Exhibit 10.182


AMENDMENT

TO

CALIFORNIACARE MEDICAL SERVICES AGREEMENT

BETWEEN

BLUE CROSS OF CALIFORNIA

AND

GATEWAY MEDICAL GROUP


 


This Amendment to the CaliforniaCare Medical Services Agreement is
entered into at Woodland Hills, Los Angeles County, California, and will be
effective as of July 1, 2000 between Blue Cross of California and its
Affiliates (“BLUE CROSS”) and Gateway Medical Group (“PARTICIPATING
MEDICAL GROUP”).


 


RECITALS


 


A.                                   BLUE CROSS and
PARTICIPATING MEDICAL GROUP have previously entered into a CaliforniaCare
Medical Services Agreement, as may have been amended (“Agreement”).


 


B.                                     The parties now
desire to amend the Agreement.


 


NOW, THEREFORE, IT IS AGREED:


 


1.                                       Mental
Health Parity Services


 


A.                                   Definitions;
Self-Referral; Covered Medical Services


 


(1)                                  The
following Sections 2.09.1 and 2.37.1 are hereby added to Article II of the
Agreement:


 


2.09.1                  “BLUE CROSS Services” means
all CALIFORNIACARE Covered Medical Services which are designated in this
Agreement or in the Division of Financial Responsibility as BLUE CROSS
Services.  BLUE CROSS shall be
financially responsible for BLUE CROSS Services provided that they have been
authorized by BLUE CROSS.


 


2.37.1                  “Mental Health Parity Services”
means those mental health services related to the diagnosis and Medically
Necessary treatment of “severe mental illnesses” and “serious emotional
disturbances of a child,” as such terms are defined in Section 1374.72 of the
California Health and Safety Code.


 


(2)                                  The
following Section 4.02.1 is hereby added to Article IV of the Agreement:


 


4.02.1                  Notwithstanding Section 4.02H herein,
PARTICIPATING MEDICAL GROUP shall allow Members to “self-refer” to
PARTICIPATING MEDICAL GROUP’s mental health providers, as permitted in the
applicable Benefit Agreement.  “Self-refer”
means that Members may visit mental health providers on PARTICIPATING MEDICAL
GROUP’s panel of providers without a referral from the Member’s Primary Care
Physician or other prior authorization from PARTICIPATING MEDICAL GROUP’s
Utilization Management Program.


 


Services to be provided during the Member’s self-referral visit(s)
shall, at a minimum, include office-based consultation, evaluation and
diagnosis.  Any services provided in
addition and/or subsequent to the foregoing shall be provided to the Member in
accordance with PARTICIPATING MEDICAL GROUP’s existing referral, authorization
and treatment protocols and procedures and the Operations Manual.


 


(3)                                  Section
II of Exhibit A of the Agreement is hereby deleted in its entirety and replaced
with the following.


 












*** Confidential Information omitted and filed separately with the
Securities and Exchange Commission.


 

















 


II.                                     Psychiatric
Care Benefits


 


Care shall be provided for (i) short-term evaluation of the Member’s
condition when such care is ordered by the attending PARTICIPATING MEDICAL
GROUP Physician and (ii) the diagnosis and medically necessary treatment of “severe mental
illnesses” and “serious emotional disturbances of a child” as such terms are
defined in California Health and Safety Code Section 1374.72.  Copayments and limitations are as set forth
in the Member’s Benefit Agreement.  This
care shall not include visits for psychoanalysis.


 


B.                                     BLUE
CROSS Services and the Division of Financial Responsibility


 


BLUE CROSS shall authorize and arrange for the provision of BLUE CROSS
Services to a Member once diagnosed with a “several mental illness” or “serious
emotional disturbance of a child”, as such terms are defined in Section 1374.72
of the California Health and Safety Code.


 


Exhibit A(1) of the Agreement is hereby amended to delete in its
entirety the category of “Mental Health Services” and all provisions thereunder
concerning financial responsibility for the professional and facility
components thereof and to replace them with the following:


 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non

  Capitated

  	
   

  	
  BLUE

  CROSS

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH NON-PARITY SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH PARITY SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


II.                                     Financial
Solvency


 


A.                                   Section
4.06 of the Agreement is hereby amended to add the following sentence to the
beginning of such Section:


 


PARTICIPATING MEDICAL GROUP agrees to provide financial information to
BLUE CROSS or its designated agent and to meet any other financial requirements
that assist BLUE CROSS in maintaining the financial viability of its
arrangements for the provision of health care services in the manner described
in Section 1375.4 of the California Health and Safety Code and applicable
regulations.


 


B.                                     The
following Sections 4.13.1 and 4.13.2 are hereby added to Article IV of the
Agreement;


 


4.13.1                  Notwithstanding any other provision
in this Agreement, BLUE CROSS shall pay all risk settlements owed to
PARTICIPATING MEDICAL GROUP no later than 180 days after the close of BLUE
CROSS' fiscal year.


 


4.13.2                  The parties agree that the financial
risk provisions of this Agreement have been negotiated and agreed to by BLUE
CROSS and PARTICIPATING MEDICAL GROUP.


 


C.                                     The
following Section 5.14.1 is hereby added to Article V of the Agreement:


 


5.14.1                  To disclose information to
PARTICIPATING MEDICAL GROUP that enables PARTICIPATING MEDICAL GROUP to be
informed regarding the financial risk assumed under this Agreement, as required
in California Health and Safety Code Section 1375.4 and applicable regulations.


 

















 


III.                                 BLUE
CROSS Managed Care Network


 


A.                                   Section 4.10E of the
Agreement is hereby amended to add the following paragraph to the beginning of
such Section.


 


BLUE CROSS will comply with all requirements of California Health and
Safety Code Section 1395.6.  The BLUE
CROSS Managed Care Network may be sold, leased, transferred or conveyed to
Affiliates or Other Payors, which may include workers’ compensation insurers or
automobile insurers.  BLUE CROSS will
disclose upon initial signing of this Agreement and within 30 days of receipt
of a written request from PARTICIPATING MEDICAL GROUP a summary of all Other
Payors and Affiliates currently eligible to pay the negotiated rates under this
Agreement as a result of their arrangement with BLUE CROSS.  BLUE CROSS requires such Affiliates and
Other Payors to actively encourage Covered Persons to use network participating
providers when obtaining medical care through the use of one or more of the
following: reduced copayments, reduced deductibles, premium discounts directly
attributable to the use of a participating provider, financial penalties
directly attributable to the non-use of a participating provider, providing
Covered Persons with the names, addresses and phone numbers of participating
providers in advance of their selection of a health care provider through the
use of provider directories, toll-free telephone numbers and internet web site
addresses.  In the event BLUE CROSS
enters into an arrangement with an Other Payor or Affiliate that does not
require such active encouragement of the use of the BLUE CROSS Managed Care
Network, PARTICIPATING MEDICAL GROUP shall be allowed to decline to provide
services to such Other Payor or Affiliate.


 


IV.                                 Utilization
Management


 


A.                                   Section
4.05C of the Agreement is hereby amended and replaced in its entirety with the
following:


 


4.05C PARTICIPATING MEDICAL GROUP shall:


 


(1)                                  Make available to
BLUE CROSS all minutes and notes from any and all Utilization Management
Committees and/or activities which relate to Members.


(2)                                  Make available to
BLUE CROSS upon request all composite Utilization Management data which include
Members in the composite data set and provide such detail as is available
regarding those Members.


(3)                                  Provide the BLUE
CROSS Medical Director  (or the Medical
Director’s clinical designee) with a schedule designating the time and place of
all Utilization Management Committee meetings that relate to Members, in order
that he or she shall, in the Medical Director’s discretion, attend.  The BLUE CROSS Medical Director shall notify
PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not
be excluded from any deliberation on activities related to Members.


(4)                                  Comply with all
applicable laws and regulations concerning utilization management criteria and
processes, including, without limitation, California Health and Safety Code
Sections 1363.5 and 1367.01.


 


Upon acceptance of the parties, this Amendment, as of the date
specified on page one hereof, shall become a part of this Agreement, and all
provisions of the Agreement not specifically inconsistent herewith shall remain
in full force and effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
  GATEWAY MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Signature

  	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Print Name

  	
   

  	
  Print Name

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
  Date

  	
   

  	
  Title

  	
  Date

  	
   

  
						



 

















 


AMENDMENT


TO


CALIFORNIACARE MEDICAL SERVICES AGREEMENT


BETWEEN


BLUE CROSS OF CALIFORNIA


AND


GATEWAY MEDICAL GROUP


 


This Amendment
to the CaliforniaCare Medical Services Agreement is entered into at Woodland
Hills, Los Angeles County, California and will be effective as of July 1, 2000
between Blue Cross of California and its Affiliates (“BLUE CROSS”) and Gateway
Medical Group (“PARTICIPATING MEDICAL GROUP”).


 


RECITALS


 


A.                                   BLUE
CROSS and PARTICIPATING MEDICAL GROUP have previously entered into a
CaliforniaCare Medical Services Agreement, as may have been amended
(“Agreement”).


 


B.                                     The
parties now desire to amend the Agreement.


 


NOW, THEREFORE, IT IS AGREED:


 


I.                                         Mental
Health Parity Services


 


A.                                   Definitions;
Self-Referral; Covered Medical Services


 


(1)                                  The
following Sections 2.09.1 and 2.37.1 are hereby added to Article II of the
Agreement:


 


2.09.1                  “BLUE
CROSS Services”  means all
CALIFORNIACARE Covered Medical Services which are designated in this Agreement
or in the Division of Financial Responsibility as BLUE CROSS Services.  BLUE CROSS shall be financially responsible
for BLUE CROSS Services provided that they have been authorized by BLUE CROSS.


 


2.37.1                  “Mental
Health Parity Services”  means those
mental health services related to the diagnosis and Medically Necessary
treatment of “severe mental illnesses” and “serious emotional disturbances of a
child,” as such terms are defined in Section 1374.72 of the California Health
and Safety Code.


 


(2)                                  The
following Section 4.02.1 is hereby added to Article IV of the Agreement:


 


4.02.1                  Notwithstanding
Section 4.02H herein, PARTICIPATING MEDICAL GROUP shall allow Members to
“self-refer” to PARTICIPATING MEDICAL GROUP’s mental health providers, as
permitted in the applicable Benefit Agreement. 
“Self-refer” means that Members may visit mental health providers on
PARTICIPATING MEDICAL GROUP’s panel of providers without a referral from the
Member’s Primary Care Physician or other prior authorization from PARTICIPATING
MEDICAL GROUP’s Utilization Management Program.


 


Services to be
provided during the Member’s self-referral visit(s) shall, at a minimum,
include office-based consultation, evaluation and diagnosis.  Any services provided in addition and/or
subsequent to the foregoing shall be provided to the Member in accordance with
PARTICIPATING MEDICAL GROUP’s existing referral, authorization and treatment
protocols and procedures and the Operations Manual.


 


(3)                                  Section
II of Exhibit A of the Agreement is hereby deleted in its entirety and replaced
with the following:


 


1

















 


II.                                     Psychiatric
Care Benefits


 


Care shall be
provided for (i) short-term evaluation of the Member’s condition when such care
is ordered by the attending PARTICIPATING MEDICAL GROUP Physician and (ii) the
diagnosis and medically necessary treatment of “severe mental illnesses” and
“serious emotional disturbances of a child” as such terms are defined in
California Health and Safety Code Section 1374.72. Copayments and limitations
are as set forth in the Member’s Benefit Agreement.  This care shall not include visits for psychoanalysis.


 


B.                                     BLUE
CROSS Services and the Division of Financial Responsibility


 


BLUE CROSS
shall authorize and arrange for the provision of BLUE CROSS Services to a
Member once diagnosed with a “severe mental illness” or “serious emotional
disturbance of a child”, as such terms are defined in Section 1374.72 of the
California Health and Safety Code.


 


Exhibit A(1)
of the Agreement is hereby amended to delete in its entirety the category of
“Mental Health Services” and all provisions thereunder concerning financial
responsibility for the professional and facility components thereof and to
replace them with the following:


 




	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non

  Capitated

  	
   

  	
  BLUE

  CROSS

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH NON-PARITY SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH PARITY SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  






 


II.                                     Financial
Solvency


 


A.                                   Section
4.06 of the Agreement is hereby amended to add the following sentence to the
beginning of such Section:


 


PARTICIPATING
MEDICAL GROUP agrees to provide financial information to BLUE CROSS or its
designated agent and to meet any other financial requirements that assist BLUE
CROSS in maintaining the financial viability of its arrangements for the
provision of health care services in the manner described in Section 1375.4 of
the California Health and Safety Code and applicable regulations.


 


B.                                     The
following Section 4.13.1 and 4.13.2 are hereby added to Article IV of the
Agreement:


 


4.13.1                  Notwithstanding
any other provision in this Agreement, BLUE CROSS shall pay all risk
settlements owed to PARTICIPATING MEDICAL GROUP no later than 180 days after
the close of BLUE CROSS’ fiscal year.


 


4.13.2                  The
parties agree that the financial risk provisions of this Agreement have been
negotiated and agreed to by BLUE CROSS and PARTICIPATING MEDICAL GROUP.


 


C.                                     The
following Section 5.14.1 is hereby added to Article V of the Agreement:


 


5.14.1                  To
disclose information to PARTICIPATING MEDICAL GROUP that enables PARTICIPATING
MEDICAL GROUP to be informed regarding the financial risk assumed under this
Agreement, as required in California Health and Safety Code Section 1375.4 and
applicable regulations.


 

















 


III.                                 BLUE
CROSS Managed Care Network


 


A.                                   Section
4.10E of the Agreement is hereby amended to add the following paragraph to the
beginning of such Section:


 


BLUE CROSS
will comply with all requirements of California Health and Safety Code Section
1395.6.  The BLUE CROSS Managed Care
Network may be sold, leased, transferred or conveyed to Affiliate or Other
Payors, which may include workers’ compensation insurers of automobile
insurers.  BLUE CROSS will disclose upon
initial signing of this Agreement and within 30 days of receipt of a written
request from PARTICIPATING MEDICAL GROUP a summary of all Other Payors and
Affiliates currently eligible to pay the negotiated rates under this Agreement
as a result of their arrangement with BLUE CROSS.  BLUE CROSS requires such Affiliates and Other Payors to actively
encourage Covered Persons to use network participating providers when obtaining
medical care through the use of one or more of the following: reduced
copayments, reduced deductibles, premium discounts directly attributable to the
use of a participating provider, financial penalties directly attributable to
the non-use of a participating provider, providing Covered Persons with the
names, addresses and phone numbers of participating providers in advance of
their selection of a health care provider through the use of provider
directories, toll-free telephone numbers and interest web site addresses.  In the event BLUE CROSS enters into an
arrangement with an Other Payor or Affiliate that does not require such active
encouragement of the use of the BLUE CROSS Managed Care Network, PARTICIPATING
MEDICAL GROUP shall be allowed to decline to provide services to such Other
Payor or Affiliate.


 


IV.                                 Utilization
Management


 


A.                                   Section
4.05C of the Agreement is hereby amended and replaced in its entirety with the
following:


 


4.05C
PARTICIPATING MEDICAL GROUP shall:


 


(1)                                  Make
available to BLUE CROSS all minutes and notes from any and all Utilization
Management Committees and/or activities which relate to Members.


(2)                                  Make
available to BLUE CROSS upon-request all composite Utilization Management data
which include Members in the composite data set and provide such detail as is
available regarding those Members.


(3)                                  Provide
the BLUE CROSS Medical Director (or the Medical Director’s clinical designee)
with a schedule designating the time and place of all Utilization Management
Committee meetings that relate to Members, in order that he or she shall, in
the Medical Director’s discretion, attend. 
The BLUE CROSS Medical Director shall notify PARTICIPATING MEDICAL GROUP
in advance of his or her attendance and shall not be excluded from any
deliberation on activities related to Members.


(4)                                  Comply
with all applicable laws and regulations concerning utilization management
criteria and processes, including, without limitation, California Health and
Safety Code Sections 1363.5 and 1367.01.


 


Upon acceptance of the parties,
this Amendment, as of the date specified on page one hereof, shall become a
part of this Agreement, and all provisions of the Agreement not specifically
inconsistent herewith shall remain in full force and effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
   

  	
  GATEWAY MEDICAL GROUP

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature

  	
   

  	
  Signature

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Print Name

  	
   

  	
  Print Name

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Title

  	
  Date

  	
   

  	
  Title

  	
  Date

  
					



 

















 


EXHIBIT A(1)


CALIFORNIACARE


 


DIVISION OF FINANCIAL RESPONSIBILITIES


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE: Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHETICS, Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL EYE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * 
  ARTIFICIAL INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * 
  CHEMICAL DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*  As set forth in the applicable Benefit Agreement


 


*** All references to division
of financial responsibility have been deleted.


 


A(1)-1

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY DRUGS (intravenously
  administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemotherapy Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHIROPRACTIC (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In Conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DENTAL SERVICES

  (accidental injury to sound natural teeth
  and dental work necessary for the construction of non-dental structures)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  DURABLE MEDICAL EQUIPMENT (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-2

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMPLOYMENT PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ENDOSCOPIC STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXPERIMENTAL PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FAMILY PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FETAL MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENETIC TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ** HEALTH EVALUATIONS / PHYSICALS

  (required by third party or outside agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
    * HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in the applicable Benefit
Agreement


**          Routine physical examinations or tests which
do not directly treat an actual illness, injury or condition unless authorized
by a Primary Care Physician, except in no event will any physical examination
or test required by employment or governmental authority, or at the request of
a third party such as a school camp or sport affiliated organization be
covered.


*** All references to division of financial
responsibility have been deleted.


 


A(1)-3

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE (in lieu of acute inpatient or SNF
  care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedic Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  HOSPITALIZATION / INPATIENT
  SERVICES, SUPPLIES & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out-of-Area (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-4

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (Audit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA MONITOR (DME)

  (in conjunction with or concurrent with
  authorized inpatient admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * 
  INFERTILITY (Diagnosis / Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFUSION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Infused Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLE MEDICATIONS: Outpatient

  (excluding take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LABORATORY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * 
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MAMMOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-5

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  NUTRITIONIST / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OBSTETRICAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ORGAN TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  OUTPATIENT DIAGNOSTIC SERVICES &
  TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Primary Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Specialty Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC
  SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  These services include, but are not limited
  to the following:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CAT Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2-D Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EKG (aka: ECG)c

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-6

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedic

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All references
to division of financial responsibility have been deleted.


 


A(1)-7

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PEDIATRIC
  SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICAL
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Specialty Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PODIATRY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREADMISSION
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE-EXISTING
  PREGNANCY

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-8

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIATION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RECONSTRUCTIVE
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REHABILITATION
  SERVICES

  (Physical Therapy, Occupational Therapy,
  Speech Therapy, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ROUTINE
  PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SKILLED
  NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SPECIALIST
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-9

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGICAL
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TEMPORO-MANDIBULAR
  JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Dental Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  (for the diagnosis and medically necessary
  correction)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous Blood Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE:
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE:
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION
  SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Lenses / Frames (covered by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Contact lenses (fitting only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*                 As set forth in
the applicable Benefit Agreement


 


*** All
references to division of financial responsibility have been deleted.


 


A(1)-10