confinement. 

CHMO 2004-C SG OF LE 21 55 

A-0062

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 62 of 172
ELIGIBILITY AND EFFECTIVE DATES 

Eligibility date 

Employee eligibility date 

The employee who lives or works in the service area is eligible for coverage on the date: 

• The eligibility requirements are satisfied as stated in the Employer Group Application, or as 

otherwise agreed to by the group plan sponsor and us; and 

• The employee is in an active status. 

Dependent eligibility date 

Each dependent is eligible for coverage on: 

• The date the employee is eligible for coverage, if he or she has dependents who may be covered on 

that date; 

• The date of the employee's marriage for any dependents (spouse or child) acquired on that date; 

• The date of birth of the employee's natural-born child; 

• The date of birth of a child born to an employee's covered dependent child; 

• The date a foster child is placed in the employee's home; 

• The date of placement of the child for the purpose of adoption by the employee; or 

• The date specified in a Qualified Medical Child Support Order (QMCSO), or National Medical 

Support Notice (NMSN) for a child, or a valid court or administrative order for a spouse, which 

requires the employee to provide coverage for a child or spouse as specified in such orders. 

The employee may cover his or her dependents onlyif the employee is also covered. 

Enrollment 

Employees and dependents eligible for coverage under the master group contract may enroll for 

coverage as specified in the enrollment provisions outlined below. 

CI-11\40 2004-C GF EE 19 56 

A-0063

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 63 of 172
ELIGIBILITY AND EFFECTIVE DATES (continued) 

Employee enrollment 

The employee must enroll, as agreed to by the group plan sponsor and us, within 31 days of the 

employee's eligibility date or within the time period specified in the "Special enrollment" provision. 

The employee is a late applicant if enrollment is requested more than 31 days after the employee's 

eligibility date or later than the time period specified in the "Special enrollment" provision. A late 

applicant must wait to enroll for coverage during the open enrollment period, unless the late applicant 

becomes eligible for special enrollment as specified in the "Special enrollment" provision. 

We reserve the right to require an eligible employee to submit evidence of health status. No eligible 

employee will be refused enrollment or charged a different premium than other group members based on 

health status-related factors. We will administer this provision in a non-discriminatory manner in 

regards to eligibility or on the basis of premium. 

Dependent enrollment 

If electing dependent coverage, the employee must enroll eligible dependents, as agreed to by the group 

plan sponsor and us, within 31 days of the dependent's eligibility date or within the time period 

specified in the "Special enrollment" provision. 

The dependent is a late applicant if enrollment is requested more than 31 days after the dependent's 

eligibility date or later than the time period specified in the "Special enrollment" provision. A late 

applicant must wait to enroll for coverage during the open enrollment period, unless the late applicant 

becomes eligible for special enrollment as specified in the "Special enrollment" provision. 

We reserve the right to require an eligible dependent to submit evidence of health status. No eligible 

dependent will be refused enrollment or charged a different premium than other group members based 

on health status-related factors. We will administer this provision in a non-discriminatory manner in 

regards to eligibility or on the basis of premium. 

Newborn, adopted and foster dependent enrollment 

A newborn dependent will be automatically covered from the date of birth to 31 days of age. A 

newborn adopted child will be covered from the moment of birth if a written agreement to adopt the 

child has been entered into by the employee prior to the birth of the child, whether or not such agreement 

is enforceable. Coverage for a newborn adopted child is not available in the event the child is not 

ultimately placed in the residence of the employee. An adopted dependent, that is not a newborn, will be 

automatically covered from the date of adoption or date of placement of the child with the employee for 

the purpose of adoption, whichever occurs first, for 31 days. A foster dependent will be automatically 

covered from the date of placement of the child for 31 days. No additional premium will be charged for 

the first 31 days of coverage if notice is given to us within 31 days after the birth of the newborn 

dependent, date of adoption or date of placement of the adopted dependent or date of placement of the 

foster dependent. 

CHIVIO 2004-C GF EE 19 57 

A-0064

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 64 of 172
ELIGIBILITY AND EFFECTIVE DATES (continued) 

If dependent child coverage is in force as of the newborn's date of birth in the case of newborn 

dependents and newborn adopted children, the earlier of the date of adoption or date of placement of the 

child with the employee for purposes of adoption in case of adopted dependents, or the date of placement 

of the foster child, coverage will continue beyond the initial 31 days. You must notify us to make sure 

we have accurate records to administer benefits. 

If dependent child coverage is not in force, you must enroll the dependent child within 60 days after the 

date of birth of the newborn dependent and newborn adopted child, date of adoption or date of 

placement of the adopted dependent, or date of placement of the foster dependent. We will provide at 

least a 45-day notice of the additional premiumyou must pay for dependent child coverage. 

If enrollment is requested more than 60 days after the date of birth, date of adoption or date of 

placement with the employee for the purpose of adoption or date of placement of the foster child, the 

dependent is a late applicant. A late applicant must wait to enroll for coverage during the open 

enrollment period, unless the late applicant becomes eligible for special enrollment as specified in the 

"Special enrollment" provision. 

Special enrollment 

Special enrollment is available if the following apply: 

• You have a change in family status due to: 

- Marriage; 

Divorce; 

A Qualified Medical Child Support Order (QMCS0); 

A National Medical Support Notice (NMSN); 

The birth of a natural born child; or 

- The adoption of a child or date of placement of a child with the employee for the purpose of 

adoption or date of placement of a foster child; and 

You enroll within 31 days after the special enrollment date; or 

• You are an employee or dependent eligible for coverage under the master group contract, and: 

You previously declined enrollment stating you were covered under another group health plan or 

other health insurance coverage; and 

- Loss of eligibility of such other coverage occurs, regardless of whether you are eligible for, or 

elect COBRA; and 

You enroll within 31 days after the special enrollment date. 

Loss of eligibility of other coverage includes: 

Termination of employment or eligibility; 

Reduction in number of hours of employment; 

Divorce, legal separation or death of a spouse; 

- Loss of dependent eligibility, such as attainment of the limiting age; 

Termination of your employer's contribution for the coverage; 

CHMO 2004-C GF EE 19 58 

A-0065

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 65 of 172
ELIGIBILITY AND EFFECTIVE DATES (continued) 

Loss of individual HMO coverage because you no longer reside, live or work in the service area; 

Loss of group HMO coverage because you no longer reside, live or work in the service area, and 

no other benefit package is available; or 

The plan no longer offers benefits to a class of similarly situated individuals; or 

• You had COBRA continuation coverage under another plan at the time of eligibility, and: 

Such coverage has since been exhausted; and 

You stated at the time of the initial enrollment that coverage under COBRA was your reason for 

declining enrollment; and 

You enroll within 31 days after the special enrollment date; or 

• You were covered under an alternate plan provided by the employer that terminates, and: 

You are replacing coverage with the master group contract, and 

You enroll within 31 days after the special enrollment date; or 

• You are an employee or dependent eligible for coverage under the master group contract, and: 

Your Medicaid coverage or your Children's Health Insurance Program (CHIP) coverage 

terminated as a result of loss of eligibility; and 

You enroll within 60 days after the special enrollment date; or 

• You are an employee or dependent eligible for coverage under the master group contract, and: 

You become eligible for premium assistance subsidy under Medicaid or CHIP; and 

You enroll within 60 days after the special enrollment date. 

The employee or dependent is a late applicant if enrollment is requested later than the time period 

specified above. A late applicant must wait to enroll for coverage during the open enrollment period. 

Dependent special enrollment 

The dependent special enrollment is the time period specified in the "Special enrollment" provision. 

If dependent coverage is available under the employer's master group contract or added to the master 

group contract, an employee who is a covered person can enroll eligible dependents during the special 

enrollment. An employee, who is otherwise eligible for coverage and had waived coverage under the 

master group contract when eligible, can enroll himself/herself and eligible dependents during the 

special enrollment. 

The employee or dependent is a late applicant if enrollment is requested later than the time period 

specified above. A late applicant must wait to enroll for coverage during the open enrollment period. 

CHMO 2004-C GF EE 19 59 

A-0066

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 66 of 172
ELIGIBILITY AND EFFECTIVE DATES (continued) 

Open enrollment 

Eligible employees or dependents, who did not enroll for coverage under the master group contract 

following their eligibility date or special enrollment date, have an opportunity to enroll for coverage 

during the open enrollment period. The open enrollment period is also the opportunity for late 

applicants to enroll for coverage. 

Eligible employees or dependents, including late applicants, must request enrollment during the open 

enrollment period. If enrollment is requested after the open enrollment period, the employee or 

dependent must wait to enroll for coverage during the next open enrollment period, unless they become 

eligible for special enrollment as specified in the "Special enrollment" provision. 

Effective date 

The provisions below specify the effective date of coverage for employees or dependents if enrollment is 

requested within 31 days of their eligibility date or within the time period specified in the "Special 

enrollment" provision. If enrollment is requested during an open enrollment period, the effective date of 

coverage is specified in the "Open enrollment effective date" provision. 

Employee effective date 

The employee's effective date provision is stated in the Employer Group Application. The employee's 

effective date of coverage may be the date immediately following completion of the waiting period or 

the first of the month following completion of the waiting period, if enrollment is requested within 31 

days of the employee's eligibility date. The special enrollment date is the effective date of coverage for 

an employee who requests enrollment within the time period specified in the "Special enrollment" 

provision. The employee effective dates specified in this provision apply to an employee who is not a 

late applicant. 

Dependent effective date 

The dependent's effective date is the date the dependent is eligible for coverage if enrollment is 

requested within 31 days of the dependent's eligibility date. The special enrollment date is the effective 

date of coverage for the dependent who requests enrollment within the time period specified in the 

"Special enrollment" provision. The dependent effective dates specified in this provision apply to a 

dependent who is not a late applicant. 

In no event will the dependent's effective date of coverage be prior to the employee's effective date of 

coverage. 

Newborn, adopted and foster dependent effective date 

The effective date of coverage for a newborn dependent is the date of birth if the newborn is not a late 

applicant. 

CHMO 2004-C GF EE 19 60 

A-0067

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 67 of 172
ELIGIBILITY AND EFFECTIVE DATES (continued) 

The effective date of coverage for an adopted dependent is the date of adoption or the date of placement 

with the employee for the purpose of adoption, whichever occurs first, if the dependent child is not a late 

applicant. 

In the case of a newborn adopted dependent, the effective date of coverage will be the birth date of the 

child if a written agreement for adoption has been entered into by the employee. Otherwise, the effective 

date of coverage will be the date of the adopted dependent's placement in the home of the employee. No 

coverage will be provided under this provision for a child who is not ultimately placed in the employee's 

home. 

The effective date of coverage for a foster dependent is the date of placement with the employee if the 

foster child is not a late applicant. Coverage for the foster dependent will terminate the date the 

employee no longer has legal custody of the child. 

Open enrollment effective date 

The effective date of coverage for an employee or dependent, including a late applicant, who requests 

enrollment during an open enrollment period, is the first day of the master group contract year as 

agreed to by the group plan sponsor and us. 

Retired employee coverage 

Retired employee eligibility date 

Retired employees are an eligible class of employees if requested on the Employer Group Application 

and if approved by us. An employee who retires while coveredunder the master group contract is 

considered eligible for retired employee medical coverage on the date of retirement if the eligibility 

requirements stated in the Employer Group Application are satisfied. 

Retired employee enrollment 

The employer must notify us of the employee's retirement within 31 days of the date of retirement. If we 

are notified more than 31 days after the date of retirement, the retired employee is a late applicant. A 

late applicant must wait to enroll for coverage during the open enrollment period, unless the late 

applicant becomes eligible for special enrollment as specified in the "Special enrollment" provision. 

Retired employee effective date 

The effective date of coverage for an eligible retired employee is the date of retirement for an employee 

who retires after the date we approve the employer's request for a retiree classification, provided we are 

notified within 31 days of the retirement. If we are notified more than 31 days after the date of 

retirement, the effective date of coverage for the late applicant is the date we specify. 

CHMO 2004-C GF EE 19 61 

A-0068

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 68 of 172
REPLACEMENT OF COVERAGE 

Applicability 

This "Replacement of Coverage" section applies when an employer's previous group health plan not 

offered by us or our affiliates (Prior Plan) is terminated and replaced by coverage under the master 

group contract and: 

• You are eligible to become covered for medical coverage on the effective date of the master group 

contract, and 

• You were covered under the employer's Prior Plan on the day before the effective date of the 

master group contract. 

Benefits available for covered expense under the master group contract will be reduced by any benefits 

payable by the Prior Plan during an extension period. 

Deductible credit 

Medical expense incurred whileyou were covered under the Prior Plan may be used to satisfy your 

deductible amount under the master group contract if the expense incurred: 

• Was applied to the deductible amount under the Prior Plan; 

• Qualifies as a covered expense under the master group contract, and 

• Would have served to partially or fully satisfy the deductible amount under the master group 

contract for the year in which your coverage becomes effective. 

The deductible credit will not be applied toward any out-of-pocket limit of the master group contract. 

This provision does not apply to coinsurance satisfied under the Prior Plan. 

Waiting period credit 

If the employee had not completed the initial waiting period under the group plan sponsor's Prior Plan 

on the day that it ended, any period of time that the employee satisfied will be applied to the appropriate 

waiting period under the master group contract, if any. The employee will then be eligible for coverage 

under the master group contract when the balance of the waiting period has been satisfied. 

Out-of-pocket limit 

Any amount applied to the Prior Plan's out-of-pocket limit or stop-loss limit will not be credited toward 

the satisfaction of any out-of-pocket limit of the master group contract. 

CHMO 2004-C GEN 16 CR 62 

A-0069

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 69 of 172
TERMINATION PROVISIONS 

Termination of coverage 

The date of termination, as described in this "Termination Provisions" section, may be the actual date 

specified or the end of that month, as selected by your employer on the Employer Group Application 

(EGA). 

You must notify us as soon as possible if you or your dependent no longer meets the eligibility 

requirements of the master group contract. Notice should be provided to us within 31 days of the 

change. 

When we receive notification of a change in eligibility status in advance of the effective date of the 

change, coverage will terminate on the actual date specified by the employer or employee or at the end of 

that month, as selected by your employer on the EGA. 

When we receive notification of a change in eligibility status more than 31 days after the date of the 

change, retroactive premium credit will be limited to one month's premium. 

Otherwise, coverage terminates on the earliest of the following: 

• The date the master group contract terminates; 

• The end of the period for which required premiums were due to us and not received by us; 

• The date the employee terminated employment with the employer; 

• The date the employee no longer qualified as an employee; 

• The date you fail to be in an eligible class of persons as stated in the EGA; 

• The date the employee entered full-time military, naval or air service; 

• The date the employee retired, except if the EGA provides coverage for a retiree class of employees 

and the retiree is in an eligible class of retirees, selected by the employer; 

• The date of an employee request for termination of coverage for the employee or dependents; 

• For a dependent, the date the employee's coverage terminates; 

• For a dependent, the date the employee ceases to be in a class of employees eligible for dependent 

coverage; 

• For a newborn child born to an employee's covered dependent child, the date he or she is 18 months 

of age; 

CHMO 2004-C GEN 16 CR 63 

A-0070

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 70 of 172
TERMINATION PROVISIONS (continued) 

• The date your dependent no longer qualifies as a dependent, 

• For any benefit, the date the benefit is deleted from the master group contract, or 

• The date fraud or an intentional misrepresentation of a material fact has been committed by you. For 

more information on fraud and intentional misrepresentation, refer to the "Fraud" provision in the 

"Miscellaneous Provisions" section of this certificate. 

Termination for cause 

We will terminate your coverage for cause under the following circumstances: 

• If you allow an unauthorized person to use your identification card or if you use the identification 

card of another covered person. Under these circumstances, the person who receives the services 

provided by use of the identification card will be responsible for paying us the maximum allowable 

fee for those services. 

• If you or the group plan sponsor perpetrate fraud or intentional misrepresentation on claims, 

identification cards or other identification in order to obtain services or a higher level of benefits. 

This includes, but is not limited to, the fabrication or alteration of a claim, identification card or 

other identification. 

CHMO 2004-C GEN 16 CR 64 

A-0071

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 71 of 172
EXTENSION OF BENEFITS 

Extension of coverage for total disability 

We extend limited coverage if: 

• The master group contract terminates while you are totally disabled due to a bodily injury or 

sickness that occurs while the master group contract is in effect. 

Benefits are payable only for those expenses incurred for the same sickness or bodily injury which 

caused you to be totally disabled. Coverage for the disabling condition continues, but not beyond the 

earliest of the following dates: 

• The date your health care practitioner certifies you are no longer totally disabled; or 

• The date any maximum benefit is reached; or 

• The last day of a 12 consecutive month period following the date the master group contract 

terminated; or 

• The date you become covered by any medical insurance or health services plan that provides 

replacement coverage without limitation as to the disability condition. 

For pregnancy, when not covered by the succeeding carrier, maternity benefits will continue until the 

date of delivery, provided the pregnancy began after your effective date and prior to the termination of 

the master group contract. This extension will not be based on total disability. 

No insurance is extended to a child born as a result of a covered person's pregnancy. 

The "Extension of coverage for total disability" provision does not apply to covered retired persons. 

CHM° 2004-C GF EB 19 65 

A-0072

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 72 of 172
CONTINUATION 

Continuation options in the event of termination 

If coverage terminates: 

• It may be continued as described in the "State continuation of coverage" provision; or 

• It may be continued under the continuation provisions as provided by the Consolidated Omnibus 

Budget Reconciliation Act (COBRA), if applicable. 

A complete description of the "State continuation of coverage" provision follows. 

State continuation of health insurance 

The following provisions apply only to small employer groups who are not currently protected by the 

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. 

If a covered person is no longer eligible for the insurance benefits provided by the small employer 

master group contract because of one of the qualibiing events described below, that person may choose 

to continue these benefits under the master group contract as a qualified beneficiary. He or she will 

then be responsible for payment of the appropriate premium for the continued coverage, including any 

portion that the employer may have paid on his or her behalf. The qualified beneficiary will be 

responsible for sending us the premium payments to continue their insurance. 

Persons eligible to continue are called qualified beneficiaries. Qualified beneficiary means, any 

individual who, on the day before the qualiffing event for the covered person, is a beneficiary under the 

group health plan by virtue of the individual being; the covered employee, except if the employee is 

terminated for gross misconduct, the spouse of the covered employee, or the dependent child of the 

covered employee. 

Qualibiing events, notification requirements and the period of time for which coverage may be continued 

are as follows: 

Qualifiiing events mean, with respect to any covered person, any of the following events which, but for 

the election of continuation of coverage, would result in a loss of coverage to a qualified beneficiary: 

• The death of the covered employee. 

• The termination or reduction of hours of the covered employee's employment, except that 

termination of an employee for gross misconduct does not constitute a qualf6,ing event. The 

employer's decision to terminate for gross misconduct is conclusive as to the carrier. 

• The divorce or legal separation of the covered employee from the covered employee's spouse. 

CHMO 2004-C GF CN 19 66 

A-0073

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 73 of 172
CONTINUATION (continued) 

• A covered employee's becoming entitled to benefits under either Part A or Part B of Title XVIII of 

the United States Social Security Act (Medicare). 

• A dependent child's ceasing to be a dependent child under the requirements of the group health plan. 

• A retiree or the spouse or child of a retiree losing coverage within one year before or after 

commencement of a bankruptcy proceeding under title XI of the United States Code by the employer 

from whose employment the covered employee retired. 

Coverage under the group health plan must, at a minimum, extend for the period beginning on the date 

of the qualifiring event and ending not earlier than the earliest of the following: 

• The date that is 18 months after the date on which the qualified beneficiary's benefits under the 

group health plan would otherwise have ceased because of a qualrbring event. 

• The date on which coverage ceases under the group health plan by reason of a failure to make timely 

payment of the applicable premium with respect to any qualified beneficiary. 

• The date a qualified beneficiary becomes covered under any other group health plan. 

• The date a qualified beneficiary is entitled to benefits under either Part A or Part B of Title XVIII of 

the Social Security Act (Medicare). 

• The date the master group contract terminates. 

A qualified beneficiary must notify us within 63 days of the qualifiring event. Within 14 days of receipt 

of the notice of a qualrnring event, we will provide a form on which to indicate election of continued 

coverage and premium notice form. The form and premium payment must be returned to us within 30 

days of receipt. 

CIEVIO 2004-C GF CN 19 67 

A-0074

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 74 of 172
CONTINUATION OF COVERAGE FOR ACTIVE MILITARY 

SERVICE 

Coverage and premium 

Continuation of coverage is available for an employee and their covered dependents while the employee 

is called to active duty or state active duty. The employee will have the same premium in effect for 

other insureds under the same master group contract. 

Notification 

The employee, or an appropriate military authority, must notify the employer that the employee wishes to 

continue coverage before reporting for active duty or state active duty. 

This notice is not required if impossible or unreasonable (such as an immediate call-up in a natural 

disaster emergency) or if military necessity precludes it. 

Reinstatement of coverage 

The employee is not required to continue coverage while on active duty or state active duty. If coverage 

is not continued, the employee will have 63 days to request reinstatement upon returning to work with 

the same employer. There will be no waiting period, nor may any condition existing at the time of 

call-up prevent them from reinstatement. 

Continuation 

If health insurance terminates: 

• It may be continued as described in the Uniformed Services Employment and Reemployment Rights 

Act (USERRA); 

• It may be continued as described in the "State continuation of health insurance" provision; or 

• It may be continued under the continuation provisions as provided by the Consolidated Omnibus 

Budget Reconciliation Act (COBRA), if applicable. 

Definitions 

The following terms are used in this provision: 

Active duty: full-time duty in the active military service of the United States. 

State active duty: those periods when the Governor orders the National Guard into service, typically in 

response to natural disasters or civic disorders. 

CHMO 2004-C GF MS 19 68 

A-0075

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 75 of 172
COORDINATION OF BENEFITS 

This "Coordination of Benefits" (COB) provision applies when a person has health care coverage under 

more than one plan. The order of benefit determination rules below determine whichp/an will pay as 

the primary plan. The primary plan pays first without regard to the possibility anotherp/an may cover 

some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so 

that payments from all plans do not exceed 100% of the total allowable expense. 

Definitions 

The following definitions are used exclusively in this provision. 

Plan means any of the following that provide benefits or services for medical or dental care or 

treatment. However, if separate contracts are used to provide coordinated coverage for members of a 

group, the separate contracts are considered part of the same plan and there is no COB among those 

separate contracts. 

Plan includes: 

• Group insurance contracts, health maintenance organization (HMO) contracts, closed panel or other 

forms of group or group-type coverage (whether insured or uninsured); 

• Medical care components of group long-term care contracts, such as skilled nursing care; 

• Medical benefits under group or individual contracts, including "No Fault" and Medical Payments 

coverages; and 

• Medicare or other governmental benefits, as permitted by law. 

Plan does not include: 

• Individual or family insurance; 

• Closed panel or other individual coverage (except for group-type coverage); 

• Hospital indemnity benefits; 

• School accident type coverage; 

• Benefits for non-medical care components of group long-term care contracts; 

• Medicare supplement policies; 

• A state plan under Medicaid; and 

• Coverage under other governmental plans, unless permitted by law. 

Each contract for coverage is a separate plan. If a plan has two parts and COB rules apply only to one 

of the two, each of the parts is treated as a separatep/an. 

Notwithstanding any statement to the contrary, for the purposes of COB, prescription drug coverage 

under this plan will be considered a separatep/an and will therefore only be coordinated with other 

prescription drug coverage. 

CHMO 2004-C GF COB 19 69 

A-0076

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COORDINATION OF BENEFITS (continued) 

Primary/secondary means the order of benefit determination stating whether this plan is primary or 

secondary covering the person when compared to anotherp/an also covering the person. 

When this plan is primary, its benefits are determined before those of any otherp/an and without 

considering any otherp/an's benefits. When this plan is secondary, its benefits are determined after 

those of anotherp/an and may be reduced because of the primary plan's benefits. 

Allowable expense means a health care service or expense, including deductibles, if any, and 

copayments, that is covered at least in part by any of the plans covering the person. When aplan 

provides benefits in the form of services (e.g. an HMO), the reasonable cash value of each service will 

be considered an allowable expense and a benefit paid. An expense or service that is not covered by any 

of the plans is not an allowable expense. The following are examples of expenses or services that are 

not allowable expenses: 

• If a covered person is confined in a private hospital room, the difference between the cost of a 

semi-private room in the hospital and the private room, (unless the patient's stay in a private hospital 

room is medically necessary in terms of generally accepted medical practice, or one of the plans 

routinely provides coverage for hospital private rooms) is not an allowable expense. 

• If a person is covered by two or more plans that compute their benefits payments on the basis of 

usual and customary fees, any amount in excess of the highest usual and customary fees for a 

specific benefit is not an allowable expense. 

• If a person is covered by two or more plans that provide benefits or services on the basis of 

negotiated fees, any amount in excess of the highest of the fees is not an allowable expense. 

• If a person is covered by one plan that calculates its benefits or services on the basis of usual and 

customary fees and anotherp/an that provides its benefits or services on the basis of negotiated fees, 

the primary plan's payment arrangement shall be the allowable expense for all plans. 

• The amount a benefit is reduced by the primary plan because a covered person does not comply 

with the plan provisions. Examples of these provisions are second surgical opinions, precertification 

of admissions and preferred provider arrangements. 

Claim determination period means a calendar year. However, it does not include any part of a year 

during which a person has no coverage under this plan, or before the date this COB provision or a 

similar provision takes effect. 

Closed panel plan is a plan that provides health benefits to covered persons primarily in the form of 

services through a panel of providers that has contracted with or are employed by the plan, and that 

limits or excludes benefits for services provided by other providers, except in the cases of emergency or 

referral by a panel member. 

Custodial parent means a parent awarded custody by a court decree. In the absence of a court decree, it 

is the parent with whom the child resides more than one half of the calendar year without regard to any 

temporary visitation. 

CHMO 2004-C GF COB 19 70 

A-0077

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 77 of 172
COORDINATION OF BENEFITS (continued) 

Order of determination rules 

General 

When two or more plans pay benefits, the rules for determining the order of payment are as follows: 

• The primary plan pays or provides its benefits as if the secondary plan or plans did not exist. 

• A plan that does not contain a COB provision that is consistent with applicable promulgated 

regulation is always primary. There is one exception: coverage that is obtained by virtue of 

membership in a group that is designed to supplement a part of a basic package of benefits may 

provide that the supplementary coverage shall be excess to any other parts of thep/an provided by 

the contract holder. Examples of these types of situations are major medical coverages that are 

superimposed over base plan hospital and surgical benefits, and insurance type coverages that are 

written in connection with a closed panel plan to provide out-of-network benefits. 

• A plan may consider the benefits paid or provided by anotherp/an in determining its benefits only 

when it is secondary to that other plan. 

Rules 

The first of the following rules that describes which plan pays its benefits before another plan is the rule 

to use. 

• Non-dependent or dependent. The plan that covers the person other than as a dependent, for 

example as an employee, member, subscriber or retiree is primary and the plan that covers the 

person as a dependent is secondary. However, if the person is a Medicare beneficiary and, as a 

result of federal law, Medicare is secondary to the plan covering the person as a dependent, and 

primary to the plan covering the person as other than a dependent (e.g. retired employee); then the 

order of benefits between the two plans is reversed so that the plan covering the person as an 

employee, member, subscriber or retiree is secondary and the other plan is primary. 

• Dependent child covered under more than one plan. The order of benefits when a child is 

covered by more than one plan is: 

The primary plan is the plan of the parent whose birthday is earlier in the year if: 

The parents are married; 

The parents are not separated (whether or not they have been married); or 

A court decree awards joint custody without specifying that one part has the responsibility 

to provide health care coverage. 

CHMO 2004-C GF COB 19 71 

A-0078

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 78 of 172
COORDINATION OF BENEFITS (continued) 

If both the parents have the same birthday, the plan that covered either of the parents longer is 

primary. 

If the specific terms of a court decree state that one parent is responsible for the child's health 

care expenses or health care coverage and the plan of that parent has actual knowledge of those 

terms, that plan is primary. This rule applies to claim determination periods or plan years 

commencing after the plan is given notice of the court decree. 

If the parents are not married, or are separated (whether or not they ever have been married) or 

are divorced, the order of benefits is: 

- The plan of the custodial parent, 

- The plan of the spouse of the custodial parent; 

- The plan of the non-custodial parent, and then 

- The plan of the spouse of the non-custodial parent. 

• Active or inactive employee. The plan that covers a person as an employee, who is neither laid off 

nor retired, is primary. The same would hold true if a person is a dependent of a person covered as 

a retiree and an employee. If the otherp/an does not have this rule, and if, as a result, the plans do 

not agree on the order of benefits, this rule is ignored. 

• Continuation coverage. If a person whose coverage is provided under a right of continuation 

provided by federal or state law also is covered under anotherp/an, the plan covering the person as 

an employee, member, subscriber or retiree (or as that person's dependent) is primary, and the 

continuation coverage is secondary. If the otherp/an does not have this rule, and if, as a result, the 

plans do not agree on the order of benefits, this rule is ignored. 

• Longer or shorter length of coverage. The plan that covered the person as an employee, member, 

subscriber or retiree longer is primary. 

If the preceding rules do not determine the primary plan, the allowable expenses shall be shared equally 

between the plans meeting the definition of plan under this provision. In addition, this plan will not pay 

more that it would have had it been primary. 

Effects on the benefits of this plan 

When this plan is secondary, benefits may be reduced to the difference between the allowable expense 

(determined by the primary plan) and the benefits paid by any primary plan during the claim 

determination period. Payment from all plans will not exceed 100% of the total allowable expense. 

If a covered person is enrolled in two or more closed panel plans and if, for any reason, including the 

provision of service by a non-panel provider, benefits are not payable by one closed panel plan, COB 

shall not apply between that plan and the other closed panel plan. 

CHMO 2004-C GF COB 19 72 

A-0079

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 79 of 172
COORDINATION OF BENEFITS (continued) 

Right to receive and release needed information 

Certain facts about health care coverage and services are needed to apply these COB rules and to 

determine benefits payable under this plan and otherp/ans. We may get the facts we need from or give 

them to other organizations or persons for the purpose of applying these rules and determining benefits 

payable under this plan and other plans covering the person claiming benefits. We need not tell, or get 

the consent of, any person to do this. Each person claiming benefits under thisp/an must give us any 

facts we need to apply those rules and determine benefits payable. 

Facility of payment 

A payment made under anotherp/an may include an amount that should have been paid under this plan. 

If it does, we may pay that amount to the organization that made the payment. That amount will then be 

treated as though it were a benefit paid under this plan. We will not have to pay that amount again. The 

term "payment made" includes providing benefits in the form of services, in which case "payment made" 

means a reasonable cash value of the benefits provided in the form of services. 

Right of recovery 

If the amount of the payments made by us is more than we should have paid under this COB provision, 

we may recover the excess from one or more of the persons we have paid or for whom we have paid; or 

any other person or organization that may be responsible for the benefits or services provided for the 

covered person. The "amount of the payments made" includes the reasonable cash value of any benefits 

provided in the form of services. 

General coordination of benefits with Medicare 

If you are covered under both Medicare and this certificate, federal law mandates that Medicare is the 

secondary plan in most situations. When permitted by law, this plan is the secondary plan. In all cases, 

coordination of benefits with Medicare will conform to federal statutes and regulations. If you are 

enrolled in Medicare, your benefits under this certificate will be coordinated to the extent benefits are 

payable under Medicare, as allowed by federal statutes and regulations. 

CHMO 2004-C GF COB 19 73 

A-0080

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 80 of 172
COORDINATION OF BENEFITS FOR MEDICARE ELIGIBLES 

General coordination of benefits with Medicare 

If you are covered under both Medicare and this certificate, federal law mandates that Medicare is the 

secondary plan in most situations. When permitted by law, this plan is the secondary plan. In all cases, 

coordination of benefits with Medicare will conform to federal statutes and regulations. If you are 

enrolled in Medicare, your benefits under this certificate will be coordinated to the extent benefits are 

payable under Medicare, as allowed by federal statutes and regulations. 

You are considered to be eligible for Medicare on the earliest date coverage under Medicare could have 

become effective for you. 

CHM° 2004-C GEN 16 CR 74 

A-0081

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 81 of 172
CLAIMS 

Notice of claim 

Network providers will submit claims to us on your behalf. If you utilize a non-network provider for 

covered expenses, you must submit a notice of claim to us. Notice of claim must be given to us in 

writing or by electronic mail as required by your plan, or as soon as is reasonably possible thereafter. 

Notice must be sent to us at our mailing address shown on your identification documentation or at our 

Website at www.humana.com. 

Claims must be complete. At a minimum a claim must contain: 

• Name of the covered person who incurred the covered expenses; 

• Name and address of the provider; 

• Diagnosis; 

• Procedure or nature of the treatment; 

• Place of service; 

• Date of service; and 

• Billed amount. 

If you receive services outside the United States or from a foreign provider, you must also submit the 

following information along withyour complete claim: 

• Your proof of payment to the provider for the services received outside the United States or from a 

foreign provider; 

• Complete medical information and medical records; 

• Your proof of travel outside of the United States, such as airline tickets or passport stamps, ifyou 

traveled to receive the services; and 

• The foreign provider's fee schedule if the provider uses a billing agency. 

The forms necessary for filing proof of loss are available at www.humana.com. When requested by you, 

we will send you the forms for filing proof of loss. If the requested forms are not sent to you within 15 

days, you will have met the proof of loss requirements by sending us a written or electronic statement of 

the nature and extent of the loss containing the above elements within the time limit stated in the "Proof 

of loss" provision. 

Proof of loss 

You must give written or electronic proof of loss within 90 days after the date of loss. Your claims will 

not be reduced or denied if it was not reasonably possible to give such proof. In any event, written or 

electronic notice must be given within one year after the date proof of loss is otherwise required, except 

if you were legally incapacitated. 

Right to require medical examinations 

We have the right to require a medical examination on any covered person as often as we may 

reasonably require. If we require a medical examination, it will be performed at our expense. We also 

have a right to request an autopsy in the case of death, if state law so allows. 

CHMO 2004-C GEN 16 CR 75 

A-0082

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 82 of 172
CLAIMS (continued) 

To whom benefits are payable 

If you receive services from a network provider, we will pay the provider directly for all covered 

expenses. You will not have to submit a claim for payment. 

All benefit payments for covered expenses rendered by a non-network provider are due and owing solely 

to the covered person. You may request that we direct a payment of selected medical benefits to the 

health care provider on whose charge the claim is based. Such payments will not constitute the 

assignment of any legal obligation to the non-network provider. 

If any covered person to whom benefits are payable is a minor or, in our opinion, not able to give a 

valid receipt for any payment due him or her, such payment will be made to his or her parent or legal 

guardian. However, if no request for payment has been made by the parent or legal guardian, we may, at 

our option, make payment to the person or institution appearing to have assumed his or her custody and 

support. 

Time of payment of claims 

Payments due under the master group contract will be paid no more than 30 days after receipt of written 

or electronic proof of loss. 

Right to request overpayments 

We reserve the right to recover any payments made by us that were: 

• Made in error; 

• Made to you or any party on your behalf, where we determine such payment made is greater than the 

amount payable under the master group contract; 

• Made to you and/or any party on your behalf, based on fraudulent or misrepresented information; or 

• Made to you and/or any party on your behalf for charges that were discounted, waived or rebated. 

We reserve the right to adjust any amount applied in error to the deductible, out-of-pocket limit or 

copayment limit, if any. 

Right to collect needed information 

You must cooperate with us and when asked, assist us by: 

• Authorizing the release of medical information including the names of all providers from whom you 

received medical attention; 

• Obtaining medical information or records from any provider as requested by us; 

• Providing information regarding the circumstances of your sickness, bodily injury or accident; 

• Providing information about other insurance coverage and benefits, including information related to 

any bodily injury or sickness for which another party may be liable to pay compensation or benefits; 

CHMO 2004-C GEN 16 CR 76 

A-0083

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 83 of 172
CLAIMS (continued) 

• Providing copies of claims and settlement demands submitted to third parties in relation to a 

bodily injury or sickness; 

• Disclosing details of liability settlement agreements reached with third parties in relation to a bodily 

injury or sickness; and 

• Providing information we request to administer the master group contract. 

If you fail to cooperate or provide the necessary information, we may recover payments made by us and 

deny any pending or subsequent claims for which the information is requested. 

Exhaustion of time limits 

If we fail to complete a claim determination or appeal within the time limits set forth in the master group 

contract, the claim shall be deemed to have been denied andyou may proceed to the next level in the 

review process outlined under the "Complaint and Appeal Procedures" section of this certificate or as 

required by law. 

Recovery rights 

You as well as your dependents agree to the following, as a condition of receiving benefits under the 

master group contract. 

Duty to cooperate in good faith 

You are obligated to cooperate with us and our agents in order to protect our recovery rights. Cooperation 

includes promptly notifying us you may have a claim, providing us relevant information, and signing and 

delivering such documents as we or our agents reasonably request to secure our recovery rights. You 

agree to obtain our consent before releasing any party from liability for payment of medical expenses. 

You agree to provide us with a copy of any summons, complaint or any other process served in any 

lawsuit in which you seek to recover compensation for your injury and its treatment. 

You will do whatever is necessary to enable us to enforce our recovery rights and will do nothing after loss 

to prejudice our recovery rights. 

You agree that you will not attempt to avoid our recovery rights by designating all (or any disproportionate 

part) of any recovery as exclusively for pain and suffering. 

In the event that you fail to cooperate with us, we shall be entitled to recover from you any payments made 

by us. 

CHMO 2004-C GEN 16 CR 77 

A-0084

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 84 of 172
CLAIMS (continued) 

Duplication of benefits/other insurance 

We will not provide duplicate coverage for benefits under the master group contract when a person is 

covered by us and has, or is entitled to, benefits as a result of their injuries from any other coverage 

including, but not limited to, first party uninsured or underinsured motorist coverage, any no-fault 

insurance, medical payment coverage (auto, homeowners or otherwise), Workers' Compensation 

settlement or awards, other group coverage (including student plans), direct recoveries from liable 

parties, premises medical pay or any other insurer providing coverage that would apply to pay your 

medical expenses, except another "plan," as defined in the "Coordination of Benefits" section (e.g., 

group health coverage), in which case coverage will be determined as described in the "Coordination of 

Benefits" section. 

Where there is such coverage, we will not duplicate other coverage available to you and shall be 

considered secondary, except where specifically prohibited. Where double coverage exists, we shall 

have the right to be repaid from whomever has received the overpayment from us to the extent of the 

duplicate coverage. 

We will not duplicate coverage under the master group contract whether or not you have made a claim 

under the other applicable coverage. 

When applicable, you are required to provide us with authorization to obtain information about the other 

coverage available, and to cooperate in the recovery of overpayments from the other coverage, including 

executing any assignment of rights necessary to obtain payment directly from the other coverage 

available. 

Workers' compensation 

If benefits are paid by us, and we determine that the benefits were for treatment of bodily injury or 

sickness that arose from or was sustained in the course of, any occupation or employment for 

compensation, profit or gain, we have the right to recover as described below. 

We shall have first priority to recover amounts we have paid and the reasonable value of services and 

benefits provided under a managed care agreement from any funds that are paid or payable by Workers' 

Compensation or similar coverage as a result of any sickness or bodily injury, and we shall not be 

required to contribute to attorney fees or recovery expenses under a Common Fund or similar doctrine. 

Our right to recover from funds that are paid or payable by Workers' Compensation or similar coverage 

will apply even though: 

• The Workers' Compensation benefits are in dispute or are made by means of settlement or 

compromise; 

• There is no final determination that bodily injury or sickness was sustained in the course of or 

resulted from your employment; 

• The amount of Workers' Compensation due to medical or health care is not agreed upon or defined 

by you or the Workers' Compensation carrier; or 

• Medical or health care benefits are specifically excluded from the Workers' Compensation settlement 

or compromise. 

CHMO 2004-C GEN 16 CR 78 

A-0085

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 85 of 172
CLAIMS (continued) 

As a condition to receiving benefits from us, you hereby agree, in consideration for the coverage 

provided by the master group contract, you will notify us of any Workers' Compensation claim you 

make, and you agree to reimburse us as described above. If we are precluded from exercising our 

recovery rights to recover from funds that are paid by Workers' Compensation or similar coverage we 

will exercise our right to recover against you. 

Right of subrogation 

As a condition to receiving benefits from us, you agree to transfer to us any rights you may have to make 

a claim, take legal action or recover any expenses paid under the master group contract. We will be 

subrogated to your rights to recover from any funds paid or payable as a result of a personal injury claim 

or any reimbursement of expenses by: 

• Any legally liable person or their carrier, including self-insured entities; 

• Any uninsured motorist or underinsured motorist coverage; 

• Medical payments/expense coverage under any automobile, homeowners, premises or similar 

coverages; 

• Workers' Compensation or other similar coverage; and 

• No-fault or other similar coverage. 

We may enforce our subrogation rights by asserting a claim to any coverage to which you may be 

entitled. We shall have first priority to recover amounts we have paid and the reasonable value of 

services and benefits provided under a managed care agreement from any funds that are paid or payable 

as a result of any sickness or bodily injury, regardless of whether available funds are sufficient to fully 

compensate you for your sickness or bodily injury. 

If we are precluded from exercising our rights of subrogation, we may exercise our right of 

reimbursement. 

Right of reimbursement 

If benefits are paid under the master group contract, and you recover from any legally responsible 

person, their insurer, or any uninsured motorist, underinsured motorist, medical payment/expense, 

Workers' Compensation, no-fault, or other similar coverage, we have the right to recover from you an 

amount equal to the amount we paid and for the reasonable value of services and benefits provided under 

a managed care agreement. 

You shall notify us, in writing or by electronic mail, within 31 days of any settlement, compromise or 

judgment. Any covered person who waives, abrogates or impairs our right of reimbursement or fails to 

comply with these obligations, relieves us from any obligation to pay past or future benefits or expenses 

until all outstanding lien(s) are resolved. 

CHMO 2004-C GEN 16 CR 79 

A-0086

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 86 of 172
CLAIMS (continued) 

If, after the inception of coverage with us, you recover payment from and release any legally responsible 

person, their insurer, or any uninsured motorist, underinsured motorist, medical payment/expense, 

Workers' Compensation, no-fault, or other similar insurer from liability for future medical expenses 

relating to a sickness or bodily injury, we shall have a continuing right to reimbursement from you to the 

extent of the benefits we provided with respect to that sickness or bodily injury. This right, however, 

shall apply only to the extent of such payment and only to the extent not limited or precluded by law in 

the state whose laws govern the master group contract, including any made whole or similar rule. 

The obligation to reimburse us in full exists, regardless of whether the settlement, compromise, or 

judgment designates the recovery as including or excluding medical expenses. 

Assignment of recovery rights 

The master group contract contains an exclusion for sickness or bodily injury for which there is medical 

payment/expenses coverage provided under any automobile, homeowner's, premises or other similar 

coverage. 

If your claim against the other insurer is denied or partially paid, we will process your claim according 

to the terms and conditions of the master group contract. If payment is made by us on your behalf, you 

agree to assign to us the right you have against the other insurer for medical expenses we pay. 

If benefits are paid under the master group contract and you recover under any automobile, 

homeowner's, premises or similar coverage, we have the right to recover from you, or whomever we have 

paid, an amount equal to the amount we paid. 

Cost of legal representation 

The costs of our legal representation in matters related to our recovery rights shall be borne solely by us. 

The costs of legal representation incurred by you shall be borne solely by you. We shall not be 

responsible to contribute to the cost of legal fees or expenses incurred by you under any Common Fund 

or similar doctrine unless we were given timely notice of the claim and an opportunity to protect our 

own interests and we failed or declined to do so. 

CHMO 2004-C GEN 16 CR 80 

A-0087

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 87 of 172
COMPLAINT AND APPEAL PROCEDURES 

There are situations when you may have questions aboutyour coverage or are dissatisfied with plan 

services. If you have an inquiry or complaint regarding a matter arising under your policy, please 

contact us at 1-800-448-6262. Such inquiries and complaints will be handled in a timely manner. 

If your grievance is not satisfactorily resolved or you are dissatisfied with an adverse determination of 

your claim, you or your authorized representative have the right to a formal grievance by writing to us at 

the address given on the denial letter you received or to the following address: 

Grievance and Appeal Department 

P.O. Box 14546 

Lexington, KY 40512-4546 

Definitions 

The following terms are used in this provision: 

Adverse determination means a denial, reduction or termination of, or failure to provide or make 

payment: 

• In whole or in part for a benefit; 

• Based on eligibility to participate in the plan; or 

• Based on rescission of coverage. 

Appeal means a request for reconsideration of an adverse determination. 

Expedited appeal is a written or oral request for review of an adverse determination when the standard 

timeframe for an appeal would seriously jeopardize your life or health or would jeopardize your ability 

to regain maximum function, or in the opinion of the treating physician would subjectyou to severe pain 

that cannot be adequately managed without the treatment. 

Grievance is a written complaint submitted by you or your authorized representative to us regarding: 

• Availability or delivery of coverage; or 

• Quality of health care services; or 

• Adverse determinations; or 

• Claims payment, handling, or reimbursement for health care services; or 

• Matters pertaining to the contract or the relationship between the subscriber and us. 

Independent Review Organization (IRO) means an organization of medical professionals with no 

connection to your health plan, qualified to review your dispute. 

Review panel is an internal review committee that includes one or more health care practitioners, other 

than the treating health care practitioner. 

CHMO 2004-C SG GF GA 21 81 

A-0088

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 88 of 172
COMPLAINT AND APPEAL PROCEDURES (continued) 

Internal grievance process 

Appeals must be submitted to us in writing within one year of your receipt of an adverse determination 

or within one year of the date of the occurrence, that initiated your grievance that is not an adverse 

determination. Should you need assistance in preparing an appeal, please call us toll-free at 

1-800-448-6262. We will acknowledge the appeal within five business days after receipt. 

During the appeal of an adverse determination, you may request a meeting with us. The location of the 

meeting shall be at our administrative offices or at a location within the service area which is 

convenient for you. If a phone call would be more convenient to you, please use the phone number 

provided in your acknowledgment letter. 

Medical necessity, experimental or investigational adverse determination appeals are forwarded to our 

review panel for a decision. You, your authorized representative will be notified of a final decision in 

writing within the following timeframes: 

• 30 calendar days after the date we receive an appeal of a medical necessity, experimental, 

investigational, pre-service or concurrent care adverse determination; 

• 60 calendar days after the date we receive an appeal for a post-service adverse determination; and 

• 60 calendar days after the date we receive a grievance that is not an adverse determination. If 

information is needed from outside the service area, we will have an additional 30 calendar days in 

which to notify you, your authorized representative, or provider acting on your behalf. The 

notification timeframe is suspended and resumes when the information is received. 

Internal expedited appeal 

All internal expedited appeals are to be investigated and a decision provided to you, your authorized 

representative, or a provider acting on your behalf as expeditiously as your medical condition requires, 

but no more than 72 hours after the request for review is received. 

Assistance 

You may contact the Agency for Health Care Administration (AHCA) for assistance with the submission 

of an appeal at any time during the appeal process. The toll free telephone hotline number and the 

address for the Agency are: 

Agency for Health Care Administration 

Bureau of Managed Health Care 

Building 1, Room 339, MS 26 

2727 Mahan Drive 

Tallahassee, FL 32308 

1-850-921-5458 or toll-free 1-888-419-3456 

CHMO 2004-C SG GF GA 21 82 

A-0089

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 89 of 172
COMPLAINT AND APPEAL PROCEDURES (continued) 

You may contact the Florida Department of Financial Services, Division of Consumer Assistance for 

assistance with billing problems. The toll-free telephone number and the address for the Florida 

Department of Financial Services, Division of Consumer Assistance are: 

Florida Department of Financial Services 

Division of Consumer Assistance 

200 East Gaines Street 

Tallahassee, FL 32399 

1-800-342-2762 

Exhaustion of remedies 

You must complete all levels of the appeal process available to you under state or federal law before 

filing a lawsuit. This assures that both you and we have a full and fair opportunity to complete the 

record and resolve the dispute. Contact us if you believe your condition requires the use of the shorter 

time lines applicable to emergency health conditions. 

The appeal process, however, does not stop you from pursuing other appropriate remedies, including 

injunctive relief or equitable relief, if the requirement of exhausting the process for appeal, including the 

expedited appeal process, would place your health in serious jeopardy. 

A coverage denial does not mean that your provider cannot provide the service or supply. Our denial 

only means we will not pay for the service or supply, unless our decision is reversed upon further review 

or in a subsequent lawsuit. 

External review 

If you or your authorized representative disagree with the outcome of the internal appeal review 

decision, you or your authorized representative have the right to request an external review by an 

Independent Review Organization (IRO) if the adverse determination involves a medical necessity, 

experimental and investigational determination, a denial based on medical judgment, or a rescission of 

coverage. Adverse determinations related to eligibility to participate in the plan are not eligible for 

external review. 

You or your authorized representative must exhaust the internal appeal process before requesting an 

external review by an IRO. If you or your authorized representative wishes to file a request for an 

external review the request must be submitted in writing to the address listed below and received by us 

within four months or the next business day following the four month period from the receipt of the 

adverse determination. 

Grievance and Appeal Department 

P.O. Box 11268 

Green Bay, WI 54307-1268 

Within five business days of our receipt of the request, an IRO will be assigned to your case through an 

unbiased rotating selection process. The assigned IRO will send you or your authorized representative a 

notice of acceptance which will include notice of the right to submit additional information within ten 

business days of receipt of the notice from the IRO. The assigned IRO will also deliver a notice of the 

final external review decision in writing to you, your authorized representative, and us within 45 days of 

their receipt of the request. 

CHMO 2004-C SG GF GA 21 83 

A-0090

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 90 of 172
COMPLAINT AND APPEAL PROCEDURES (continued) 

Should the IRO find in your or your authorized representative's favor in whole or in part, we will take 

the necessary actions to ensure the implementation of the IRO decision. 

External expedited review 

An external expedited review is a review involving cases where the normal duration of the external 

independent review process would jeopardize a covered person's life, health or ability to regain 

maximum function. This request should be submitted to us immediately. 

The IRO must provide a decision to you or your authorized representative and to us within 72 hours of 

the IRO 's receipt of the request. 

Once the IRO makes a final coverage decision, the fmal coverage decision is binding on us and we will 

take the necessary actions to ensure the implementation of the IRO decision. 

Legal actions and limitations 

No legal action to recover on the master group contract may be brought until 60 days after written proof 

of loss has been given in accordance with the "Proof of loss" provision of the master group contract. 

No legal action to recover on the master group contract may be brought after the expiration of the 

applicable statute of limitations from the date written proof of loss is required to be given. 

CHMO 2004-C SG GF GA 21 84 

A-0091

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DISCLOSURE PROVISIONS 

Employee assistance program 

We may provide you access to an employee assistance program (EAP). The EAP may include 

confidential, telephonic consultations and work-life services. The EAP provides you with short-term, 

problem solving services for issues that may otherwise affect your work, personal life or health. The 

EAP is designed to provide you with information and assistance regarding your issue and may also assist 

you with finding a medical provider or local community resource. 

The services provided by the EAP are not covered expenses under the master group contract, therefore 

the cop ayments, deductible or coinsurance do not apply. However, there may be additional costs to you, 

if you obtain services from a professional or organization the EAP has recommended or has referred you 

to. The EAP does not provide medical care. You are not required to participate in the EAP before using 

your benefits under the master group contract, and the EAP services are not coordinated with covered 

expenses under the master group contract. The decision to participate in the EAP is voluntary, and you 

may participate at any time during the year. Refer to the marketing literature for additional information. 

Discount programs 

From time to time, we may offer or provide access to discount programs to you. In addition, we may 

arrange for third party service providers such as pharmacies, optometrists, dentists and alternative 

medicine providers to provide discounts on goods and services to you. Some of these third party service 

providers may make payments to us when covered persons take advantage of these discount programs. 

These payments offset the cost to us of making these programs available and may help reduce the costs 

of your plan administration. Although we have arranged for third parties to offer discounts on these 

goods and services, these discount programs are not covered services under the master group contract. 

The third party service providers are solely responsible to you for the provision of any such goods and/or 

services. We are not responsible for any such goods and/or services, nor are we liable if vendors refuse 

to honor such discounts. Further, we are not liable to covered persons for the negligent provision of 

such goods and/or services by third party service providers. Discount programs may not be available to 

persons who "opt out" of marketing communications and where otherwise restricted by law. 

Wellness programs 

From time to time we may offer directly, or enter into agreements with third parties who administer 

participatory or health-contingent wellness programs to you. 

"Participatory" wellness programs do not require you to meet a standard related to a health factor. 

Examples of participatory wellness programs may include membership in a fitness center, certain 

preventive testing, or attending a no-cost health education seminar. 

"Health-contingent" wellness programs require you to attain certain wellness goals that are related to a 

health factor. Examples of health-contingent wellness programs may include completing a 5k event, 

lowering blood pressure, reduction in weight and body mass index or ceasing the use of tobacco. 

CHMO 2004-C GF DP 19 85 

A-0092

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DISCLOSURE PROVISIONS (continued) 

The rewards may include payment for all or a portion of a participatory wellness program, merchandise, 

gift cards, debit cards, discounts or contributions to your health spending account. We are not 

responsible for any rewards provided by third parties that are non-insurance benefits or for your receipt 

of such reward(s). 

The rewards may also include premium discounts, premium rebates or credits toward premium or a 

reduction in copayments, deductibles or coinsurance, as permitted under applicable state and federal 

laws. Such insurance premium or benefit rewards may be made available at the individual or group 

health plan level. 

The rewards may be taxable income. You may consult a tax advisor for further guidance. 

Our agreement with any third party does not eliminate any ofyour obligations under this master group 

contract or change any of the terms of this master group contract. Our agreement with the third parties 

and the program may be terminated at any time, although insurance benefits will be subject to applicable 

state and federal laws. 

We are committed to helping you achieve your best health. Some wellness programs may be offered 

only to covered persons with particular health factors. Ifyou think you might be unable to meet a 

standard for a reward under a health contingent wellness program, you might qualify for an opportunity 

to earn the same reward by different means. Contact us at the number listed on your ID card or in the 

marketing literature issued by the wellness program administrator for more information. 

The wellness program administrator or we may require proof in writing from your health care 

practitioner that your medical condition prevents you from taking part in the available activities. 

The decision to participate in wellness program activities is voluntary and if eligible, you may decide to 

participate anytime during the year. Refer to the marketing literature issued by the wellness program 

administrator for their program's eligibility, rules and limitations. 

CHMO 2004-C GF DP 19 86 

A-0093

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DISCLOSURE PROVISIONS (continued) 

If you would like to inquire in advance to determine if services rendered by a non-network provider 

may be subject to the Shared Savings Program, please contact our customer service department at the 

telephone number shown on your ID card. Provider arrangements in the Shared Savings Program are 

subject to change without notice. We cannot guarantee that the services you receive from a non-network 

provider are still subject to the Shared Savings Program at the time services are received. Discounts are 

dependent upon availability and cannot be guaranteed. 

We reserve the right to modify, amend or discontinue the Shared Savings Program at any time. 

CHMO 2004-C GF DP 19 87 

A-0094

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 94 of 172
MISCELLANEOUS PROVISIONS 

Entire contract 

The entire contract is made up of the master group contract, the Employer Group Application of the 

group plan sponsor, incorporated by reference herein, and the applications or enrollment forms, if any, 

of the covered persons. All statements made by the group plan sponsor or by a covered person are 

considered to be representations, not warranties. This means that the statements are made in good faith. 

No statement will void the master group contract, reduce the benefits it provides or be used in defense 

to a claim unless it is contained in a written or electronic application or enrollment form and a copy is 

furnished to the person making such statement or his or her beneficiary. 

Additional group plan sponsor responsibilities 

In addition to responsibilities outlined in the master group contract, the group plan sponsor is 

responsible for: 

• Collection of premium; and 

• Distributing and providing covered persons access to: 

Benefit plan documents and the Summary of Benefits and Coverage (SBC); 

Renewal notices and master group contract modification information; 

Discontinuance notices; and 

Information regarding continuation rights. 

No group plan sponsor may change or waive any provision of the master group contract. 

Certificates 

A certificate setting forth the benefits available to the employee and the employee's covered dependents 

will be available at www.humana.comor in writing when requested. The employer is responsible for 

providing employees access to the certificate. 

No document inconsistent with the master group contract shall take precedence over it. This is true, 

also, when this certificate is incorporated by reference into a summary description of plan benefits by 

the administrator of a group plan subject to ERISA. If the terms of a summary plan description differ 

with the terms of this certificate, the terms of this certificate will control. 

Incontestability 

No misstatement made by the group plan sponsor, except for fraud or an intentional misrepresentation 

of a material fact made in the application may be used to void the master group contract or deny any 

claim for loss incurred or disability starting after the two-year period. 

CHMO 2004-C GF MP 19 88 

A-0095

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MISCELLANEOUS PROVISIONS (continued) 

After you are covered without interruption for two years, we cannot contest the validity of your 

coverage, except for: 

• Nonpayment of premiums; or 

• Any fraud or intentional misrepresentation of a material fact made by you. 

At any time, we may assert defenses based upon provisions in the master group contract which relate to 

your eligibility for coverage under the master group contract. 

No statement made by you can be contested unless it is in a written or electronic form signed by you. A 

copy of the form must be given to you or your beneficiary. 

An independent incontestability period begins for each type of change in coverage or when a new 

application or enrollment form of the covered person is completed. 

Third party beneficiary 

This master group contract is between your employer and us. Covered persons are third party 

beneficiaries. There are no other third party beneficiaries. Providers are not third party beneficiaries. 

Fraud 

Health insurance fraud is a criminal offense that can be prosecuted. Any person(s) who willingly and 

knowingly engages in an activity intended to defraud us by filing a claim or form that contains a false or 

deceptive statement may be guilty of insurance fraud. 

If you commit fraud against us or your employer commits fraud pertaining to you against us, as 

determined by us, we reserve the right to rescind your coverage after we provide you a 45-day advance 

written notice that coverage will be rescinded. You have the right to appeal the rescission. 

Clerical error or misstatement 

If it is determined that information about a covered person was omitted or misstated in error, an 

adjustment may be made in premiums and/or coverage in effect. This provision applies to you and to us. 

Modification of master group contract 

The master group contract may be modified by us, upon renewal of the master group contract, as 

permitted by state and federal law. The group plan sponsor will be notified in writing or electronically 

as follows: 

• For a small employer, at least 60 days prior to the effective date of the change; 

• For a large employer, at least 45 days prior to the effective date of the change. 

CITMO 2004-C GF MP 19 89 

A-0096

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MISCELLANEOUS PROVISIONS (continued) 

The master group contract may be modified by agreement between us and the group plan sponsor 

without the consent of any covered person or any beneficiary. No modification will be valid unless 

approved by our President, Secretary or Vice-President. The approval must be endorsed on or attached 

to the master group contract. No agent has authority to modify the master group contract, or waive 

any of the master group contract provisions, to extend the time of premium payment, or bind us by 

making any promise or representation. 

Corrections due to clerical errors or clarifications that do not change benefits are not modifications of the 

master group contract and may be made by us at any time without prior consent of, or notice to, the 

group plan sponsor. 

Discontinuation of coverage 

If we decide to discontinue offering a particular group health plan: 

• The group plan sponsor and the employees will be notified of such discontinuation at least 90 days 

prior to the date of nonrenewal of such coverage; and 

• The group plan sponsor will be given the option to purchase all (or, in the case of a large employer, 

any) other group plans providing medical benefits that are being offered by us at such time. 

If we cease doing business in the small employer or the large employer group market, the group plan 

sponsors, covered persons and the Commissioner of Insurance will be notified of such discontinuation at 

least 180 days prior to the date of nonrenewal of such coverage. 

Premium contributions 

Your employer must pay the required premium to us as they become due. Your employer may require 

you to contribute toward the cost of your coverage. Failure of your employer to pay any required 

premium to us when due may result in the termination of your coverage. 

Premium rate change 

We reserve the right to change any premium rates in accordance with applicable law upon notice to the 

employer. We will provide a 30-day advance written notice to the employer of any such premium 

changes. Questions regarding changes to premium rates should be addressed to the employer. 

Assignment 

The master group contract and its benefits may not be assigned by the group plan sponsor. 

CHMO 2004-C GF MP 19 90 

A-0097

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MISCELLANEOUS PROVISIONS (continued) 

Conformity with statutes 

Any provision of the master group contract which is not in conformity with applicable state law(s) or 

other applicable law(s) shall not be rendered invalid, but shall be construed and applied as if it were in 

full compliance with the applicable state law(s) and other applicable law(s). 

CHMO 2004-C GF MY 19 91 

A-0098

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 98 of 172
GLOSSARY 

Terms printed in italic type in this certificate have the meaning indicated below. Defined terms are 

printed in italic type wherever found in this certificate. 

A 

Accident means a sudden event that results in a bodily injury or dental injury and is exact as to time and 

place of occurrence. 

Active status means the employee is performing all of his or her customary duties, whether performed at 

the employer's business establishment, some other location which is usual for the employee's particular 

duties or another location, when required to travel on the job: 

• On a regularfu//-time basis, having a normal workweek of 25 or more hours; 

• For 48 weeks a year; and 

• Is maintaining a bona fide employer-employee relationship with the group plan sponsor of the 

master group contract on a regular basis. 

Each day of a regular vacation and any regular non-working holiday are deemed active status, if the 

employee was in active status on his or her last regular working day prior to the vacation or holiday. An 

employee is deemed to be in active status if an absence from work is due to a sickness or bodily injury, 

provided the individual otherwise meets the definition of employee. 

Acute inpatient services mean care given in a hospital or health care treatment facility which: 

• Maintains permanent full-time facilities for room and board of resident patients; 

• Provides emergency, diagnostic and therapeutic services with a capability to provide life-saving 

medical and psychiatric interventions; 

• Has physician services, appropriately licensed behavioral health practitioners and skilled nursing 

services available 24-hours a day; 

• Provides direct daily involvement of the physician; and 

• Is licensed and legally operated in the jurisdiction where located. 

Acute inpatient services are utilized when there is an immediate risk to engage in actions, which would 

result in death or harm to self or others, or there is a deteriorating condition in which an alternative 

treatment setting is not appropriate. 

Admission means entry into a facility as a registered bed patient according to the rules and regulations 

of that facility. An admission ends when you are discharged, or released, from the facility and are no 

longer registered as a bed patient. 

Advanced imaging, for the purpose of this definition, includes Magnetic Resonance Imaging (MRI), 

Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET), Single Photon 

Emission Computed Tomography (SPEC), and Computed Tomography (CT) imaging. 

Alternative medicine, for the purposes of this definition, includes: acupressure, aromatherapy, ayurveda, 

biofeedback, faith healing, guided mental imagery, herbal supplements and medicine, holistic medicine, 

homeopathy, hypnosis, macrobiotics, massage therapy, naturopathy, ozone therapy, reflexotherapy, 

relaxation response, rolfing, shiatsu, yoga, and chelation therapy. 

CHMO 2004-C SG GF GL 21 92 

A-0099

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GLOSSARY (continued) 

Ambulance means a professionally operated vehicle, provided by a licensed ambulance service, 

equipped for the transportation of a sick or injured person to or from the nearest medical facility 

qualified to treat the person's sickness or bodily injury. Use of the ambulance must be medically 

necessary and/or ordered by a health care practitioner. 

Ambulatory surgical center means an institution which meets all of the following requirements: 

• It must be staffed by physicians and a medical staff which includes registered nurses. 

• It must have permanent facilities and equipment for the primary purpose of performing surgery. 

• It must provide continuous physicians' services on an outpatient basis. 

• It must admit and discharge patients from the facility within a 24-hour period. 

• It must be licensed in accordance with the laws of the jurisdiction where it is located. It must be 

operated as an ambulatory surgical center as defined by those laws. 

• It must not be used for the primary purpose of terminating pregnancies, or as an office or clinic for 

the private practice of any physician or dentist. 

Assistant surgeon means a health care practitioner who assists at surgery and is a Doctor of Medicine 

(MD), Doctor of Osteopathic Medicine (DO), Doctor of Podiatric Medicine (DPM) or where state law 

requires a specific health care practitioner be treated and reimbursed the same as an MD, DO or DPM. 

Autism spectrum disorder means any of the following disorders as defined in the most recent edition of 

the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association: a) 

autistic disorder; b) asperger's syndrome; and c) pervasive developmental disorder not otherwise 

specified. 

Behavioral health means mental health services and chemical dependency services. 

Bodily injury means bodily damage other than a sickness, including all related conditions and recurrent 

symptoms. However, bodily damage resulting from infection or muscle strain due to athletic or physical 

activity is considered a sickness and not a bodily injury. 

Bone marrow means the transplant of human blood precursor cells which are administered to a patient 

to restore normal hematological and immunological functions following ablative or non-ablative therapy 

with curative or life-prolonging intent. 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, from a medically acceptable related or unrelated donor or cord blood. If chemotherapy is an 

integral part of the treatment involving a transplant of bone marrow, the term bone marrow includes the 

harvesting, the transplantation and the chemotherapy components. 

Certificate means this benefit plan document that describes the benefits, provisions and limitations of 

the master group contract. This certificate is part of the master group contract and is subject to the 

terms of the master group contract. 

CHMO 2004-C SG GF GL 21 93 

A-0100

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GLOSSARY (continued) 

Chemical dependency means the abuse of, or psychological or physical dependence on, or addiction to 

alcohol or a controlled substance. 

Coinsurance means the amount expressed as a percentage of the covered expense that you must pay. 

Confinement or confined means you are a registered bed patient as the result of a health care 

practitioner's recommendation. It does not mean you are in observation status. 

Congenital anomaly means an abnormality of the body that is present from the time of birth. 

Copayment means the specified dollar amount you must pay to a provider for covered expenses, 

regardless of any amounts that may be paid by us. 

Cosmetic surgery means surgery performed to reshape normal structures of the body in order to improve 

or change your appearance or self-esteem. 

Covered expense means: 

• Medically necessary services to treat a sickness or bodily injury, such as: 

Procedures; 

Surgeries; 

Consultations; 

Advice; 

Diagnosis; 

Referrals; 

Treatment; 

Supplies; 

- Drugs, including prescription and specialty drugs; 

Devices; or 

Technologies; 

• Preventive services. 

To be considered a covered expense, services must be: 

• Ordered by a health care practitioner; 

• For the benefits described herein, subject to any maximum benefit and all other terms, provisions 

limitations and exclusions of the master group contract; and 

• Incurred when you are insured for that benefit under the master group contract on the date that the 

service is rendered. 

Covered person means the employee or the employee's dependents, who are enrolled for benefits 

provided under the master group contract. 

CHMO 2004-C SG GF GL 21 94 

A-0101

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GLOSSARY (continued) 

Dental injury means an injury to a sound natural tooth caused by a sudden and external force that could 

not be predicted in advance and could not be avoided. It does not include biting or chewing injuries, 

unless the biting or chewing injury is a result of an act of domestic violence or a medical condition 

(including both physical and mental health conditions). 

Dependent means a covered employee's: 

• Legally recognized spouse; 

• Natural born child, step-child, foster child, legally adopted child, or child placed for adoption, whose 

age is less than the limiting age; 

• Child whose age is less than the limiting age and for whom the employee has received a Qualified 

Medical Child Support Order (QMCSO) or National Medical Support Notice (NMSN) to provide 

coverage, if the employee is eligible for family coverage until: 

Such QMCSO or NMSN is no longer in effect; or 

The child is enrolled for comparable health coverage, which is effective no later than the 

termination of the child's coverage under the master group contract. 

• Child in court-ordered temporary or other custody; 

CHMO 2004-C SG GF GL 21 95 

A-0102

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GLOSSARY (continued) 

• Newborn child of a covered dependent child. Coverage for such child terminates 18 months after 

the date of birth or the date as determined by the "Termination of coverage" provision, whichever is 

earliest; 

• Great-grandchild if the parent of a minor child delegates to any grandparent residing in this state, 

caregiving authority regarding the minor child when hardship prevents the parent from caring for the 

child. Coverage for such child terminates 18 months after the date of birth or the date as determined 

by the "Termination of coverage" provision, whichever is the earliest. 

The limiting age means the end of the month the dependent child attains age 26. Each dependent child 

is covered to the limiting age, regardless if the child is: 

• Married; 

• A tax dependent; 

• A student; 

• Employed; 

• Residing with or receiving fmancial support from you; 

• Eligible for other coverage through employment; or 

• Residing or working outside of the service area. Benefits for dependents residing outside of the 

service area are limited to emergency care and urgent care services as specified in the "Dependent 

eligibility date" provision, unless additional coverage is provided by addenda or authorized by us. 

A covered dependent child who attains the limiting age while coveredunder the master group contract 

remains eligible if the covered dependent child is: 

• Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and 

• Chiefly dependent upon the employee or spouse for support and maintenance. 

In order for the covered dependent child to remain eligible as specified above, we must receive 

notification within 31 days prior to the covered dependent child attaining the limiting age. 

You must furnish satisfactory proof to us, upon our request, that the conditions, as defined in the 

bulleted items above, continuously exist on and after the date the limiting age is reached. After two 

years from the date the first proof was furnished, we may not request such proof more often than 

annually. If satisfactory proof is not submitted to us, the child's coverage will not continue beyond the 

last date of eligibility. 

CHMO 2004-C SG GF GL 21 96 

A-0103

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GLOSSARY (continued) 

Dependent adult child 

If the covered employee has a dependent adult child who has attained the limiting age of 26 and meets 

the following requirements, coverage may be available for that dependent adult child until the end of the 

calendar year in which they reach age 30. 

To be eligible for coverage, a dependent adult child must satisfy the following requirements: 

• The dependent adult child is unmarried and does not have dependents of his or her own; 

• The dependent adult child is a resident of Florida, or a full-time or part-time student; and 

• The dependent adult child does not have coverage as a covered person under any other health 

insurance coverage or individual health benefits plan, or Medicare. 

A dependent adult child, as defined in the bulleted items above, ceases to be eligible for coverage under 

this provision: 

• On the last day of the calendar year following the dependent adult child's attainment of the limiting 

age; or 

• When the dependent adult child no longer meets the requirements listed above. 

A dependent adult child who takes a medically necessary leave of absence from an accredited 

educational institution while in full-time status, will continue to be eligible for coverage until the earlier 

of the following: 

• Up to one year after the first day of the medically necessary leave of absence, unless the dependent 

adult child continues to meet the eligibility requirements stated above; or 

• The date coverage would otherwise terminate under this certificate. 

We must receive written certification from the dependent adult child's health care practitioner that the 

dependent adult child has a serious bodily injury or sickness requiring a medically necessary leave of 

absence. 

You must furnish satisfactory proof to us, upon our request, that the above conditions continuously exist. 

If satisfactory proof is not submitted to us, the dependent adult child's coverage will not continue beyond 

the last date of eligibility. 

Diabetes equipment means blood glucose monitors, including monitors designed to be used by blind 

individuals; insulin pumps and associated accessories; insulin infusion devices; and podiatric appliances 

for the prevention of complications associated with diabetes. 

Diabetes self-management training means the training provided to a covered person after the initial 

diagnosis of diabetes for care and management of the condition including nutritional counseling and use 

of diabetes equipment and supplies. It also includes training when changes are required to the 

self-management regime and when new techniques and treatments are developed. 

Diabetes supplies means test strips for blood glucose monitors; visual reading and urine test strips; 

lancets and lancet devices; insulin and insulin analogs; injection aids; syringes; prescriptive agents for 

controlling blood sugar levels; prescriptive non-insulin injectable agents for controlling blood sugar 

levels; glucagon emergency kits; and alcohol swabs. 

CHMO 2004-C SG GF GL 21 97 

A-0104

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GLOSSARY (continued) 

Durable medical equipment means equipment that meets all of the following criteria: 

• It is prescribed by a health care practitioner; 

• It can withstand repeated use; 

• It is primarily and customarily used for a medical purpose rather than being primarily for comfort or 

convenience; 

• It is generally not useful to you in the absence of sickness or bodily injury; 

• It is appropriate for home use or use at other locations as necessary for daily living; 

• It is related to and meets the basic functional needs ofyour physical disorder; 

• It is not typically furnished by a hospital or skilled nursing facility, and 

• It is provided in the most cost effective manner required by your condition, including, at our 

discretion, rental or purchase. 

Effective date means the date your coverage begins under the master group contract. 

Electronic or electronically means relating to technology having electrical, digital, magnetic, wireless, 

optical, electromagnetic, or similar capabilities. 

Electronic mail means a computerized system that allows a user of a network computer system and/or 

computer system to send and receive messages and documents among other users on the network and/or 

with a computer system. 

Electronic signature means an electronic sound, symbol, or process attached to or logically associated 

with a record and executed or adopted by a person with the intent to sign the record. 

Eligibility date means the date the employee or dependent is eligible to participate in the plan. 

Emergency care means services provided in a hospital emergency facility for a bodily injury or sickness 

manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent 

layperson, who possesses an average knowledge of health and medicine, could reasonably expect the 

absence of immediate medical attention to result in: 

• Placing the health of that individual (or, with respect to a pregnant woman, the health of the woman 

or her unborn child) in serious jeopardy; 

CHMO 2004-C SG GF GL 21 98 

A-0105

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GLOSSARY (continued) 

• Serious impairment of bodily functions; or 

• Serious dysfunction of any bodily organ or part. 

Emergency care does not mean services for the convenience of the covered person or the provider of 

treatment or services. 

Employee means a person who is in active status for the employer on a full-time basis, having a normal 

workweek of 25 or more hours and who has met the waiting period, if any, elected by the group plan 

sponsor. The employee must be paid a salary or wage by the employer that meets the minimum wage 

requirements of your state or federal minimum wage law for work done at the employer's usual place of 

business or some other location, which is usual for the employee's particular duties. 

Employee also includes a sole proprietor, partner or corporate officer where: 

• The employer is a sole proprietorship, partnership or corporation; 

• The sole proprietorship or other entity (other than a partnership) has at least one common-law 

employee (other than the business owner and his or her spouse); and 

• The sole proprietor, partner or corporate officer is actively performing activities relating to the 

business, gains their livelihood from the sole proprietorship, partnership, or corporation and is in an 

active status at the employer's usual place of business or some other location, which is usual for the 

sole proprietor's, partner's or corporate officer's particular duties. 

If specified on the Employer Group Application and approved by us, employee also includes retirees of 

the employer. A retired employee is not required to be in active status to be eligible for coverage under 

this master group contract. 

Employee may also include independent contractors of the employer if the employer includes the 

independent contractor under the employer's group health plan. 

Employer means the sponsor of this group plan or any subsidiary or affiliate described in the Employer 

Group Application. An employer must either employ at least one common-law employee or be a 

partnership with a bona fide partner who provides services on behalf of the partnership. A business 

owner and his or her spouse are not considered common-law employees for this purpose if the entity is 

considered to be wholly owned by one individual or one individual and his or her spouse. 

Experimental, investigational or for research purposes means a drug, biological product, device, 

treatment, or procedure that meets any one of the following criteria, as determined by us: 

• Cannot be lawfully marketed without the final approval of the United States Food and Drug 

Administration (FDA) and lacks such final FDA approval for the use or proposed use, unless (a) 

found to be accepted for that use in the most recently published edition of the United States 

Pharmacopeia-Drug Information for Healthcare Professional (USP-DI) or in the most recently 

published edition of the American Hospital Formulary Service (AHFS) Drug Information; (b) 

identified as safe, widely used and generally accepted as effective for that use as reported in 

nationally recognized peer reviewed medical literature published in the English language as of the 

date of service; or (c) is mandated by state law; 

• Is a device required to receive Premarket Approval (PMA) or 510K approval by the FDA but has not 

received a PMA or 510K approval; 

CHMO 2004-C SG GF GL 21 99 

A-0106

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GLOSSARY (continued) 

• Is not identified as safe, widely used and generally accepted as effective for the proposed use as 

reported in nationally recognized peer reviewed medical literature published in the English language 

as of the date of service; 

• Is the subject of a National Cancer Institute (NCI) Phase I, II or III trial or a treatment protocol 

comparable to a NCI Phase I, II or III trial, or any trial not recognized by NCI regardless of phase; 

Or 

• Is identified as not covered by the Centers for Medicare & Medicaid Services (CMS) Medicare 

Coverage Issues Manual, a CMS Operational Policy Letter or a CMS National Coverage Decision, 

except as required by state or federal law. 

Family member means you or your spouse. It also means your or your spouse's child, brother, sister, or 

parent. 

Free-standing facility means any licensed public or private establishment other than a hospital which 

has permanent facilities equipped and operated to provide laboratory and diagnostic laboratory, 

outpatient radiology, advanced imaging, chemotherapy, inhalation therapy, radiation therapy, lithotripsy, 

physical, cardiac, speech and occupational therapy, or renal dialysis services. An appropriately licensed 

birthing center is also considered afree-standing facility. 

Full-time, for an employee, means having a normal workweek of 25 or more hours. 

Functional impairment means a direct and measurable reduction in physical performance of an organ or 

body part. 

Group means the persons for whom this health coverage has been arranged to be provided. 

Group plan sponsor means the legal entity identified as the group plan sponsor on the face page of the 

master group contract or "Certificate of Coverage" who establishes, sponsors and endorses an employee 

benefit plan for health care coverage. 

Health care practitioner means a practitioner professionally licensed by the appropriate state agency to 

provide preventive services or diagnose or treat a sickness or bodily injury and who provides services 

within the scope of that license. 

CHMO 2004-C SG GF GL 21 100 

A-0107

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GLOSSARY (continued) 

Health care treatment facility means a facility, institution or clinic, duly licensed by the appropriate 

state agency to provide medical services, behavioral health services, and is primarily established and 

operating within the scope of its license. 

Health insurance coverage means medical coverage under any hospital or medical service policy or 

certificate, hospital or medical service plan contract or health maintenance organization (HMO) contract 

offered by a health insurance issuer. "Health insurance issuer" means an insurance company, insurance 

service or insurance organization (including an HMO) that is required to be licensed to engage in the 

business of insurance in a state and that is subject to the state law that regulates insurance. 

Health status-related factor means any of the following: 

• Health status or medical history; 

• Medical condition, either physical or mental; 

• Claims experience; 

• Receipt of health care; 

• Genetic information; 

• Disability; or 

• Evidence of insurability, including conditions arising out of acts of domestic violence. 

Home health care agency means a home health care agency or hospital which meets all of the 

following requirements: 

• It must primarily provide skilled nursing services and other therapeutic services under the 

supervision of physicians or registered nurses; 

• It must be operated according to established processes and procedures by a group of medical 

professionals, including health care practitioners and nurses; 

• It must maintain clinical records on all patients; and 

• It must be licensed by the jurisdiction where it is located, if licensure is required. It must be 

operated according to the laws of that jurisdiction which pertains to agencies providing home health 

care. 

Home health care plan means a plan of care and treatment for you to be provided in your home. To 

qualify, the home health care plan must be established and approved by a health care practitioner. The 

services to be provided by the plan must require the skills of a nurse, or another health care practitioner 

and must not be for custodial care. 

Hospice care program means a coordinated, interdisciplinary program provided by a hospice that is 

designed to meet the special physical, psychological, spiritual and social needs of a terminally ill 

covered person and his or her immediate coveredfami/y members, by providing palliative care and 

supportive medical, nursing and other services through at-home or inpatient care. A hospice must be 

licensed by the laws of the jurisdiction where it is located and must be operated as a hospice as defined 

by those laws. It must provide a program of treatment for at least two unrelated individuals who have 

been medically diagnosed as having no reasonable prospect for cure for their sickness and, as estimated 

by their physicians, are expected to live 18 months or less as a result of that sickness. 

CHMO 2004-C SG GF GL 21 101 

A-0108

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GLOSSARY (continued) 

Hospital means an institution that meets all of the following requirements: 

• It must provide, for a fee, medical care and treatment of sick or injured patients on an inpatient 

basis; 

• It must provide or operate, either on its premises or in facilities available to the hospital on a 

pre-arranged basis, medical, diagnostic and surgical facilities. The requirement for provision or 

operation of surgical facilities does not apply to a hospital that is primarily for the rehabilitation of 

physical disability. Claims may not be denied for care or services provided for the treatment of a 

physical disability by a licensed hospital accredited by one of the organizations listed below even if 

such hospital lacks major surgical facilities; 

• Care and treatment must be given by and supervised by physicians. Nursing services must be 

provided on a 24-hour basis and must be given by or supervised by registered nurses; 

• It must be licensed by the laws of the jurisdiction where it is located. It must be operated as a 

hospital as defined by those laws; and 

• It must not be primarily a: 

Convalescent, rest or nursing home; or 

Facility providing custodial or educational care. 

The hospital must be accredited by one of the following: 

• The Joint Commission on the Accreditation of Hospitals; 

• The American Osteopathic Hospital Association; or 

• The Commission on the Accreditation of Rehabilitative Facilities. 

Individual lifetime maximum benefit means the maximum amount of benefits payable by us for all 

covered expenses incurred by you. 

Infertility services mean any treatment, supply, medication, or service provided to achieve pregnancy or 

to achieve or maintain ovulation. This includes: 

• Artificial insemination; 

• In vitro fertilization; 

• Gamete Intrafallopian Transfer (GIFT); 

• Zygote Intrafallopian Transfer (ZIFT); 

• Tubal ovum transfer; 

• Embryo freezing or transfer; 

• Sperm storage or banking; 

• Ovum storage or banking; 

• Embryo or zygote banking; and 

• Any other assisted reproductive techniques or cloning methods. 

CHMO 2004-C SG GF GL 21 102 

A-0109

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GLOSSARY (continued) 

Inpatient means you are confined as a registered bed patient. 

Intensive outpatient program means outpatient services providing: 

• Group therapeutic sessions greater than one hour a day, three days a week; 

• Behavioral health therapeutic focus; 

• Group sessions centered on cognitive behavioral constructs, social/occupational/educational skills 

development and family interaction; 

• Additional emphasis on recovery strategies, monitoring of participation in 12-step programs and 

random drug screenings for the treatment of chemical dependency; and 

• Physician availability for medical and medication management. 

Intensive outpatient program does not include services that are for: 

• Custodial care; or 

• Day care. 

Late applicant means an employee or dependent who requests enrollment for coverage under the master 

group contract more than 31 days or more than 60 days for a newborn, adopted child or foster child 

after his or her eligibility date, later than the time period specified in the "Special enrollment" provision, 

or after the open enrollment period. 

Maintenance care means services and supplies furnished mainly to: 

• Maintain, rather than improve, a level of physical or mental function; or 

• Provide a protected environment free from exposure that can worsen the covered person's physical 

or mental condition. 

Master group contract means the legal agreement between us and the group plan sponsor, including the 

Employer Group Application and certificate, together with any riders, amendments and endorsements. 

Maximum allowable fee for a covered expense, other than emergency care services provided by 

non-network providers in a hospital's emergency department, is the lesser of: 

• The fee charged by the provider for the services; 

CHMO 2004-C SG GF GL 21 103 

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GLOSSARY (continued) 

• The fee that has been negotiated with the provider whether directly or through one or more 

intermediaries or shared savings contracts for the services; 

• The fee established by us by comparing rates from one or more regional or national databases or 

schedules for the same or similar services from a geographical area determined by us; 

• The fee based upon rates negotiated by us or other payors with one or more network providers in a 

geographic area determined by us for the same or similar services; 

• The fee based upon the provider's cost for providing the same or similar services as reported by such 

provider in its most recent publicly available Medicare cost report submitted to the Centers for 

Medicare & Medicaid Services (CMS) annually; or 

• The fee based on a percentage determined by us of the fee Medicare allows for the same or similar 

services provided in the same geographic area. 

Maximum allowable fee for a covered expense for emergency care services provided by non-network 

providers in a hospital's emergency department is an amount equal to the greatest of: 

• The fee negotiated with network providers; 

• The fee calculated using the same method to determine maximum allowable fee for a covered 

expense, other than emergency care services provided by non-network providers; or 

• The fee paid by Medicare for the same services. 

The bill you receive for services from non-network providers may be significantly higher than the 

maximum allowable fee. Non-network providers have not signed an agreement with us to accept 

discounted or negotiated fees for services and may billyou for charges in excess of the maximum 

allowable fee. In addition to any copayment, deductibles and coinsurance, you may be responsible for 

the difference between the maximum allowable fee and the amount the provider bills you for the 

services, unless balance billing is prohibited by applicable law. Any amount you pay to the non-network 

provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or 

deductible, if any. 

Medicaid means a state program of medical care for needy persons, as established under Title 19 of the 

Social Security Act of 1965, as amended. 

Medically necessary means health care services that a health care practitioner exercising prudent 

clinical judgment would provide to his or her patient for the purpose of preventing, evaluating, 

diagnosing or treating a sickness or bodily injury, or its symptoms. Such health care service must be: 

• In accordance with nationally recognized standards of medical practice; 

• Clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective 

for the patient's sickness or bodily injury, 

• Not primarily for the convenience of the patient, physician or other health care provider; 

• Not more costly than an alternative service or sequence of services at least as likely to produce 

equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's sickness 

or bodily injury; and 

• Performed in the least costly site. 

CHMO 2004-C SG GF GL 21 104 

A-0111

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GLOSSARY (continued) 

For the purpose of medically necessary, generally accepted standards of medical practice means 

standards that are based on credible scientific evidence published in peer-reviewed medical literature 

generally recognized by the relevant medical community, Physician Specialty Society recommendations, 

the views of physicians practicing in relevant clinical areas and any other relevant factors. 

Medically necessary leave of absence means a leave of absence for a dependent adult child, who is no 

longer enrolled for sufficient course credits to maintain full-time status as defmed by an accredited 

secondary school, college or university, or licensed technical school or had any other change in 

enrollment at such institution. 

The medically necessary leave of absence must: 

• Begin due to a bodily injury or sickness; 

• Be determined necessary by the dependent adult child's health care practitioner, who must send us 

written certification; and 

• Cause the dependent adult child to lose full-time student status as defined in the definition of" 

dependent." 

Medicare means a program of medical insurance for the aged and disabled, as established under Title 18 

of the Social Security Act of 1965, as amended. 

Mental health services mean those diagnoses and treatments related to the care of a covered person who 

exhibits a mental, nervous or emotional condition classified in the Diagnostic and Statistical Manual of 

Mental Disorders. 

Morbid obesity means a body mass index (BMI) as determined by a health care practitioner as of the 

date of service of: 

• 40 kilograms or greater per meter squared (kg/m2); or 

• 35 kilograms or greater per meter squared (cg/m2) with an associated comorbid condition such as 

hypertension, type I1 diabetes, life-threatening cardiopulmonary conditions; or joint disease that is 

treatable, if not for the obesity. 

Network health care practitioner means a health care practitioner who has been designated as such or 

has signed an agreement with us as an independent contractor, or who has been designated by us to 

provide services to all covered persons. Network health care practitioner designation by us may be 

limited to specified services. 

Network hospital means a hospital which has been designated as such or has signed an agreement with 

us as an independent contractor, or has been designated by us to provide services to all covered persons. 

Network hospital designation by us may be limited to specified services. 

Network provider means a hospital, health care treatment facility, health care practitioner, or other 

health services provider who is designated as such or has signed an agreement with us as an independent 

contractor, or who has been designated by us to provide services to all covered persons. Network 

provider designation by us may be limited to specified services. 

CHMO 2004-C SG GF GL 21 105 

A-0112

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GLOSSARY (continued) 

Non-network health care practitioner means a health care practitioner who has not been designated by 

us as a network health care practitioner. 

Non-network hospital means a hospital which has not been designated by us as a network hospital. 

Non-network provider means a hospital, health care treatment facility, health care practitioner, or 

other health services provider who has not been designated by us as a network provider. 

Nurse means a registered nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse 

(L.V.N.). 

Observation status means hospital outpatient services provided to you to help the health care 

practitioner decide if you need to be admitted as an inpatient. 

Open enrollment period means no less than a 31-day period of time, occurring annually for the group, 

during which employees have an opportunity to enroll themselves and their eligible dependents for 

coverage under the master group contract. 

Oral surgery means procedures to correct diseases, injuries and defects of the jaw and mouth structures. 

These procedures include the following: 

• Surgical removal of full bony impactions; 

• Mandibular or maxillary implant; 

• Maxillary or mandibular frenectomy; 

• Alveolectomy and alveoplasty; 

• Orthognathic surgery, 

• Surgery for treatment of temporomandibular joint syndrome/dysfunction; and 

• Periodontal surgical procedures, including gingivectomies. 

Outpatient means you are not confined as a registered bed patient. 

Outpatient surgery means surgery performed in a health care practitioner's office, ambulatory surgical 

center, or the outpatient department of a hospital. 

Palliative care means care given to a covered person to relieve, ease, or alleviate, but not to cure, a 

bodily injury or sickness. 

CHMO 2004-C SG GF GL 21 106 

A-0113

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GLOSSARY (continued) 

Partial hospitalization means outpatient services provided by a hospital or health care treatment 

facility in which patients do not reside for a full 24-hour period and: 

• Has a comprehensive and intensive interdisciplinary psychiatric treatment for minimum of 5 hours a 

day, 5 days per week under the supervision of a psychiatrist for mental health services or a 

psychiatrist or addictionologist for chemical dependency, and patients are seen by a psychiatrist or 

addictionologist, as applicable, at least once a week; 

• Provides for social, psychological and rehabilitative training programs with a focus on reintegration 

back into the community and admits children and adolescents who must have a treatment program 

designed to meet the special needs of that age range; and 

• Has physicians and appropriately licensed behavioral health practitioners readily available for the 

emergent and urgent needs of the patients. 

The partial hospitalization program must be accredited by the Joint Commission of the Accreditation of 

Hospitals or in compliance with an equivalent standard. 

Licensed drug abuse rehabilitation programs and alcohol rehabilitation programs accredited by the Joint 

Commission on the Accreditation of Health Care Organizations or approved by the appropriate state 

agency are also consideredpartia/ hospitalization services. 

Partial hospitalization does not include services that are for: 

• Custodial care; or 

• Day care. 

Periodontics means the branch of dentistry concerned with the study, prevention and treatment of 

diseases of the tissues and bones supporting the teeth. 

Pre-surgical/procedural testing means: 

• Laboratory tests or radiological examinations done on an outpatient basis in a hospital or other 

facility accepted by the hospital before hospital confinement or outpatient surgery or procedure; 

• The tests must be accepted by the hospital or health care practitioner in place of like tests made 

during confinement; and 

• The tests must be for the same bodily injury or sickness causing you to be hospital confined or to 

have the outpatient surgery or procedure. 

Preauthorization means approval by us, or our designee, of a service prior to it being provided. Certain 

services require medical review by us in order to determine eligibility for coverage. 

Preauthorization is granted when such a review determines that a given service is a covered expense 

according to the terms and provisions of the master group contract. 

Preventive services means services determined to be effective and accepted for the detection and 

prevention of disease in persons with no symptoms as recommended by the U.S. Preventive Services 

Task Force. 

CHMO 2004-C SG GF GL 21 107 

A-0114

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GLOSSARY (continued) 

Primary care physician means a network health care practitioner who provides initial and primary care 

services to covered persons, maintains the continuity of covered persons' medical care and helps direct 

covered persons to specialty care physicians and other providers. 

A primary care physician is a health care practitioner in one of the following specialties: 

• Family medicine/General practice; 

• Internal medicine; and 

• Pediatrics. 

Q 

Qualified provider means a person, facility or any other health care provider: 

• That is licensed by the appropriate state agency to: 

- Diagnose or treat a sickness or bodily injury, or 

- Provide preventive services; 

• That provides services within the scope of their license; and 

• Whose primary purpose is to provide health care services. 

R 

Rehabilitation facility means any licensed public or private establishment which has permanent facilities 

that are equipped and operated primarily to render physical and occupational therapies, diagnostic 

services and other therapeutic services. 

CHMO 2004-C SG GF GL 21 108 

A-0115

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GLOSSARY (continued) 

Rescission, rescind or rescinded means a cancellation or discontinuance of coverage that has a 

retroactive effect. 

Residential treatment facility means an institution that: 

• Is licensed as a 24-hour residential facility for behavioral health treatment, although not licensed as 

a hospital; 

• Provides a multidisciplinary treatment plan in a controlled environment, under the supervision of a 

physician who is able to provide treatment on a daily basis; 

• Provides supervision and treatment by a Ph.D. psychologist, licensed therapist, psychiatric nursing 

staff or registered nurse; 

• Provides programs such as social, psychological, family counseling and rehabilitative training, age 

appropriate for the special needs of the age group of patients, with focus on reintegration back into 

the community; and 

• Provides structured activities throughout the day and evening, for a minimum of 6 hours a day. 

Residential treatment is utilized to provide structure, support and reinforcement of the treatment required 

to reverse the course of behavioral deterioration. 

Room and board means all charges made by a hospital or other health care treatment facility on its 

own behalf for room and meals and all general services and activities needed for the care of registered 

bed patients. 

Routine nursery care means the charges made by a hospital or licensed birthing center for the use of the 

nursery. It includes normal services and supplies given to well newborn children following birth. 

Health care practitioner visits are not considered routine nursery care. Treatment of a bodily injury, 

sickness, birth abnormality, or congenital anomaly following birth and care resulting from prematurity is 

not considered routine nursery care. 

Routine patient care means all health care services, including drugs, items, devices and services that 

would otherwise be covered under the certificate if those health care services were not provided in 

connection with an approved cancer clinical trial, including the following: 

• Absent a cancer clinical trial; 

• Required only for the provision of the investigational drug, item, device or service; 

• Required for clinical appropriate monitoring of the investigational item of service; and 

• Needed for the reasonable, necessary care resulting from the investigations of the drug, item, device 

or service, including the diagnosis or treatment of complications. 

S 

Self-administered injectable drugs means an FDA approved medication which a person may administer 

to himself or herself by means of intramuscular, intravenous, or subcutaneous injection, excluding 

insulin, and prescribed for use by you. 

CHMO 2004-C SG GF GL 21 109 

A-0116

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GLOSSARY (continued) 

Service area means the geographic area designated by us, or as otherwise agreed upon between the 

group plan sponsor and us and approved by the Department of Insurance of the state in which the 

master group contract is issued, if such approval is required. The service area is the geographic area 

where the network provider services are available to you. A description of the service area is provided 

in the provider directories. 

Sickness means a disturbance in function or structure of the body which causes physical signs or 

physical symptoms and which, if left untreated, will result in a deterioration of the health state of the 

structure or system(s) of the body. The term also includes: (a) pregnancy; (b) any medical complications 

of pregnancy; and (c) behavioral health. 

Skilled nursing facility means a licensed institution (other than a hospital, as defined) which meets all 

of the following requirements: 

• It must provide permanent and full-time bed care facilities for resident patients; 

• It must maintain, on the premises and under arrangements, all facilities necessary for medical care 

and treatment; 

• It must provide such services under the supervision of physicians at all times; 

• It must provide 24-hours-a-day nursing services by or under the supervision of a registered nurse; 

and 

• It must maintain a daily record for each patient. 

A skilled nursing facility is not, except by incident, a rest home, a home for the care of the aged, or 

engaged in the care and treatment of chemical dependency. 

Small employer means, in connection with a health benefit plan with respect to a calendar year or plan 

year, any person, sole proprietor, self-employed individual, independent contactor, firm, corporation, 

partnership, or association that is actively engaged in business, has its principal place of business in 

Florida, employed an average of at least one but not more than 50 employees on business days during 

the preceding calendar year the majority of whom were employed in Florida, employs at least one 

employee on the first day of the year, and is not formed primarily for purposes of purchasing insurance. 

In determining the number of employees, companies that are an affiliated group as defined in s. 1504(a) 

of the Internal Revenue Code of 1986, as amended, are considered a single employer. An independent 

contractor or self-employed individual is considered a small employer only if all of the conditions and 

criteria established in this section are met. 

Sound natural tooth means a tooth that: 

• Is organic and formed by the natural development of the body (not manufactured, capped, crowned 

or bonded); 

• Has not been extensively restored; 

• Has not become extensively decayed or involved in periodontal disease; and 

• Is not more susceptible to injury than a whole natural tooth, (for example a tooth that has not been 

previously broken, chipped, filled, cracked or fractured). 

Special enrollment date means the date of: 

• Change in family status after the eligibility date; 

• Loss of other coverage under another group health plan or other health insurance coverage; 

• COBRA exhaustion; 

CHMO 2004-C SG GF GL 21 110 

A-0117

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GLOSSARY (continued) 

• Loss of coverage under your employer's alternate plan; 

• Termination of your Medicaid coverage or your Children's Health Insurance Program (CHIP) 

coverage as a result of loss of eligibility; or 

• Eligibility for a premium assistance subsidy under Medicaid or CHIP. 

To be eligible for special enrollment, you must meet the requirements specified in the "Special 

enrollment" provision within the "Eligibility and Effective Dates" section of this certificate. 

Specialty care physician means a health care practitioner who has received training in a specific 

medical field other than the specialties listed as primary care. 

Surgery means procedures categorized as Surgery in either the: 

• Current Procedural Terminology (CPT) manuals published by the American Medical Association; or 

• Healthcare Common Procedure Coding System (HCPCS) Level II manual published by the Centers 

for Medicare & Medicaid Services (CMS). 

The term surgery includes: 

• Excision or incision of the skin or mucosal tissues; 

• Insertion for exploratory purposes into a natural body opening; 

• Insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other 

therapeutic purposes; 

• Treatment of fractures; 

• Procedures to repair, remove or replace any body part or foreign object in or on the body; and 

• Endoscopic procedures. 

Surgical assistant means a health care practitioner who assists at surgery and is not a Doctor of 

Medicine (MD), Doctor of Osteopathic Medicine (DO) or Doctor of Podiatric Medicine (DPM), or 

where state law does not require that specific health care practitioners be treated and reimbursed the 

same as an MD, DO or DPM. 

Total disability or totally disabled means your continuing inability, as a result of a bodily injury or 

sickness, to perform the material and substantial duties of any job for which you are or become qualified 

by reason of education, training or experience. 

The term also means a dependent's inability to engage in the normal activities of a person of like age. If 

the dependent is employed, the dependent must be unable to perform his or her job. 

Urgent care means health care services provided on an outpatient basis for an unforeseen condition that 

usually requires attention without delay but does not pose a threat to life, limb or permanent health of 

the covered person. 

Urgent care center means any licensed public or private non-hospital five-standing facility which has 

permanent facilities equipped to provide urgent care services. 

CHMO 2004-C SG GF GL 21 111 

A-0118

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GLOSSARY (continued) 

V 

w 

Waiting period means the period of time, elected by the group plan sponsor, that must pass before an 

employee is eligible for coverage under the master group contract. 

We, us or our means the offering company as shown on the cover page of the master group contract 

and certificate. 

X 

Y 

Year means the period of time which begins on any January 1st and ends on the following December 

31st. When you first become covered by the master group contract, the first year begins for you on the 

effective date of your coverage and ends on the following December 31st. 

You or your means any covered person. 

z 

CHMO 2004-C SG GF GL 21 112 

A-0119

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SPECIALTY DRUG BENEFIT 

This "Specialty Drug Benefit" section describes services that will be considered covered expenses for 

specialty drugs under the master group contract. 

Notwithstanding any other provisions of the master group contract, expenses covered under this 

"Specialty Drug Benefit" are not covered under any other provision of the master group contract. Any 

amount in excess of the maximum amount provided under this benefit, if any, is not covered under any 

other provision in the master group contract. 

Any expenses incurred by you under provisions of this benefit do not apply toward your out-of-pocket 

limit, if any. 

All terms used in this benefit have the same meaning given to them in this certificate and in any 

"Prescription Drug Benefit Rider" attached to this certificate, unless otherwise specifically defined in 

this benefit. All other terms, provisions, limitations and exclusions of the master group contract, unless 

otherwise stated, are applicable. 

H250000 02/11 

Specialty drug cost sharing 

You are responsible for any and all cost share, when applicable, for specialty drugs, according to the 

"Schedule of benefits — specialty drugs" provision of this section. We share the cost of covered expenses 

for specialty drugs as shown in the "Schedule of benefits — specialty drugs" provision. 

If the health care provider's or dispensingpharmacy's charge is less than your copayment, you will be 

responsible for the lesser amount. 

The amount paid by us to the providers listed in the "Schedule of benefits — specialty drugs" provision 

of this benefit may not reflect the ultimate cost to us for the specialty drug. Your cost share is made on 

a per prescription or refill basis and will not be adjusted if we receive any retrospective volume 

discounts or prescription drug rebates. 

H251000 02/12 

Definitions 

Copayment means the amount to be paid by you toward the cost of each separate prescription or refill of 

a covered prescription drug. 

Cost share means any copayment, deductible, drug deductible, and/or percentage amount that you must 

pay per prescription drug or refill per year. 

Network pharmacy means a pharmacy that has signed a direct agreement with us or has been designated 

by us to provide: 

CHMO 2004-C 113 

A-0120

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SPECIALTY DRUG BENEFIT (continued) 

• Coveredpharmacy services; or 

• Covered specialty pharmacy services; 

as defined by us, to covered persons, including covered prescriptions or refills delivered to your home. 

Network specialty drug and network level 4 drug out-of-pocket limit means the amount of cop ayment 

that you must pay in a year for specialty drugs and level 4 drugs from network pharmacies before a 

benefit percentage will be increased. 

Non-network pharmacy means a pharmacy that has not signed a direct agreement with us or has not 

been designated by us to provide: 

• Coveredpharmacy services; or 

• Covered specialty pharmacy services; 

as defined by us, to covered persons, including covered prescriptions or refills delivered to your home. 

Specialty drug means a drug, medicine, medication or biological used as a specialized therapy developed 

for chronic, complex sicknesses or bodily injuries. Specialty drugs may: 

• Require nursing services or special programs to support patient compliance; 

• Require disease-specific treatment programs; 

• Have limited distribution requirements; or 

• Have special handling, storage or shipping requirements. 

Specialty drug list means a list of specialty drugs specified by us. This list indicates applicable 

dispensing limits and/or anypreauthorizationlprior authorization or step therapy requirements. Visit 

our Website at www.humana.comor call the customer service telephone number on your identification 

card to obtain the specialty drug list. This list is subject to change without notice. 

Specialty pharmacy means a pharmacy that provides covered specialty pharmacy services, as defined by 

us, to covered persons. 

H252000 02/12 

Specialty drug benefit 

We will pay benefits for covered expenses incurred by you for specialty drugs that are included on our 

specialty drug list. Benefits may be subject to dispensing limits, preauthorizationlprior authorization 

or step therapy requirements, if any. Any charge for the administration of a specialty drug is not 

covered under this benefit. Specialty drugs received in places of service not listed under the "Schedule 

of benefits — specialty drugs" provision are not covered under this benefit. Payment for the 

administration of specialty drugs and for places of services not listed under the "Schedule of benefits — 

specialty drugs" is addressed in the "Schedule of Benefits" section of this certificate. 

CFLMO 2004-C 114 

A-0121

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SPECIALTY DRUG BENEFIT (continued) 

Prior authorization and step therapy may be required for specialty drugs obtained from a specialty 

pharmacy or a retail pharmacy. Preauthorization and step therapy may be required for specialty drugs 

received from any other provider. Please contact us or our designee prior to the purchase of any 

specialty drug. 

H253000 02/11 

Covered expenses 

The following are covered expenses for specialty drugs: 

• Prescription drugs, medicines, medications, self-administered injectable drugs or biologicals that 

under federal or state law may be dispensed only by prescription from a health care practitioner 

and are included on our specialty drug list. 

• Hypodermic needles, syringes or other method of delivery necessary for administration of the 

specialty drug, if included with the charge for the specialty drug. (These may be available at no 

cost to you.) 

Notwithstanding any other provisions of the master group contract, we may decline coverage or, if 

applicable, exclude from the specialty drug list any and all prescriptions until the conclusion of a review 

period not to exceed six months following FDA approval for the use and release of the prescriptions into 

the market. 

H254000 04/10 

Schedule of benefits — specialty drugs 

You are responsible for the following: 

Retail pharmacy and specialty pharmacy* Up to 30-day supply 

Network pharmacy designated by us as a preferred 

provider of specialty drugs 

25% copayment per specialty drug prescription or 

refill 

Network pharmacy 35% copayment per specialty drug prescription or 

refill 

*Following the initial fill and one refill of a covered specialty drug from a pharmacy, all subsequent 

refills must be obtained through a network pharmacy designated by us as a preferred provider of 

specialty drugs. 

H255000FL 02/12 

CHMO 2004-C 115 

A-0122

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SPECIALTY DRUG BENEFIT (continued) 

Office visit, home health care, 

free-standing facility and urgent care Up to 30-day supply 

Network provider $50 copayment per visit. 

H256000FL 02/12 

Limitations and exclusions 

Refer to the "Limitations and Exclusions" section of this certificate and the "Prescription Drug Benefit 

Rider" attached to this certificate for additional exclusions. Unless specifically stated otherwise, no 

benefit will be provided for, or on account of, the following items: 

H258000 02/11 

• Specialty drugs which are not included on our specialty drug list. 

• Specialty drug refills obtained from a pharmacy which is not designated by us as a preferred 

provider of specialty drugs. 

• Specialty drugs for which coverage is not approved by us. 

• Growth hormones (medications, drugs or hormones to stimulate growth) for idiopathic short stature. 

• Growth hormones (medications, drugs or hormones to stimulate growth), unless there is a laboratory 

confirmed diagnosis of growth hormone deficiency, or as otherwise determined by us. 

• Any portion of a specialty drug that exceeds a 30-day supply, unless otherwise determined by us. 

H259000 02/12 

CHMO 2004-C 116 

A-0123

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PRESCRIPTION DRUG BENEFIT RIDER 

This benefit rider is made part of the master group contract to which it is attached. The effective date 

of this change is the latter of the effective date of the certificate or the date this benefit rider is added to 

the master group contract. 

Notwithstanding any other provisions of the master group contract, expenses covered under this 

"Prescription Drug Benefit Rider" are not covered under any other provision of the master group 

contract. Any amount in excess of the maximum amount provided under this benefit rider, if any, is not 

covered under any other provision in the master group contract. 

Any expenses incurred by you under provisions of this benefit rider do not apply toward your 

out-of-pocket limit, if any. 

For the purposes of coordination of benefits,prescription drug coverage under this benefit rider will be 

considered a separate plan and will therefore only be coordinated with other prescription drug coverage. 

All terms used in this benefit rider have the same meaning given to them in the certificate, unless 

otherwise specifically defined in this benefit rider. All other terms, provisions, limitations, and 

exclusions of the master group contract, unless otherwise stated, are applicable. 

Definitions 

The following terms are used in this benefit rider: 

Brand-name medication means a drug, medicine or medication that is manufactured and distributed by 

only one pharmaceutical manufacturer, or any drug product that has been designated as brand-name by 

an industry-recognized source used by us. 

Coinsurance means the amount expressed as a percentage of the covered expense that you must pay 

toward the cost of each separate prescription fill or refill dispensed by apharmacy. 

Copayment means the specified dollar amount to be paid by you toward the cost of each separate 

prescription fill or refill dispensed by a pharmacy. 

Cost share means any copayment and/or coinsurance that you must pay per prescription fill or refill. 

Dispensing limit means the monthly drug dosage limit and/or the number of months the drug usage is 

commonly prescribed to treat a particular condition, as determined by us. 

Drug deductible means a specified amount of prescription drug expenses you must incur per year before 

benefits will be paid under this benefit rider. These expenses do not apply toward any other deductible, 

if any, stated in the master group contract. 

BRx P14 SG GF 20 117 

A-0124

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Drug list means a list of covered prescription drugs, medicines or medications and supplies specified by 

us. 

Generic medication means a drug, medicine or medication that is manufactured, distributed, and 

available from a pharmaceutical manufacturer and identified by the chemical name, or any drug product 

that has been designated as generic by an industry-recognized source used by us. 

Legend drug means any medicinal substance, the label of which, under the Federal Food, Drug and 

Cosmetic Act, is required to bear the legend: "Caution: Federal Law Prohibits dispensing without 

prescription." 

Level 1 drugs mean a category of prescription drugs, medicines or medications within the drug list that 

are designated by us as level 1. 

Level 2 drugs mean a category of prescription drugs, medicines or medications within the drug list that 

are designated by us as level 2. 

Level 3 drugs mean a category of prescription drugs, medicines or medications within the drug list that 

are designated by us as level 3. 

Level 4 drugs mean a category of prescription drugs, medicines or medications within the drug list that 

are designated by us as level 4. 

Mail order pharmacy means apharmacy that provides covered mail order pharmacy services, as 

defined by us, and delivers covered prescription drug, medicine or medication fills or refills through the 

mail to covered persons. 

Network pharmacy means apharmacy that has signed a direct agreement with us or has been designated 

by us to provide: 

• Covered pharmacy services; or 

• Covered mail order pharmacy services, 

as defined by us, to covered persons, including covered prescription fills or refills delivered to your 

home. 

Network specialty drug and network level 4 drug out-of-pocket limit means the amount of cost share 

you must pay in a year for specialty drugs and level 4 drugs from network pharmacies before a benefit 

percentage will be increased. 

HRx P14 SG GF 20 118 

A-0125

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Non-network pharmacy means a pharmacy that has not signed a direct agreement with us or has not 

been designated by us to provide: 

• Covered pharmacy services; or 

• Covered mail order pharmacy services, 

as defined by us, to covered persons, including covered prescription fills or refills delivered to your 

home. 

Pharmacist means a person, who is licensed to prepare, compound and dispense medication, and who is 

practicing within the scope of his or her license. 

Pharmacy means a licensed establishment where prescription drugs, medicines or medications are 

dispensed by a pharmacist. 

Prescription means a direct order for the preparation and use of a drug, medicine or medication. The 

prescription must be given by a health care practitioner to a pharmacist for your benefit and used for 

the treatment of a sickness or bodily injury which is covered under this plan, or for drugs, medicines or 

medications on the Women's Preventive Drug List. The drug, medicine or medication must be 

obtainable only by prescription or must be obtained by prescription for drugs, medicines or medications 

on the Women's Preventive Drug List. The prescription may be given to the pharmacist verbally, 

electronically or in writing by the health care practitioner. The prescription must include at least: 

• Your name; 

• The type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 

• The date the prescription was prescribed; and 

• The name and address of the prescribing health care practitioner. 

Prior authorization means the required prior approval from us for the coverage of certain prescription 

drugs, medicines and medications, including specialty drugs. The required prior approval from us for 

coverage includes the dosage, quantity and duration, as medically necessary for the covered person. 

Specialty drug means a drug, medicine, medication, or biological used as a specialized therapy 

developed for chronic, complex sicknesses or bodily injuries. Specialty drugs may: 

• Require nursing services or special programs to support patient compliance; 

• Require disease-specific treatment programs; 

• Have limited distribution requirements; or 

• Have special handling, storage or shipping requirements. 

Specialty pharmacy means a pharmacy that provides covered specialty pharmacy services, as defined by 

us, to covered persons. 

HRx P14 SG GF 20 119 

A-0126

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Step therapy means a requirement for you to first try certain drugs, medicines or medications to treat 

your medical condition before we will cover another prescription drug, medicine or medication for that 

condition. 

Year means the period of time which begins on any January 1st and ends on the following December 

31st. When you first become covered by the master group contract, the first year begins for you on the 

effective date of your coverage and ends on the following December 31st. 

Schedule of benefits - prescription drugs 

Prescription drug cost sharing 

You are responsible for any drug deductible and all cost share, when applicable, as specified in this 

"Schedule of benefits-prescription drugs" provision. If the dispensingpharmacy's charge is less than 

your cost share for a prescription, you will be responsible for the dispensingpharmacy's charge amount. 

The amount paid by us to the dispensingpharmacy may not reflect the ultimate cost to us for the drug. 

Your cost share is made on a per prescription fill or refill basis and will not be adjusted if we receive 

any retrospective volume discounts or prescription drug rebates. 

Prescription synchronization 

We will cover a prescription dispensed by a pharmacy for less than a 30-day supply, when requested by 

you, to synchronize your prescriptions that treat a permanent or long-term sickness or bodily injury. 

Synchronizing your prescriptions is to align the dispensing of multiple prescriptions by a pharmacy. 

Your prescribing health care practitioner or the pharmacist will determine if synchronizing the fill or 

refill of your prescription is in your best interest. The cost share for a partial supply of a prescription 

will be prorated when dispensed to synchronize your prescriptions. 

Prior authorization and step therapy requirements 

Prior authorization is required for certain prescription drugs, medicines, medications, and specialty 

drugs. Your health care practitioner must submit a request for prior authorization to Clinical 

Pharmacy Review and receive our approval before benefits are paid by us. 

Step therapy is another type of prior authorization that requires you to follow certain steps before 

benefits are paid by us. To receive benefits, you are required to first try alternative drugs, medicines, 

medications or specialty drugs that have been determined to be safe, effective and more cost-effective 

for your condition. Alternatives may include over-the-counter drugs, generic medications and 

brand-name medications. 

Visit our Website at www.humana.comor call the customer service telephone number on your ID card 

to obtain our drug list that identifies the prescription drugs, medicines, medications, and specialty drugs 

that require prior authorization and/or step therapy. The drug list is subject to change. Coverage 

provided in the past is not a guarantee of future coverage. 

HRx P14 SG GF 20 120 

A-0127

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Network drug out-of-pocket limit 

Network specialty drug and network level 4 drug 

out-of-pocket limit 

Network drug out-of-pocket limit amount 

$5,000 

PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Network specialty drug and network level 4 drug out-of-pocket limit 

Any expenses incurred by you, under the provisions of this rider do not apply toward your out-of-pocket 

limit, if any. However, there is a network specialty drug and network level 4 drug out-of-pocket limit. 

The network specialty drug and network level 4 drug out-of-pocket limit is applicable to network 

pharmacies and specialty pharmacies and is a combined limit between this "Prescription Drug Benefit 

Rider" and the "Specialty Drug Benefit" section of the certificate. Deductibles do not apply towards 

your network specialty drug and network level 4 drug out-of-pocket limit. 

After the network specialty drug and network level 4 drug out-of-pocket limit has been satisfied in a 

year, the network pharmacy benefit percentage for specialty drugs and level 4 drugs for that covered 

person will be payable at the rate of 100% for the rest of the year, subject to all other terms, provisions, 

limitations and exclusions of the master group contract. 

If the cost share applied to your claim is waived by your pharmacy or health care provider, you are 

required to inform us. Any amount waived and not paid by you, would not apply to any out-of-pocket 

limit. 

Retail pharmacy Up to 30-day supply 

Level 1 drugs $10 copayment per prescription fill or refill 

Level 2 drugs $40 copayment per prescription fill or refill 

Level 3 drugs $70 copayment per prescription fill or refill 

Level 4 drugs 25% coinsurance per prescription fill or refill 

HRx P14 SG OF 20 121 

A-0128

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

90-day Retail pharmacy 

Some retail pharmacies participate in our program, which allows you to receive a 90-day supply of a 

prescription fill or refill. Your cost is 3 times the applicable cost share as specified above. 

Self-administered injectable drugs are limited to a 30-day supply from a retail pharmacy, unless 

otherwise determined by us. 

Mail order pharmacy Up to 90-day supply 

Excludes specialty drugs and self-administered injectable drugs. 

Level I drugs, level 2 drugs, level 3 drugs, and 

level 4 drugs 

2.5 times the applicable cost share per 

prescription fill or refill, as specified under Retail 

pharmacy 

***Drugs, medicines or medications on the Women's Preventive Drug List are covered in full 

when obtained from a network pharmacy with a prescription from a health care practitioner. 

HRx P14 SG GF 20 122 

A-0129

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Oral cancer treatment medications 

Your cost share for covered orally administered cancer treatment medications will not exceed $50 per 

prescription fill or refill. 

Dispense as written 

If you request a brand-name medication when a generic medication is available, your cost share is 

greater. You are responsible for the applicable generic medication copayment and 100% of the 

difference between the amount we would have paid the dispensingpharmacy for the brand-name 

medication and the amount we would have paid the dispensing pharmacy for the generic medication. If 

the prescribing health care practitioner determines that the brand-name medication is medically 

necessary, you are only responsible for the applicable cop ayment of a brand-name medication. 

About our drug list 

Prescription drugs, medicines or medications, including specialty drugs and self-administered injectable 

drugs prescribed by health care practitioners and covered by us are specified on our printable drug list. 

The drug list identifies categories of drugs, medicines or medications by levels and indicates dispensing 

limits, specialty drug designation, any applicableprior authorization and/or step therapy requirements. 

This information is reviewed on a regular basis by a Pharmacy and Therapeutics committee made up of 

physicians and pharmacists. Placement on the drug list does not guarantee your health care 

practitioner will prescribe that prescription drug, medicine or medication for a particular medical 

condition. You can obtain a copy of our drug list by visiting our Website at www.humana.comor 

calling the customer service telephone number on your ID card. 

Coverage description 

We will cover prescription drugs that are received by you from a network pharmacy while you are 

covered under this "Prescription Drug Benefit Rider." Benefits may be subject to dispensing limits, 

prior authorization and step therapy requirements, if any. 

Covered prescription drugs are: 

• Drugs, medicines or medications that under federal or state law may be dispensed only by 

prescription from a health care practitioner. 

• Drugs, medicines or medications that are included on the drug list. 

HRx P14 SG GF 20 123 

A-0130

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

• Insulin and diabetes supplies. 

• Hypodermic needles or syringes when prescribed by a health care practitioner for use with insulin 

or self-administered injectable drugs. (Hypodermic needles and syringes used in conjunction with 

covered drugs may be available at no cost to you). 

• Self-administered injectable drugs approved by us. 

• Enteral formulas and nutritional supplements for the treatment of phenylketonuria (PKU) or other 

inherited metabolic disease, or as otherwise determined by us. 

• Spacers and/or peak flow meters for the treatment of asthma. 

• Drugs, medicines or medications on the Women's Preventive Drug List with a prescription from a 

health care practitioner. 

Notwithstanding any other provisions of the master group contract, we may decline coverage or, if 

applicable, exclude from the drug list any and all prescriptions until the conclusion of a review period 

not to exceed six months following FDA approval for the use and release of the prescriptions into the 

market. 

Restrictions on choice of providers 

If we determine you are using prescription drugs in a potentially abusive, excessive, or harmful manner, 

we may restrict your coverage ofpharmacy services in one or more of the following ways: 

• By restricting your choice of pharmacy to a single network pharmacy store or physical location for 

pharmacy services; 

• By restricting your choice of pharmacy for covered specialty pharmacy services to a specific 

specialty pharmacy, if the network pharmacy store or physical location for pharmacy services is 

unable to provide or is not contracted with us to provide covered specialty pharmacy services; and 

• By restricting your choice of a prescribing network health care practitioner to a specific network 

health care practitioner. 

We will determine if we will allow you to change a selected network provider. Only prescriptions 

obtained from the network pharmacy store or physical location or specialty pharmacy to which you 

have been restricted will be eligible to be considered covered expenses. Additionally, only prescriptions 

prescribed by the network health care practitioner to whom you have been restricted will be eligible to 

be considered covered expenses. 

Fffix P14 SG GF 20 124 

A-0131

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

Step therapy exception request 

Your health care practitioner may submit to us a written step therapy exception request for a clinically 

appropriate prescription drug. The health care practitioner should use the prior authorization form on 

our Website at www.humana.comor call the customer service telephone number on your ID card. 

We will respond to a step therapy exception request within: 

• 24 hours after receipt of an expedited step therapy exception request. 

• 72 hours after receipt of a standard step therapy exception request. 

A covered prescription drug on our drug list will not be subject to step therapy if: 

• The covered person has previously been approved to receive the prescription drug by completing 

step therapy required by a prior health carrier; and 

• The covered person provides us documentation from the prior health carrier that approved the 

prescription drug indicating the prior health carrier paid for the prescription drug during the 90 days 

immediately before the request for coverage under this cerhficate. 

We will approve a written step therapy exception request when the request includes the prescribing 

health care practitioner's written statement and supporting documentation that: 

• The prescription drug requiring step therapy has been ineffective in the treatment of your disease or 

medical condition; or 

• Based on sound clinical evidence or medical and scientific evidence, the prescription drug requiring 

step therapy: 

Is expected or likely to be ineffective based on your known relevant clinical characteristics and 

the known characteristics of the prescription drug regimen; or 

Will cause or will likely cause an adverse reaction in or physical harm to you. 

If we deny a step therapy exception request, we will provide you or your appointed representative, and 

your prescribing health care practitioner: 

• The reason for the denial; 

• An alternative covered medication; and 

• The right to appeal our decision as described in the "Complaint and Appeals Procedures" section of 

this certificate. 

Limitations and exclusions 

Unless specifically stated otherwise, no benefit will be provided for, or on account of, the following 

items: 

• Legend drugs, which are not deemed medically necessary by us. 

HRx P14 SG GF 20 125 

A-0132

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

• Any drug prescribed for intended use other than for: 

Indications approved by the FDA; or 

Off-label indications recognized through peer-reviewed medical literature. 

• Any drug prescribed for a sickness or bodily injury not covered under the master group contract. 

• Any drug, medicine or medication that is either: 

- Labeled "Caution-limited by federal law to investigational use;" or 

- Experimental, investigational or for research purposes, 

even though a charge is made to you. 

• Allergen extracts. 

• Therapeutic devices or appliances, including: 

Hypodermic needles and syringes (except needles and syringes for use with insulin and 

self-administered injectable drugs, whose coverage is approved by us); 

Support garments; 

Test reagents; 

- Mechanical pumps for delivery of medications; and 

Other non-medical substances. 

• Dietary supplements, except enteral formulas and nutritional supplements for the treatment of 

phenyllcetonuria (PKU) or other inherited metabolic disease. Refer to the "Covered Expenses" 

section of the certificate for coverage of low protein modified foods. 

• Nutritional products. 

• Fluoride supplements. 

• Minerals. 

• Growth hormones for idiopathic short stature or any other condition, unless there is a laboratory 

confirmed diagnosis of growth hormone deficiency, or as otherwise determined by us. 

• Herbs and vitamins, except prenatal (including greater than one milligram of folic acid), pediatric 

multi-vitamins with fluoride and vitamins on the $0 Preventive Medication Coverage drug list when 

obtained from a network pharmacy with aprescription from a health care practitioner. 

• Anabolic steroids. 

• Any drug used for the purpose of weight loss. 

1-1Rx P14 SG GF 20 126 

A-0133

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• Any drug or medicine that is lawfully obtainable without a prescription (over-the-counter drugs), - 

except: 

Insulin; and 

Drugs, medicines or medications and supplies on the $0 Preventive Medication Coverage drug 

list when obtained from a network pharmacy with a prescription from a health care 

practitioner. 

• Any drug or medicine that is available in prescription strength without a prescription. 

A-0134

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

• Compounded drugs that: 

Are prescribed for a use or route of administration that is not FDA approved or compendia 

supported; 

- Are prescribed without a documented medical need for specialized dosing or administration; 

- Only contain ingredients that are available over-the-counter; 

- Only contain non-commercially available ingredients; or 

- Contain ingredients that are not FDA approved, including bulk compounding powders. 

• Infertility services including medications. 

• Any drug prescribed for impotence and/or sexual dysfunction. 

• Any drug, medicine or medication that is consumed or injected at the place where the prescription is 

given, or dispensed by the health care practitioner. 

• The administration of covered medication(s). 

• Prescriptions that are to be taken by or administered to you, in whole or in part, while you are a 

patient in a facility where drugs are ordinarily provided by the facility on an inpatient basis. 

Inpatient facilities include, but are not limited to: 

- Hospital; 

- Skilled nursing facility, or 

- Hospice facility. 

• Injectable drugs, including: 

- Immunizing agents, unless otherwise determined by us; 

- Biological sera; 

- Blood; 

- Blood plasma; or 

- Self-administered injectable drugs for which coverage is not approved by us. 

• Prescription refills: 

- In excess of the number specified by the health care practitioner; or 

- Dispensed more than one year from the date of the original order. 

Hltx P14 SG GF 20 128 

A-0135

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

• Any portion of a prescription fill or refill that exceeds a 90-day supply when received from a mail 

order pharmacy or a retailphannacy that participates in our program, which allowsyou to receive a 

90-day supply of aprescrzption fill or refill. 

• Any portion of a prescription fill or refill that exceeds a 30-day supply when received from a retail 

pharmacy that does not participate in our program, which allows you to receive a 90-day supply of a 

prescription fill or refill. 

• Any portion of a self-administered injectable drug that exceeds a 30-day supply, unless otherwise 

determined by us. 

• Any portion of a prescription fill or refill that: 

Exceeds our drug specific dispensing limit; 

Is dispensed to a covered person, whose age is outside the drug specific age limits defined by 

us; 

Is refilled early, as defined by us; or 

Exceeds the duration-specific dispensing limit. 

• Any drug for which prior authorization or step therapy is required, as determined by us, and not 

obtained. 

• Any drug for which a charge is customarily not made. 

• Any drug, medicine or medication received by you: 

- Before becoming covered under this rider; or 

- After the date your coverage under this rider has ended. 

• Any costs related to the mailing, sending or delivery of prescription drugs. 

• Any intentional misuse of this benefit, including prescriptions purchased for consumption by 

someone other than you. 

• Any prescription fill or refill for drugs, medicines or medications that are lost, stolen, spilled, 

spoiled, or damaged. 

• Drug delivery implants. 

• Treatment for onychomycosis (nail fungus). 

HRx P14 SG GF 20 129 

A-0136

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PRESCRIPTION DRUG BENEFIT RIDER (continued) 

• Any amount you paid for a prescnption that has been filled, regardless of whether the prescription 

is revoked or changed due to adverse reaction or change in dosage or prescription. 

• Prescriptions filled at a non-network pharmacy, except for prescriptions required during an 

emergency. 

These limitations and exclusions apply even if a health care practitioner has performed or prescribed a 

medically appropriate procedure, service, treatment, supply, or prescription. This does not prevent your 

health care practitioner or pharmacist from providing or performing the procedure, service, treatment, 

supply, or prescription. However, the procedure, service, treatment, supply, or prescription will not be a 

covered expense. 

Humana Medical Plan, Inc. 

/7it' A 6177 4t'‘ ) 

Bruce Broussard 

President 

IfRx P14 SG GF 20 130 

A-0137

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PRESCRIPTION DRUG EXPEDITED REVIEW AMENDMENT 

This amendment is made part of the master group contract to which it is attached. The amendment is 

applicable to the master group contract issued or renewed on or after 01/01/2015. 

All terms used in this amendment have the same meaning given to them in the certificate unless 

otherwise specifically defined in this amendment. Except as modified below, all terms, conditions and 

limitations of the master group contract apply. 

The following provision is added to the 'Prescription Drug Benefit' section: 

About our drug list 

The most common prescription drugs, medicines, and medications, specialty drugs and 

self-administered injectable drugs prescribed by health care practitioners and covered by us are 

specified on our printable drug list. The drug list identifies categories of drugs, medicines or 

medications by levels. It also indicates dispensing limits and any applicable prior authorization or step 

therapy requirements. This information is reviewed on a regular basis by a Pharmacy and Therapeutics 

committee made up of physicians and pharmacists. Placement on the drug list does not guarantee your 

health care practitioner will prescribe that prescription drug, medicine, or medication for a particular 

medical condition. 

You can obtain a copy of our drug list by visiting our Website at www.humana.comor calling the 

customer service telephone number on your identification card. If a specific drug, medicine or 

medication is not listed on the drug list, you may contact us by phone or in writing with a request to 

determine whether a specific drug or specialty drug is included on our drug list. An exception request 

for clinically appropriate drugs not included on our drug list may be initiated by you, your appointed 

representative, or the health care practitioner prescribing the drug by calling our toll-free customer 

service number listed on your ID card. We will respond to the exception request no later than the fifth 

business day after the receipt date of the request. 

An expedited review request based on exigent circumstances may be initiated by you, your appointed 

representative, or your prescribing health care practitioner for clinically appropriate drugs not included 

on our drug list. We will respond to the expedited review request within 24 hours after receipt of the 

request. An exigent circumstance exists when a covered person is: 

• Suffering from a health condition that may seriously jeopardize their life, health, or ability to regain 

maximum function; or 

• Undergoing a current course of treatment using a drug not included on the drug list. 

As part of the expedited review request, the prescribing health care practitioner should include an oral 

or written: 

• Statement that an exigent circumstance exists and explain the harm that could reasonably be 

expected to the covered person if the requested drug is not provided within the timeframes of the 

standard drug exception request process; and 

CHMO RxEXR AMD 07/14 131 

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PRESCRIPTION DRUG EXPEDITED REVIEW AMENDMENT 

(continued) 

• Justification supporting the need for the prescribed drug not included on the drug list to treat the 

covered person's condition, including a statement that: 

All covered drugs on the drug list on any tier will be or have been ineffective; 

Would not be as effective as the drug not included on the drug list, or 

Would have adverse effects. 

If we grant an exception for coverage of the prescribed drug that is not on the drug list based on exigent 

circumstances, we will provide access to the prescribed drug: 

• Without unreasonable delay; and 

• For the duration of the exigent circumstance. 

Humana Medical Plan, Inc. 

Bruce Broussard 

President 

H4030000FL 

CHMO RxEXR AMD 07/14 132 

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Humana. 

Toll Free: 1-888-357-6767 

3501 SW 160th Avenue 

Miramar, FL 33027 

OFFERED BY 

Humana Medical Plan, Inc. 

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FEDERAL NOTICES 

The following pages contain important information about certain federal laws. There may be 

differences between the Certificate of Insurance and this Notice packet. There may also be 

differences between this notice packet and state law. You are eligible for the rights more 

beneficial to you, unless preempted by state or federal law. 

This section includes notices about: 

Federal legislation 

Women's health and cancer rights act 

Statement of rights under the newborns' and mothers' health Protection act 

Medical child support orders 

General notice of COBRA continuation of coverage rights 

Tax equity and fiscal responsibility act of 1982 (TEFRA) 

Family and medical leave act (FMLA) 

Uniformed services employment and reemployment rights act of 1994 (USERRA) 

Your rights under ERISA 

Patient protection act 

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FEDERAL NOTICES (continued) 

Federal legislation 

Women's health and cancer rights act of 1998 

Required coverage for reconstructive surgery following mastectomies 

Under federal law, group health plans and health insurance issuers offering group health insurance 

providing medical and surgical benefits with respect to mastectomy shall provide, in a case of a 

participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects 

breast reconstruction in connection with such mastectomy, coverage for: 

• Reconstruction of the breast on which the mastectomy has been performed; 

• Surgery and reconstruction of the other breast to produce symmetrical appearance; and 

• Prostheses and physical complications of all stages of mastectomy, including lymphedemas; 

in a manner determined in consultation with the attending physician and the patient. Such coverage may 

be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are 

consistent with those established for other benefits under the plan. 

Statement of rights under the newborns' and mothers' health protection act (NMHPA) 

If your plan covers normal pregnancy benefits, the following notice applies to you. 

Under federal law, group health plans and health insurance issuers offering group health insurance 

coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth 

for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours 

following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the 

attending provider (e.g., physician, nurse midwife, or physician assistant), after consultation with the 

mother, discharges the mother or newborn earlier. 

Also, under federal law, group health plans and health insurance issuers may not set the level of benefits 

or out-of-pocket costs so any later portion of the 48-hour (or 96-hour) stay is treated in a manner less 

favorable to the mother or newborn than any earlier portion of the stay. 

In addition, a group health plan or health insurance issuer may not, under federal law, require a 

physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 

hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket 

costs, you may be required to obtain pre-authorization. For information on pre-authorization, contact 

your plan administrator. 

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FEDERAL NOTICES (continued) 

Medical child support orders 

An individual who is a child of a covered employee shall be enrolled for coverage under the group 

health plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a 

National Medical Support Notice (NMSO). 

A QMCSO is a state-court order or judgment, including approval of a settlement agreement that: 

• Provides for support of a covered employee's child; 

• Provides for health care coverage for that child; 

• Is made under state domestic relations law (including a community property law); 

• Relates to benefits under the group health plan; and 

• Is "qualified," i.e., it meets the technical requirements of ERISA or applicable state law. 

QMCSO also means a state court order or judgment enforcing state Medicaid law regarding medical 

child support required by the Social Security Act §1908 (as added by Omnibus Budget Reconciliation 

Act of 1993). 

An NMSO is a notice issued by an appropriate agency of a state or local government that is similar to a 

QMCSO requiring coverage under the group health plan for a dependent child of a non-custodial parent 

who is (or will become) a covered person by a domestic relations order providing for health care 

coverage. 

Procedures for determining the qualified status of medical child support orders are available at no cost 

upon request from the plan administrator. 

General notice of COBRA continuation coverage rights 

Introduction 

You are getting this notice because you recently gained coverage under a group health plan (the Plan). 

This notice has important information about your right to COBRA continuation coverage, which is a 

temporary extension of coverage under the Plan. This notice explains COBRA continuation 

coverage, when it may become available to you and your family, and what you need to do to 

protect your right to get it. When you become eligible for COBRA, you may also become eligible for 

other coverage options that may cost less than COBRA continuation coverage. 

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus 

Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to 

you and other members of your family when group health coverage would otherwise end. For more 

information about your rights and obligations under the Plan and under federal law, you should review 

the Plan's Summary Plan Description or contact the Plan Administrator. 

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FEDERAL NOTICES (continued) 

You may have other options available to you when you lose group health coverage. For example, 

you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling 

in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and 

lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for 

another group health plan for which you are eligible (such as a spouse's plan), even if that plan generally 

doesn't accept late enrollees. 

What is COBRA continuation coverage? 

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because 

of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this 

notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a 

"qualified beneficiary". You, your spouse, and your dependent children could become qualified 

beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified 

beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. 

If you are an employee, you will become a qualified beneficiary if you to lose your coverage under the 

Plan because of the following qualifying events: 

• Your hours of employment are reduced; or 

• Your employment ends for any reason other than your gross misconduct. 

If you are the spouse of an employee, you will become a qualified beneficiary if you to lose your 

coverage under the Plan because of the following qualifying events: 

• Your spouse dies; 

• Your spouse's hours of employment are reduced; 

• Your spouse's employment ends for any reason other than his or her gross misconduct; 

• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or 

• You become divorced or legally separated from your spouse. 

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan 

because of the following events: 

• The parent-employee dies; 

• The parent-employee's hours of employment are reduced; 

• The parent-employee's employment ends for any reason other than his or her gross misconduct; 

• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); 

• The parents become divorced or legally separated; or 

• The child stops being eligible for coverage under the plan as a "dependent child". 

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a 

qualifying event. If a proceeding in bankruptcy is filed with respect to the employer, and that 

bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired 

employee will become a qualified beneficiary. The retired employee's spouse, surviving spouse, and 

dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their 

coverage under the Plan. 

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FEDERAL NOTICES (continued) 

When is COBRA coverage available? 

The plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan 

Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan 

Administrator of the following qualifying events: 

• The end of employment or reduction of hours of employment; 

• Death of the employee; 

• Commencement of a proceeding in bankruptcy with respect to the employer; or 

• The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both). 

For all other qualifying events (divorce or legal separation of the employee and spouse or a 

dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan 

Administrator within 60 days after the qualifying event occurs. 

How is COBRA Coverage Provided? 

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation 

coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an 

independent right to elect COBRA continuation coverage. Covered employees may elect COBRA 

continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage 

on behalf of their children. 

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 

months due to employment termination or reduction of hours of work. Certain qualifying events, or a 

second qualifying event during the initial period of coverage, may permit a beneficiary to receive a 

maximum of 36 months of coverage. 

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: 

• Disability extension of 18-month period of continuation coverage - If you or anyone in your 

family covered under the Plan is determined by Social Security to be disabled and you notify the 

Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an 

additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The 

disability would have to have started at some time before the 60thday of COBRA continuation 

coverage and must last at least until the end of the 18-month period of COBRA continuation 

coverage; 

• Second quallfring event extension 0118-month period of continuation coverage - If your family 

experiences another qualifying event during the 18 months of COBRA continuation coverage, the 

spouse and dependent children in your family can get up to 18 additional months of COBRA 

continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the 

second qualifying event. This extension may be available to the spouse and any dependent children 

getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to 

Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the 

dependent child stops being eligible under the Plan as a dependent child. This extension is only 

available if the second qualifying event would have caused the spouse or dependent child to lose 

coverage under the Plan had the first qualifying event not occurred. 

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FEDERAL NOTICES (continued) 

Are there other coverage options besides COBRA Continuation Coverage? 

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for 

you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan 

coverage options (such as a spouse's plan) through what is called a "special enrollment period". Some of 

these options may cost less than COBRA continuation coverage. You can learn more about many of 

these options at www.healthcare.gov. 

If you have questions 

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the 

contact or contacts identified below. For more information about your rights under the Employee 

Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care 

Act, and other laws affecting your group health plans, contact the nearest Regional or District Office of 

the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit 

www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available 

through EBSA's website.) For more information about the Marketplace, visit www.HealthCare.gov. 

Keep your plan informed of address changes 

To protect your family's rights, let the Plan Administrator know about any changes in the addresses of 

family members. You should also keep a copy, for your records, of any notices you send to the Plan 

Administrator. 

Plan contact information: 

Humana 

Billing/Enrollment Department 

101 E Main Street 

Louisville, KY 40201 

1-800-872-7207 

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FEDERAL NOTICES (continued) 

Important notice for individuals entitled to Medicare tax equity and fiscal responsibility 

act of 1982 (TEFRA) options 

Where an employer employs more than 20 people, the Tax Equity And Fiscal Responsibility Act of 

1982 (TEFRA) allows covered employees in active service who are age 65 or older and their covered 

spouses who are eligible for Medicare to choose one of the following options: 

• Option 1 - The benefits of their group health plan will be payable first and the benefits of Medicare 

will be payable second. 

• Option 2- Medicare benefits only. The employee and his or her dependents, if any, will not be 

insured by the group health plan. 

The employer must provide each covered employee and each covered spouse with the choice to elect one 

of these options at least one month before the covered employee or the insured spouse becomes age 65. 

All new covered employees and newly covered spouses age 65 or older must be offered these options. If 

Option 1 is chosen, its issue is subject to the same requirements as for an employee or dependent that is 

under age 65. 

Under TEFRA regulations, there are two categories of persons eligible for Medicare. The calculation 

and payment of benefits by the group health plan differs for each category. 

• Category 1 Medicare eligibles are: 

- Covered employees in active service who are age 65 or older who choose Option 1; 

- Age 65 or older covered spouses; and 

Age 65 or older covered spouses of employees in active service who are either under age 65 or 

age 70 or older; 

• Category 2 Medicare eligibles are any other covered persons entitled to Medicare, whether or not 

they enrolled. This category includes, but is not limited to: 

- Retired employees and their spouses; or 

- Covered dependents of a covered employee, other than his or her spouse. 

Calculation and payment of benefits 

For covered persons in Category 1, benefits are payable by the policy without regard to any benefits 

payable by Medicare. Medicare will then determine its benefits. 

For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the 

policy. The benefits of the policy will then be reduced by the full amount of all Medicare benefits the 

covered person is entitled to receive, whether or not the eligible individual is actually enrolled for 

Medicare Benefits. 

7 

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FEDERAL NOTICES (continued) 

Family and Medical Leave Act (F1V1LA) 

If an employee is granted a leave of absence (Leave) by the employer as required by the Federal Family 

and Medical Leave Act, s/he may continue to be covered under the plan for the duration of the Leave 

under the same conditions as other employees who are currently employed and covered by the plan. If 

the employee chooses to terminate coverage during the Leave, or if coverage terminates as a result of 

nonpayment of any required contribution, coverage may be reinstated on the date the employee returns 

to work immediately following the end of the Leave. Charges incurred after the date of reinstatement 

will be paid as if the employee had been continuously covered. 

Uniformed services employment and reemployment rights act of 1994 (USERRA) 

Continuation of benefits 

Effective October 13, 1994, federal law requires health plans offer to continue coverage for employees 

that are absent due to service in the uniformed services and/or dependents. 

Eligibility 

An employee is eligible for continuation under USERRA if he or she is absent from employment 

because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, 

Air National Guard, or commissioned corps of the Public Health Service. Duty includes absence for 

active duty, active duty for training, initial active duty for training, inactive duty training and for the 

purpose of an examination to determine fitness for duty. 

An employee's dependents that have coverage under the plan immediately prior to the date of the 

employee's covered absence are eligible to elect continuation under USERRA. 

If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for 

payment of the applicable cost of coverage. If the employee is absent for not longer than 31 days, the 

cost will be the amount the employee would otherwise pay for coverage. For absences exceeding 30 

days, the cost may be up to 102% of the cost of coverage under the plan. This includes the employee's 

share and any portion previously paid by the employer. 

8 

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FEDERAL NOTICES (continued) 

Duration of coverage 

If elected, continuation coverage under USERRA will continue until the earlier of: 

• 24 months beginning the first day of absence from employment due to service in the uniformed 

services; or 

• The day after the employee fails to apply for a return to employment as required by USERRA, after 

the completion of a period of service. 

Under federal law, the period coverage available under USERRA shall run concurrently with the 

COBRA period available to an employee and/or eligible dependent. 

Other information 

Employees should contact their employer with any questions regarding coverage normally available 

during a military leave of absence or continuation coverage and notify the employer of any changes in 

marital status, or change of address. 

Your rights under the Employee Retirement Income Security Act of 1974 (ERISA) 

Under ERISA, all plan participants covered by ERISA are entitled to certain rights and protections, as 

described below. Notwithstanding anything in the group health plan or group insurance policy, 

following are a covered person's minimum rights under ERISA. ERISA requirements do not apply to 

plans maintained by governmental agencies or churches. 

Information about the plan and benefits 

Plan participants may: 

• Examine, free of charge, all documents governing the plan. These documents are available in the 

plan administrator's office; 

• Obtain, at a reasonable charge, copies of documents governing the plan, including a copy of any 

updated summary plan description and a copy of the latest annual report for the plan (Form 5500), if 

any, by writing to the plan administrator; 

• Obtain, at a reasonable charge, a copy of the latest annual report (Form 5500) for the plan, if any, by 

writing to the plan administrator. 

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FEDERAL NOTICES (continued) 

As a plan participant, you will receive a summary of any material changes made in the plan within 210 

days after the end of the plan year in which the changes are made unless the change is a material 

reduction in covered services or benefits, in which case you will receive a summary of the material 

reduction within 60 days after the date of its adoption. 

If the plan is required to file a summary annual financial report, you will receive a copy from the plan 

administrator. 

Responsibilities of plan fiduciaries 

In addition to creating rights for plan participants, ERISA imposes duties upon the people who are 

responsible for the operation of the plan. These people, called "fiduciaries" of the plan, have a duty to 

act prudently and in the interest of plan participants and beneficiaries. 

No one, including an employer, may discharge or otherwise discriminate against a plan participant in 

any way to prevent the participant from obtaining a benefit to which the participant is otherwise entitled 

under the plan or from exercising ERISA rights. 

Continue group health plan coverage 

Participants may be eligible to continue health care coverage for themselves, their spouse or dependents 

if there is a loss of coverage under the group health plan as a result of a qualifying event. You or your 

dependents may have to pay for such coverage. Review the COBRA notice in this document regarding 

the rules governing COBRA continuation coverage rights. 

Claims determinations 

If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to 

know why this was done, to obtain copies of documents relating to the decision without charge and to 

appeal any denial within certain time schedules. 

Enforce your rights 

Under ERISA, there are steps participants may take to enforce the above rights. For instance: 

• If a participant requests a copy of plan documents and does not receive them within 30 days, the 

participant may file suit in a Federal court. In such a case, the court may require the plan 

administrator to provide the materials and pay you up to $110 a day until the participant receives the 

materials, unless the materials were not sent because of reasons beyond the control of the plan 

administrator; 

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FEDERAL NOTICES (continued) 

• If a claim for benefits is denied or disregarded, in whole or in part, the participant may file suit in a 

state or Federal court; 

• If the participant disagrees with the plan's decision, or lack thereof, concerning the qualified status of 

a domestic relations order or a medical child support order, the participant may file suit in Federal 

court; 

• If plan fiduciaries misuse the plan's money, or if participants are discriminated against for asserting 

their rights, they may seek assistance from the U.S. Department of Labor, or may file suit in a 

Federal court. 

The court will decide who should pay court costs and legal fees. If the participant is successful, the 

court may order the person sued to pay costs and fees. If the participant loses, the court may order the 

participant to pay the costs and fees. 

Assistance with questions 

• Contact the group health plan human resources department or the plan administrator with questions 

about the plan; 

• For questions about ERISA rights, contact the nearest area office of the Employee Benefits Security 

Administration, U.S. Department of Labor, listed in your telephone directory or: 

The Division of Technical Assistance and Inquiries 

Employee Benefits Security Administration 

U.S. Department of Labor 

200 Constitution Avenue N.W. 

Washington, D.C. 20210; 

• Call the publications hotline of the Employee Benefits Security Administration to obtain 

publications about ERISA rights. 

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FEDERAL NOTICES (continued) 

Patient Protection Act 

Humana generally allows the designation of a primary care provider. You have the right to designate 

any primary care provider who participates in our network and who is available to accept you or your 

family members. For children, you may designate a pediatrician as the primary care provider. For 

information on how to select a primary care provider, and for a list of the participating primary care 

providers, visit our Website at www.humana.comor call the customer service telephone number on your 

identification card. 

If your plan provides coverage for obstetric or gynecological care, you do not need prior authorization 

from us or from any other person (including a primary care provider) in order to obtain access to this 

care from a health care professional in our network who specialize in obstetrics or gynecology. The 

health care professional, however, may be required to comply with certain procedures, including 

obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures 

for making referrals. For a list of participating health care professionals who specialize in obstetrics or 

gynecology, visit our Website at wwvv.humana.comor call the customer service telephone number on 

your identification card. 

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Appeal and External Review Notice 

The following pages contain important information about Humana's claims procedures, internal 

appeals and external review. There may be differences between the Certificate of Insurance and 

this Notice packet. There may also be differences between this notice packet and state law. You 

are eligible for the rights more beneficial to you, unless preempted by state or federal law. 

Federal standards 

The Employee Retirement Income Security Act of 1974 (ERISA) established minimum requirements for 

claims procedures. The Patient Protection and Affordable Care Act (PPACA) including all regulation 

enforcing PPACA established additional requirements for claims procedures, internal appeal and external 

review processes. Humana complies with these standards. In addition to the procedures below, you 

should also refer to your insurance benefit plan documents (e.g., the Certificate of Insurance or Evidence 

of Coverage). 

Definitions 

Adverse benefit determination means a denial, reduction, or termination of, or a failure to provide or 

make a payment (in whole or in part) for a benefit based on: 

• A determination of your eligibility to participate in the plan or health insurance coverage; 

• A determination that the benefit is not covered; 

• The imposition of a source-of-injury exclusion, network exclusion, or other limitation on otherwise 

covered benefits; or 

• A determination that a benefit is experimental, investigational, or not medically necessary or 

appropriate. 

An adverse benefit determination also includes any rescission of coverage. 

Claimant means a covered person (or authorized representative) who files a claim. 

Clinical peer reviewer is: 

• An expert in the treatment of your medical condition that is the subject of an external review; 

• Knowledgeable about the recommended healthcare service or treatment through recent or current 

actual clinical experience treating patients with the same or similar to your medical condition; 

• Holds a non-restricted license in a state of the United States and, for physicians, a current 

certification by a recognized American medical specialty board in the area or areas appropriate to the 

subject of the external review; 

• Has no history of disciplinary actions or sanctions, including loss of staff privileges or participation 

restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or 

regulatory body that raise a substantial question as to the clinical peer reviewer's physical, mental or 

professional competence or moral character; and 

1 

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Appeal and External Review Notice (continued) 

• Does not have a material professional, family or financial conflict of interest with the claimant, 

Humana and any of the following: 

The healthcare provider, the healthcare provider's medical group or independent practice 

association recommending the healthcare service or treatment; 

The facility at which the recommended healthcare service or treatment would be provided; or 

- The developer or manufacturer of the principal drug, device, procedure or other therapy being 

recommended. 

Commissioner means the Commissioner of Insurance. 

Concurrent-care decision means a decision by the plan to reduce or terminate benefits otherwise 

payable for a course of treatment that has been approved by the plan (other than by plan amendment or 

termination) or a decision with respect to a request by a claimant to extend a course of treatment beyond 

the period of time or number of treatments that has been approved by the plan. 

Evidence-based standard means the conscientious, explicit and judicious use of the current best 

evidence based on the overall systematic review of the research in making decisions about the care of 

individual patients. 

External review means a review of an adverse benefit determination including a final adverse benefit 

determination conducted by an Independent review organization (IRO). 

Final adverse benefit determination means an adverse benefit determination that has been upheld by us 

at the completion of the internal appeals process or when the internal appeals process has been 

exhausted. 

Group health plan means an employee welfare benefit plan to the extent the plan provides medical care 

to employees or their dependents directly (self insured) or through insurance (including HMO plans), 

reimbursement or otherwise. 

Health insurance issuer means the offering company listed on the face page of your Certificate of 

Insurance and referred to in this document as "Humana," "we," "us," or "our." 

Independent review organization (IRO) means an entity that conducts independent external reviews of 

adverse benefit determinations and final adverse benefit determinations. All IRO's must be accredited 

by a nationally recognized private accrediting organization and have no conflicts of interest to influence 

its independence. 

Medical or scientific evidence means evidence found in the following sources: 

• Peer-reviewed scientific studies published in or accepted for publication by medical journals that 

meet nationally recognized requirements for scientific manuscripts and that submit most of their 

published articles for review by experts who are not part of the editorial staff; 

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Appeal and External Review Notice (continued) 

• Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by 

a qualified institutional review board, biomedical compendia and other medical literature that meet 

the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus 

(Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); 

• Medical journals recognized by the Secretary of Health and Human Services; 

• The following standard reference compendia: 

The American Hospital Formulary Service—Drug Information; 

- Drug Facts and Comparisons; 

The American Dental Association Accepted Dental Therapeutics; and 

The United States Pharmacopoeia—Drug Information; 

• Findings, studies or research conducted by or under the auspices of federal government agencies and 

nationally recognized federal research institutes, including: 

The federal Agency for Healthcare Research and Quality; 

The National Institutes of Health; 

The National Cancer Institute; 

The National Academy of Sciences; 

The Centers for Medicare & Medicaid Services; 

The federal Food and Drug Administration; and 

Any national board recognized by the National Institutes of Health for the purpose of evaluating 

the medical value of health care services; or 

• Any other medical or scientific evidence that is comparable to the sources listed above. 

Preliminary review means a review by Humana of an external review request to determination if: 

• You are or were covered under the plan at the time a service was recommended, requested, or 

provided; 

• The service is covered under the plan except when we determine the service is: 

- Not covered because it does not meet plan requirements for medical necessity, appropriateness, 

healthcare setting, level of care or effectiveness; or 

- Experimental or investigational for a particular medical condition and is not explicitly listed as 

an excluded benefit under the plan. 

• In the case of experimental or investigational treatment: 

Your treating physician has certified one of the following situations is applicable: 

Standard services have not been effective in improving your condition; 

Standard services are not medically appropriate for you; or 

There is no available standard service covered by the plan that is more beneficial to you than 

the recommended or requested service. 

3 

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Appeal and External Review Notice (continued) 

The treating physician certifies in writing: 

- The recommended service is likely to be more beneficial to you, in the physician's opinion, 

than any available standard services; or 

Scientifically valid studies using accepted protocols demonstrate the service is likely to be 

more beneficial to you than any available standard services and the physician is a licensed, 

board certified or board eligible physician qualified to practice in the area of medicine 

appropriate to treat your condition. 

• The internal appeals process has been exhausted as specified under the "Exhaustion of remedies" 

section; 

• You have provided all information required to process an external review; including: 

An external review request form provided with the adverse benefit determination or final 

adverse benefit determination; and 

- Release forms authorizing us to disclose protected health information that is pertinent to the 

external review. 

Post-service claim means any claim for a benefit under a group health plan that is not a pre-service 

claim. 

Pre-service claim means a request for authorization of a benefit for which the plan conditions receipt of 

the benefit, in whole or in part, on advance approval. 

Urgent-care claim means a claim for covered services to which the application of the time periods for 

making non-urgent care determinations: 

• Could seriously jeopardize the life or health of the covered person or the ability of the covered 

person to regain maximum function; or 

• In the opinion of a physician with knowledge of the covered person's medical condition, would 

subject the covered person to severe pain that cannot be adequately managed without the service that 

is the subject of the claim. 

Humana will make a determination of whether a claim is an urgent-care claim. However, any claim a 

physician, with knowledge of a covered person's medical condition, determines is an "urgent-care 

claim" will be treated as a "claim involving urgent care." 

Claim procedures 

Discretionary authority 

With respect to paying claims for benefits or determining eligibility for coverage under a policy issued 

by Humana, Humana as administrator for claims determinations and as ERISA claims review fiduciary, 

shall have full and exclusive discretionary authority to: 

• Interpret plan provisions; 

• Make decisions regarding eligibility for coverage and benefits; and 

• Resolve factual questions relating to coverage and benefits. 

4 

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Appeal and External Review Notice (continued) 

Submitting a claim 

This section describes how a claimant files a claim for plan benefits. A claim must be filed in writing 

and delivered by mail, postage prepaid, by FAX or e-mail. A request for pre-authorization may be filed 

by telephone. The claim or request for pre-authorization must be submitted to Humana or to Humana's 

designee at the address indicated in the covered person's benefit plan document or identification card. 

This is particularly important with respect to mental health coordinators and other providers to whom 

Humana has delegated responsibility for claims administration. Claims will be not be deemed submitted 

for purposes of these procedures unless and until received at the correct address. 

Claims submissions must be in a format acceptable to Humana and compliant with any legal 

requirements. Claims not submitted in accordance with the requirements of applicable federal law 

respecting privacy of protected health information and/or electronic claims standards will not be 

accepted by Humana. 

Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are 

incurred, and in no event later than the period of time described in the benefit plan document. 

Claims submissions must be complete and delivered to the designated address. At a minimum they 

must include: 

• Name of the covered person who incurred the covered expense; 

• Name and address of the provider; 

• Diagnosis; 

• Procedure or nature of the treatment; 

• Place of service; 

• Date of service; and 

• Billed amount. 

Presentation of a prescription to a pharmacy does not constitute a claim for benefits under the plan. If a 

covered person is required to pay the cost of a covered prescription drug, he or she may submit a written 

claim for plan benefits to Humana. 

A general request for an interpretation of plan provisions will not be considered a claim. Requests of 

this type, such as a request for an interpretation of the eligibility provisions of the plan, should be 

directed to the plan administrator. 

Failure to provide necessary information 

If a pre-service claim submission is not made in accordance with the plan's requirements, Humana will 

notify the claimant of the problem and how it may be remedied within five days (or as soon as possible 

but not more than 24 hours, in the case of an urgent-care claim). If a post-service claim is not made in 

accordance with the plan's requirements, it will be returned to the submitter. 

Authorized representatives 

A covered person may designate an authorized representative to act on his or her behalf in pursuing a 

benefit claim, an internal appeal or an external review. The designation must be in writing and must be 

made by the covered person on Humana's Appointment of Representation (AOR) Form or on a form 

approved in advance by Humana. An assignment of benefits does not constitute designation of an 

authorized representative. 

5 

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Appeal and External Review Notice (continued) 

Humana's AOR Form must be submitted to Humana at the time or prior to the date an authorized 

representative commences a course of action on behalf of the covered person. At the same time, the 

authorized representative should also provide notice of commencement of the action on behalf of the 

covered person to the covered person, which Humana may verify with the covered person prior to 

recognizing authorized representative status. 

In any event, a health care provider with knowledge of a covered person's medical condition acting in 

connection with an urgent-care claim will be recognized by the plan as the covered person's authorized 

representative. 

Covered persons should carefully consider whether to designate an authorized representative. An 

authorized representative may make decisions independent of the covered person, such as whether and 

how to appeal a claim denial. 

Claims decisions 

After a determination on a claim is made, Humana will notify the claimant within a reasonable time, as 

follows: 

• Pre-service claims - Humana will provide notice of a favorable or adverse benefit determination 

within a reasonable time appropriate to the medical circumstances but no later than 15 days after the 

plan receives the claim. 

This period may be extended by an additional 15 days, if Humana determines the extension is 

necessary due to matters beyond the control of the plan. Before the end of the initial 15-day period, 

Humana will notify the claimant of the circumstances requiring the extension and the date by which 

Humana expects to make a decision. 

If the reason for the extension is because Humana does not have enough information to decide the 

claim, the notice of extension will describe the required information, and the claimant will have at 

least 45 days from the date the notice is received to provide the necessary information. 

• Urgent-care claims - Humana will determine whether a particular claim is an urgent-care claim. 

This determination will be based on information furnished by or on behalf of a covered person. 

Humana will exercise its judgment when making the determination with deference to the judgment 

of a physician with knowledge of the covered person's condition. Humana may require a claimant 

to clarify the medical urgency and circumstances supporting the urgent-care claim for expedited 

decision-making. 

Notice of a favorable or adverse benefit determination will be made by Humana as soon as possible, 

taking into account the medical urgency particular to the covered person's situation, but not later 

than 24 hours after receiving the urgent-care claim. 

If a claim does not provide sufficient information to determine whether, or to what extent, services are 

covered under the plan, Humana will notify the claimant as soon as possible, but not more than 24 

hours after receiving the urgent-care claim. The notice will describe the specific information 

necessary to complete the claim. The claimant will have a reasonable amount of time, taking into 

account the covered person's circumstances, to provide the necessary information — but not less than 

48 hours. 

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Appeal and External Review Notice (continued) 

Humana will provide notice of the plan's urgent-care claim determination as soon as possible but no 

more than 48 hours after the earlier of: 

- The plan receives the specified information; or 

- The end of the period afforded the claimant to provide the specified additional information. 

• Concurrent-care decisions - Humana will notify a claimant of a concurrent-care decision involving 

a reduction or termination of pre-authorized benefits sufficiently in advance of the reduction or 

termination to allow the claimant to appeal and obtain a determination. 

Humana will decide urgent-care claims involving an extension of a course of treatment as soon as 

possible taking into account medical circumstances. Humana will notify a claimant of the benefit 

determination, whether adverse or not, within 24 hours after the plan receives the claim, provided 

the claim is submitted to the plan 24 hours prior to the expiration of the prescribed period of time or 

number of treatments. 

• Post-service claims - Humana will provide notice of a favorable or adverse benefit determination 

within a reasonable time appropriate to the medical circumstances but no later than 30 days after the 

plan receives the claim. 

This period may be extended an additional 15 days, if Humana determines the extension is necessary 

due to matters beyond the plan's control. Before the end of the initial 30-day period, Humana will 

notify the affected claimant of the extension, the circumstances requiring the extension and the date 

by which the plan expects to make a decision. 

If the reason for the extension is because Humana does not have enough information to decide the 

claim, the notice of extension will describe the required information, and the claimant will have at 

least 45 days from the date the notice is received to provide the specified information. Humana will 

make a decision on the earlier of the date on which the claimant responds or the expiration of the 

time allowed for submission of the requested information. 

Initial denial notices 

Notice of a claim denial (including a partial denial) will be provided to claimants by mail, postage 

prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. With respect to 

adverse decisions involving urgent-care claims, notice may be provided to claimants orally within the 

time frames noted above. If oral notice is given, written notification must be provided no later than 

three days after oral notification. 

A claims denial notice will convey the specific reason for the adverse benefit determination and the 

specific plan provisions upon which the determination is based. The notice will also include a 

description of any additional information necessary to perfect the claim and an explanation of why such 

information is necessary. The notice will disclose if any internal plan rule, protocol or similar criterion 

was relied upon to deny the claim and a copy of the rule, protocol or similar criterion will be provided to 

claimants, free of charge. In addition to the information provided in the notice, a claimant has the right 

to request the diagnosis and treatment codes and descriptions upon which the determination is based. 

The notice will describe the plan's review procedures and the time limits applicable to such procedures, 

including a statement of the claimant's right to bring a civil action under ERISA Section 502(a) 

following an adverse benefit determination on review. 

7 

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Appeal and External Review Notice (continued) 

If an adverse benefit determination is based on medical necessity, experimental treatment or similar 

exclusion or limitation, the notice will provide an explanation of the scientific or clinical basis for the 

determination, free of charge. The explanation will apply the terms of the plan to the covered person's 

medical circumstances. 

In the case of an adverse decision of an urgent-care claim, the notice will provide a description of the 

plan's expedited review procedures. 

Contact information 

For questions about your rights, this notice, or assistance, you can contact: Humana, Inc. at 

www.humana.comor the Employee Benefits Security Administration at 1-866-444-EBSA (3272). 

You may contact the commissioner for assistance at any time at the address and telephone number 

below: 

Florida Office of Insurance Regulation 

200 East Gaines Street 

Tallahassee, FL 32399-0322 

Phone: 850-413-3140 or 1-877-693-5236 

Out of State: 850-413-3089 

8 

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Appeal and External Review Notice (continued) 

Internal appeals and external review of adverse benefit determinations 

Internal appeals 

A claimant must appeal an adverse benefit determination within 180 daysafter receiving written notice 

of the denial (or partial denial). An appeal may be made by a claimant by means of written application 

to Humana, in person, or by mail, postage prepaid. 

A claimant, on appeal, may request an expedited internal appeal of an adverse urgent-care claim 

decision orallyor in writing. In such case, all necessary information, including the plan's benefit 

determination on review, will be transmitted between the plan and the claimant by telephone, FAX, or 

other available similarly expeditious method, to the extent permitted by applicable law. 

A claimant may request an expedited external review at the same time a request is made for an 

expedited internal appeal of an adverse benefit determination for an urgent-care claim or when you are 

receiving an ongoing course of treatment. 

Determination of appeals of denied claims will be conducted promptly, will not defer to the initial 

determination and will not be made by the person who made the initial adverse claim determination or a 

subordinate of that person. The determination will take into account all comments, documents, records, 

and other information submitted by the claimant relating to the claim. 

On appeal, a claimant may review relevant documents and may submit issues and comments in writing. 

A claimant on appeal may, upon request, discover the identity of medical or vocational experts whose 

advice was obtained on behalf of the plan in connection with the adverse benefit determination being 

appealed, as permitted under applicable law. 

If the claims denial is based in whole, or in part, upon a medical judgment, including determinations as 

to whether a particular treatment, drug, or other service is experimental, investigational, or not medically 

necessary or appropriate, the person deciding the appeal will consult with a health care professional who 

has appropriate training and experience in the field of medicine involved in the medical judgment. The 

consulting health care professional will not be the same person who decided the initial appeal or a 

subordinate of that person. 

If new or additional evidence is relied upon or if new or additional rational is used during the internal 

appeal process, Humana will provide the claimant, free of charge, the evidence or rational as soon as 

possible and in advance of the appeals decision in order to provide the claimant a reasonable opportunity 

to respond. 

9 

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Appeal and External Review Notice (continued) 

Time periods for decisions on appeal 

Appeals of claims denials will be decided and notice of the decision provided as follows: 

• Urgent-care claims - As soon as possible but not later than 72 hours after Humana receives the 

appeal request; 

• Pre-service claims - Within a reasonable period but not later than 30 days after Humana received the 

appeal request; 

• Post-service claims - Within a reasonable period but not later than 60 days after Humana receives 

the appeal request; 

• Concurrent-care decisions - Within the time periods specified above depending on the type of claim 

involved. 

Appeals denial notices 

Notice of a claim denial (including a partial denial) will be provided to claimants by mail, postage 

prepaid, by FAX or by e-mail, as appropriate, within the time periods noted above. 

A notice that a claim appeal has been denied will include: 

• The specific reason or reasons for the adverse benefit determination; 

• Reference to the specific plan provision upon which the determination is based; 

• If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of 

the rule, protocol or similar criterion will be provided to the claimant, free of charge; 

• A statement of the claimant's right to external review, a description of the external review process, 

and the forms for submitting an external review request, including release forms authorizing 

Humana to disclose protected health information pertinent to the external review; 

• A statement about the claimant's right to bring an action under §502(a) of ERISA; 

• If an adverse benefit determination is based on medical necessity, experimental treatment or similar 

exclusion or limitation, the notice will provide an explanation of the scientific or clinical basis for 

the determination, free of charge. The explanation will apply the terms of the plan to the covered 

person's medical circumstances. 

In addition to the information provided in the notice, a claimant has the right to request the diagnosis 

and treatment codes and descriptions upon which the determination is based. 

10 

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Appeal and External Review Notice (continued) 

Exhaustion of remedies 

Upon completion of the internal appeals process under this section, a claimant will have exhausted his 

or her administrative remedies under the plan. If Humana fails to adhere to all requirements of the 

internal appeal process, except for failures that are based on a minimal error, the claim shall be deemed 

to have been denied and the claimant may request an external review. 

After exhaustion of remedies, a claimant may pursue any other legal remedies available, which may 

include bringing civil action under ERISA section 502(a) for judicial review of the plan's determination. 

Additional information may be available from the local U.S. Department of Labor Office. 

External review 

Withinfour monthsafter a claimant receives notice of an adverse benefit determination or final adverse 

benefit determination the claimant may request an external review if the determination concerns 

treatment that is experimental, investigational or not medically necessary or the determination concerns 

a rescission of coverage. The request for external review must be made in writing to the commissioner. 

Please refer to the section titled "Expedited external review" if the adverse benefit determination 

involves an urgent-care claim or an ongoing course of treatment. 

Within one business dayafter the receipt of a request for external review, the commissioner will send a 

copy of the request to Humana. Within five business days,we will complete a preliminary review of the 

request. 

Within one business dayafter we complete the preliminary review, we will notify the claimant and the 

commissioner in writing whether: 

• The request is complete and is eligible for external review; 

• The request is not complete and the information or materials needed to make the request complete; 

or 

• The request is not eligible for external review, the reasons for ineligibility and the claimant's right to 

appeal to the commissioner. If appealed, the commissioner may determine that the request is eligible 

for external review. 

Within one business dayafter the commissioner receives notice that the request is eligible for external 

review, the commissioner will: 

• Impartially assign an IRO from a list compiled and maintained by the commissioner to conduct the 

external review; 

• Provide Humana with the name of the IRO. Within five business daysafter the date of receipt of 

this notice, we will provide the IRO with all documents and information we considered in making 

the adverse benefit determination or final adverse benefit determination; 

11 

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Appeal and External Review Notice (continued) 

• Notify the claimant in writing of the following: 

The eligibility of the request and acceptance for external review; and 

The right to submit additional information in writing to the IRO and the time limits to submit 

the information. 

Any information received by the IRO will be forwarded to Humana within one business day of receipt. 

Upon receipt of additional information, we may reconsider the adverse benefit determination or final 

adverse benefit determination. If we reverse the adverse benefit determination or final adverse benefit 

determination, the external review will be terminated and we will provide coverage for the service. We 

will immediately notify the claimant, the IRO, and the commissioner in writing of our decision. 

The IRO will review all of the information received including, if available and considered appropriate 

the following: 

• Your medical records; 

• The attending healthcare professional's recommendation; 

• Consulting reports from appropriate healthcare professionals and other documents submitted by 

Humana, the claimant, and treating provider; 

• The terms of the coverage under the plan; 

• The most appropriate practice guidelines, which will include applicable evidence-based standards 

and may include any other practice guidelines developed by the federal government, national or 

professional medical societies, boards and associations; 

• Any applicable clinical review criteria developed and used by Humana; and 

• The opinion of the IRO's clinical peer reviewer or reviewers after considering the information and 

documents listed above. 

If the external review involves experimental or investigational treatment, within one business day after 

the IRO receives notice of assignment to conduct the external review, the IRO will select one or more 

clinical peer reviewers to conduct the external review. The clinical peer reviewer will review all of the 

information and within 20 days after being selected, will provide a written opinion to the IRO on 

whether the service should be covered. The written opinion will include: 

• A description of the medical condition; 

• A description of the indicators relevant to determining whether there is sufficient evidence to 

demonstrate that the service is more likely than not to be beneficial to you than any available 

standard services; 

• The adverse risks of the service would not be substantially increased over those of available standard 

services; 

• A description and analysis of any medical or scientific evidence, or evidence-based standard 

considered in reaching the opinion; 

12 

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Appeal and External Review Notice (continued) 

• Information on whether the reviewer's rationale for the opinion is based on either: 

The service has been approved by the federal Food and Drug Administration, if applicable, for 

the condition; or 

Medical or scientific evidence or evidence-based standards demonstrate that the expected 

benefits of the service is more likely than not to be beneficial to you than any available standard 

health care service and the adverse risks of the service would not be substantially increased over 

those of available standard services. 

The IRO's decision to either uphold or reverse the adverse benefit determination or final adverse benefit 

determination will be provided in writing to the claimant, the commissioner and Humana within: 

• 20 daysafter receipt of each clinical peer reviewer opinion for an experimental or investigational 

treatment; or 

• 45 daysafter receipt of the request for an external review. 

In the case of experimental or investigational treatment, if a majority of clinical peer reviewers 

recommend the service should be covered, the IRO will make a decision to reverse the adverse benefit 

determination or final adverse benefit determination. If a majority of clinical peer reviewers 

recommend the service should not be covered, the IRO will make a decision to uphold the adverse 

benefit determination or final adverse benefit determination. If the clinical peer reviewers are evenly 

split, the IRO will obtain the opinion of an additional clinical peer reviewer in order for the IRO to 

make a decision. 

The IRO's written notice of the decision will include: 

• A general description of the reason for the request for external review; 

• The date the IRO received the assignment from the commissioner to conduct the external review; 

• The date the external review was conducted; 

• The date of the IRO's decision; 

• The principal reason for the decision, including applicable evidence-based standards, if any, used as 

a basis for the decision; 

• The rationale for the decision; 

• References to the evidence or documentation, including the evidence-based standards, considered in 

reaching the decision; and 

• In the case of experimental or investigational treatment, the written opinion and rational for the 

recommendation of each clinical peer reviewer. 

Immediately upon our receipt of the IRO's decision reversing the adverse benefit determination or final 

adverse determination, we will approve the service. 

Expedited external review 

You may request an expedited external review from the commissioner: 

• At the same time you request an expedited internal appeal of an adverse benefit determination for an 

urgent-care claim or when you are receiving an ongoing course of treatment; or 

13 

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Appeal and External Review Notice (continued) 

• When you receive an adverse benefit determination or final adverse benefit determination of: 

An urgent-care claim; 

An admission, availability of care, continued stay or health care service for which you received 

emergency services, but you have not been discharged from the facility; or 

An experimental or investigational treatment if the treating physician certifies, in writing, that 

the recommended service would be significantly less effective if not promptly initiated. 

The commissioner will immediately send a copy of the request to Humana and upon receipt; we will 

immediately complete a preliminary review of the request. We will immediately notify the claimant and 

the commissioner of the preliminary review determination. If we determine the request is not eligible, 

the notice will advise you of your right to appeal to the commissioner. If appealed, the commissioner 

may determine that the request is eligible for external review. 

Immediately after the commissioner receives notice that the request is eligible for external review, the 

commissioner will: 

• Impartially assign an IRO to conduct the expedited external review. 

• Provide Humana with the name of the IRO and we will immediately provide the IRO with all 

necessary documents and information. 

The IRO will review all of the information received including, if available and considered appropriate, 

the following: 

• Your medical records; 

• The attending healthcare professional's recommendation; 

• Consulting reports from appropriate healthcare professionals and other documents submitted by 

Humana, the claimant and treating provider; 

• The terms of the coverage under the plan; 

• The most appropriate practice guidelines, which will include evidence-based standards and may 

include any other practice guidelines developed by the federal government, national or professional 

medical societies, boards and associations; 

• Any applicable clinical review criteria developed and used by Humana; and 

• The opinion of the IRO's clinical peer reviewer or reviewers after considering the information and 

documents listed above. 

If the expedited external review request involves experimental or investigational treatment, within one 

business day after the IRO receives notice of assignment to conduct the external review, the IRO will 

select one or more clinical peer reviewers to conduct the external review. The clinical peer reviewer 

will: 

• Review all of the information noted above including whether: 

- The recommended service has been approved by the federal Food and Drug Administration, if 

applicable, for the condition; or 

14 

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Appeal and External Review Notice (continued) 

Medical or scientific evidence or evidence-based standards demonstrate that the expected 

benefits of the recommended service is more likely than not to be beneficial to you than any 

available standard service and the adverse risks of the recommended service would not be 

substantially increased over those of available standard services. 

• Provide an opinion to the IRO as expeditiously as your condition or circumstances require, but in no 

event more than five calendar days after being selected. 

The IRO's decision to either uphold or reverse the adverse benefit determination or final adverse benefit 

determination will be provided orally or in writing to the claimant, the commissioner and Humana 

within: 

• 48 hours after receipt of each clinical peer reviewer opinion of an expedited external review for an 

experimental or investigational treatment; or 

• 72 hours after the date of receipt of the request for an expedited external review. 

In the case of experimental or investigational treatment, if a majority of clinical peer reviewers 

recommend the service should be covered, the IRO will make a decision to reverse the adverse benefit 

determination or final adverse benefit determination. If a majority of clinical peer reviewers 

recommend the service should not be covered, the IRO will make a decision to uphold the adverse 

benefit determination or final adverse benefit determination. If the clinical peer reviewers are evenly 

split, the IRO will obtain the opinion of an additional clinical peer reviewer in order for the IRO to 

make a decision. 

The IRO will send written confirmation within 48 hours of an oral decision and will include: 

• A general description of the reason for the request for an expedited external review; 

• The date the IRO received the assignment from the commissioner to conduct the expedited external 

review; 

• The date the expedited external review was conducted; 

• The date of the IRO's decision; 

• The principal reason for the decision, including applicable evidence-based standards, if any, used as 

a basis for the decision; 

• The rationale for the decision; 

• References to the evidence or documentation, including the evidence-based standards, considered in 

reaching the decision, except in the case of experimental or investigational treatment; and 

• In the case of experimental or investigational treatment, the written opinion and rational for the 

recommendation of each clinical peer reviewer. 

Immediately upon receipt of the IRO's decision reversing the adverse benefit determination or final 

adverse benefit determination, we will approve the service. 

Legal actions and limitations 

No lawsuit may be brought with respect to plan benefits until all remedies under the plan have been 

exhausted. 

No lawsuit with respect to plan benefits may be brought after the expiration of the applicable limitations 

period stated in the benefit plan document. If no limitation is stated in the benefit plan document, then 

no such suit may be brought after the expiration of the applicable limitations under applicable law. 

15 

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EXHIBIT "B" 

A-0168

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 168 of

172
000300573 

HUMANA MEDICAL PLAN, INC. 

P.O. BOX 14601 

LEXINGTON, KY 40512-4601 

TEOBMTE0B006W1229202108040091572-MTV 

ERICA R WHITE 

13100 ARCH CREEK TER 

NORTH MIAMI, FL 33181-2209 

Humana. 

Claim Receipt 

Explanation of benefits and claim payments 

THIS IS NOT A BILL page 1 of 10 

Patient 

Name: 

Member ID: 

Relationship: 

Group name: 

Group ID: 

Plan type: 

Birth year: 

Patient account: 

ERICA R. WHITE 

100228820 02 

Dependent 

WHITE, WHITE & ASSOCIATES 

665238 

HML 

2000 

21256038411 

Subscriber 

Name: 

Subscriber ID: 

Address: 

JAY A. WHITE 

100228820 01 

13100 ARCH CREEK TER 

NORTH MIAMI, FL 

33181-2209 

Plan payment has not been issued. 

Please refer to Claim Detail on the 

opposite side of this Claim Receipt. 

Your provider may bill you for the 

"Amount you pay provider" section of 

the "Plan/Benefit exclusions." 

Claim summary 

Claim number: 202112178325524 

Provider: TALLAHASSEE MEMORIAL 

Service date: 9/15/21 - 9/15/21 

Processed on: 12/28/21 

Benefits paid to: TALLAHASSEE MEMORIAL 

Provider Paid to 

charges provider 

,TniA rilb,unt,yoja

öidë 

Total charge 

Plan discounts 

Plan/Benefit exclusions 

Your share 

Copay 

Deductible 

Coinsurance 

Amount plan pays 

Claim totals . 

$30,457.49 

$30,457.49 

30.k1,57L4 

t.J4 

6:00 

-000 

0.00 

00k b 

$0.00 41030r57„1491 Amount you pay provider 

Notes: Please compare these totals with the bill you receive from your provider. 

Document ID: 202112285039022 Questions about your plan or this receipt call 

CeN wry% Ain rlf." A nrcnuu 

A-0169

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EXHIBIT "C" 

A-0170

Case 1:22-cv-24030-RKA Document 1-2 Entered on FLSD Docket 12/13/2022 Page 170 of

172
Humana. 

P.O. Box 14546 

Lexington, KY 40512-4546 

June 7, 2022 

JAY WHITE 

13100 ARCH CREEK TER 

NORTH MIAMI FL 33181 

Member: Erica White 

Member ID Number: 100228820 

Company Name: Humana Medical Plan Inc. 

Reference Number: A2214046922 

Humana Received Date: May 17, 2022 

Dear Mr. White: 

We've reviewed your appeal and made our decision. 

Thank you for your patience while we investigated your appeal about claim number 202112178325524 for 

date of service September 15, 2021. A Grievance and Appeal Panel thoroughly reviewed the following 

information on June 1 2022: 

• Appeal letter 

• Appointment of Authorized Representative form 

• Claim 202112178325524 

• Medical records 

• Humana's internal documentation 

• Medical Coverage Guideline for Diabetes 

• Benefit Plan Document (BPD) 

The panel consisted of: 

• Humana Medical Director, specializing in Family Medicine 

• Humana Medical Director, specializing in Family Medicine 

Unfortunately, the panel was unable to approve benefits on claim number 202112178325524. 

Why we were unable to approve your appeal 

The inpatient hospital services billed on claim number 202112178325524 were correctly denied according to 

the provisions of the plan. The medical necessity coverage criteria for the services were not satisfied. In order 

for the requested services to be covered, you would need to have one of the following: 

• High acid levels in your body (diabetic ketoacidosis or DKA) with all of the following: blood sugars greater 

than 200 mg/dL, the presence of certain particles (called ketones) in your blood r- urine, blood with high acid 

level, and certain conditions with increased risk that require inpatient level of care 

• A diabetic-related illness (called hyperglycemic hyperosmolar state) with all of the following: high blood 

sugars over 600 mg/dL, abnormal thickened blood, and changes in brain function 

• High blood sugars with dangerous blood pressures or heart rates, new problems with thinking that are not 

better with treatment, or non-stop vomiting because of high blood sugar. 

'11S. 

tt, 

A-0171

13 

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The records do not indicate the above problems. Although Erica had acidosis, high blood sugars, these 

problems were corrected with the initial medical care she receive-d. In addition, acidosis and high blood sugars 

are a result of turning off her insulin pump2Theservices could have been provided in an alternate level of care," 

such as ambulatory or observation. 

The Limitations and Exclusions section of the plan indicates there is no coverage for any treatments, services, 

supplies or surgeries that are not medically necessa?y, except preventive services. See the enclosed Health 

Benefits Processing Chart and BPD pages that show the claim and further explain the benefits. 

What you can do now 

If you disagree with this decision, you can: 

• Ask for the materials we reviewed 

• Ask for a review of our decision 

• If your plan is governed by the Employment Retirement Income Security Act (ERISA), you may file a civil 

action 

• To learn more, see the enclosure Your Rights 

We're here to help 

If you have any questions about the review process, call us at 1-800-901-1303. If you use a TTY, call 711. Our 

customer care specialists are available to help you 8 a.m. —8 p.m. Eastern time, Monday through Friday. 

Sincerely, 

Specialist 

Humana Grievance and Appeal Department 

Si necesita asistencia en espafiol, Ilamenos al telefono clue aparece at dorso de su tadeta 

de identificacion como afiliado. 

13 

A-0172

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