Document:

Exhibit
10.181

 

 

AMENDMENT

TO THE CALIFORNIACARE MEDICAL SERVICES AGREEMENT

BETWEEN BLUE CROSS OF CALIFORNIA AND

STARCARE MEDICAL GROUP D.B.A., GATEWAY MEDICAL

GROUP, INC.

 

This Amendment to the
CALIFORNIACARE Medical Services Agreement is entered into at Woodland Hills Los
Angeles County, California, as of January
1, 2000, between Blue Cross of California and its Affiliates
(“BLUE CROSS”) and Starcare Medical Group
d.b.a.. Gateway Medical Group, Inc. (“PARTICIPATING MEDICAL
GROUP”).

 

RECITALS

 

A.                                   BLUE CROSS and PARTICIPATING MEDICAL GROUP
have previously entered into a CALIFORNIACARE Medical Services Agreement
(“Agreement”), effective January 1, 2000 whereby
PARTICIPATING MEDICAL GROUP is designated as a PARTICIPATING MEDICAL GROUP.

 

B.                                     Pursuant to Section 16.01 of the Agreement,
the parties now desire to amend the Agreement to add language regarding the
provision of services to Members of the AIM Program. The terms of this
Amendment apply only to the BLUE CROSS AIM Program.

 

NOW, THEREFORE, IT IS AGREED:

 

1.                                       Article II, DEFINITIONS, Section 2.03.1
is hereby added to read: 

 

“AIM
Capitation” means a uniform prepayment fee per AIM Program Member per
month, adjusted by age.

 

2.                                       Article II, DEFINITIONS, Section 2.03.2
is hereby added to read:

 

“AIM
Capitation Services”
means all AIM Covered Medical Services which are not otherwise designated as
Insured Services or the responsibility of BLUE CROSS, in the Division of
Financial Responsibilities under Exhibit A(2).

 

3.                                       Article II, DEFINITIONS, Section 2.03.3
is hereby added to read:

 

“AIM
Program” means the
program for increased access to maternity, delivery, and infant care services
for low income women, offered by BLUE CROSS as a CALIFORNIACARE program under
contract with the State of California pursuant to California Insurance Code
Section 12695 et  seq. Although the AIM Program is a
CALIFORNIACARE program, it is in some ways unique and will, therefore, be
separately identified in this Agreement.

 

4.                                       Article II, DEFINITIONS, Section 2.08, “Benefit
Agreements” is hereby amended to delete the period at the end of the first
sentence of Section 2.08 and replace it with the words, “or the AIM Program.”

 

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

 

1

 

5                                          Article ll, DEFINITIONS, Section 2.20.
“Covered Medical Services” is hereby deleted and Section 2.20 shall be
restated in full to read:

 

“Covered
Medical Services” means the services and benefits covered under
the Benefit Agreements.  A matrix of
financial responsibility for those services and benefits to CALIFORNIACARE
Members is set forth as Exhibit A(1) (attached and incorporated by reference
herein). A matrix of financial responsibility for those services and benefits
to Members enrolled in the AIM Program is set forth as Exhibit A(2) (attached
and incorporated by reference herein).

 

6.                                       Article II DEFINITIONS, is hereby
amended to add Section 2.34.1 to read:

 

“Insured
Services” applies to
the AIM Program only and means the benefits and services as set forth in
Article VII, COMPENSATION TO PARTICIPATING MEDICAL GROUP, including:

 

A.           The benefits and services referenced in
Section 7.09 (expenses which are paid directly by PARTICIPATING MEDICAL GROUP,
to be reimbursed by BLUE CROSS).

 

B.             The benefits and services referenced in
Section 7.10 (expenses which are paid directly by BLUE CROSS).

 

7.                                       Article II, DEFINITIONS, Section 2.36, “Member”
shall be deleted and Section 2.36 is hereby restated in full to read:

 

“Member” shall mean a Subscriber or enrolled
dependent covered by a Benefit Agreement, or an AIM Benefit Agreement.

 

8.                                       Article II, DEFINITIONS, Section 2.41. “Non-Capitated
Services”, is hereby amended to add, after the first sentence of Section
2.41, the following language:

 

Non-Capitated
Services shall not apply to Members enrolled in the AIM Program.

 

9.                                       Article IV, PARTICIPATING MEDICAL GROUP
SERVICES AND RESPONSIBILITIES, is hereby amended to add Section 4.01.A1 to
read:

 

To
promptly provide or arrange for available and accessible AIM Covered Medical
Services for each Member enrolled in BLUE CROSS’ AIM Program and assigned to
PARTICIPATING MEDICAL GROUP, in accordance with that Member’s Benefit Agreement
and this Agreement and to provide those services in and through the facilities
designated in Exhibit J (attached and incorporated by reference herein).

 

10.                                 Article IV, PARTICIPATING MEDICAL GROUP
SERVICES AND RESPONSIBILITIES, is hereby amended to add Section 4.02.J1 to
read:

 

PARTICIPATING
MEDICAL GROUP shall comply with State of California non-discrimination
requirements.

 

2

 

11.                                 Article IV, PARTICIPATING MEDICAL GROUP
SERVICES AND RESPONSIBILITIES, is hereby amended to add Section 4.02. M to
read:

 

PARTICIPATING
MEDICAL GROUP agrees to provide a patient education program on smoking for AIM
Program Members.

 

12.                                 Article V, BLUE CROSS SERVICES AND
RESPONSIBILITIES, Section 5.01 shall be deleted and Section 5.01 is hereby
restated in full to read:

 

To
perform or arrange for the performance of all necessary accounting and
enrollment functions with respect to marketing and administering the
CALIFORNIACARE program and AIM Program and to issue a CALIFORNIACARE or an AIM
identification card to each Subscriber or each Subscriber and one additional
eligible Member covered under a two-party or family contract as described in
the Operations Manual. However, AIM Program enrollment shall be determined by
the State of California and shall be reported to PARTICIPATING MEDICAL GROUP by
BLUE CROSS as directed by the State of California.

 

13.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, the first paragraph of Section 7.01 shall be deleted and the
first paragraph of Section 7.01 is hereby restated in full to read:

 

Exhibit
D, G and G-1 (all incorporated by reference herein), set forth CALIFORNIACARE
Capitation payments for new and renewing business. The applicable Capitation
payment for each Member assigned to PARTICIPATING MEDICAL GROUP, shall be paid
monthly, prorated in accordance with Member eligibility.

 

14.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, shall be amended to add Section 7.01.1 to read:

 

7.01.1                  AIM CAPITATION

 

A.           Exhibit K-1 (incorporated by reference herein,
sets forth AIM Capitation payments. The applicable AIM Capitation payment for
each AIM Program Member assigned to PARTICIPATING MEDICAL GROUP, shall be paid
monthly, prorated in accordance with Member eligibility.

 

B.             AIM Capitation payment to PARTICIPATING
MEDICAL GROUP for each mother will begin on the date the mother is assigned to
PARTICIPATING MEDICAL GROUP and will continue up to sixty (60) days after
delivery.

 

C.             In the event BLUE CROSS assigns a mother to
PARTICIPATING MEDICAL GROUP retroactively, AIM Capitation payment will be made
from the date the mother is assigned to PARTICIPATING MEDICAL GROUP. BLUE CROSS
will discourage retroactive additions beyond a ninety (90) day period.

 

D.            AIM Capitation payment to PARTICIPATING
MEDICAL GROUP will be made for each infant for professional services related to
normal pregnancy and cesarean section delivery including the administration of
pediatric immunizations, periodic checkups, other covered professional services
and covered outpatient services.  The
AIM Capitation payment made under this Paragraph 7.01.1D will begin from the
date of birth and continue for a period of up to twenty-four (24) months after
birth.

 

3

 

E.              The provision of professional services for
treatment of complications for an infant on an inpatient basis will be paid at
the rates set forth at Exhibit E. Complications means it is Medically Necessary
to admit the infant to a Level II or Level III intensive care newborn nursery
(hereafter referred to as “Complications”). PARTICIPATING MEDICAL GROUP shall
bill BLUE CROSS for services rendered in conjunction with the treatment of
Complications within twelve (12) months of date of service

 

F.              All covered professional services and supplies
for infants treated for Complications will be paid in accordance to the
coverage limits of the AIM Benefit Agreement, not to exceed total expense
incurred for those services and supplies.

 

G.             AIM Capitation payment for infants treated for
Complications will be suspended and resume when further confinement in a Level
II or Level III intensive care newborn nursery is not Medically Necessary. BLUE
CROSS will reconcile the AIM Capitation payment for infants on a retroactive
basis pursuant to the date an infant begins treatment for Complications and therefore
the PARTICIPATING MEDICAL GROUP commences receiving payment under Paragraphs E
and F above.

 

H.            PARTICIPATING MEDICAL GROUP will not be at
risk for the provision of institutional services to AIM Program Members. For
AIM Program Members, hospitals and other institutions will be paid based on
BLUE CROSS contracted rates and/or fee-for-service.

 

15.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, Section 7.02 is hereby amended to add, at the beginning of
the Section prior to the word “Capitation”, the word “CALIFORNIACARE”.

 

16.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, is hereby amended to add Section 7.02.1 to read:

 

AIM
compensation shall be paid in consideration for providing the AIM Capitation
Services and arranging non-Capitation Services designated as BLUE CROSS
responsibility, as set forth in Exhibit A(2), in a manner consistent with this
Agreement for each Member enrolled in the AIM Program and assigned to
PARTICIPATING MEDICAL GROUP, and in consideration for all AIM Capitation
Services arranged through referral for Members by PARTICIPATING MEDICAL GROUP.
The AIM Capitation payment shall be made by the tenth of each month and shall
be computed on the basis of the most current information available.

 

Each
AIM Capitation payment shall be accompanied by a remittance summary as set
forth in Section 7.02 above. A complete listing of Members that are eligible
for AIM Capitation Services is provided in the monthly Eligibility Report, as
set forth in Article VI.

 

17.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, is hereby amended to add Section 7.07. to read:

 

With
respect to BLUE CROSS’ AIM Program, pregnancy and maternity services (as set
forth in the AIM Benefit Agreement) rendered by PARTICIPATING MEDICAL GROUP to
a Member, shall, at the date of delivery, be compensated at One Thousand Eight
Hundred Fifty Dollars ($1,850.00) per applicable Member (hereafter referred to
as the “Global Fee”).  For the purposes
of this Section, “delivery” shall mean a live birth, either by vaginal or
cesarean delivery with both a minimum fetal weight of 500 grams and a minimum
length of 20 centimeters or with a minimum of 20 weeks

 

4

 

gestation.
Alternately, “delivery” shall mean the vaginal delivery of a stillbirth of a
minimum of 20 weeks gestation, labor induced by pitosin or prostoglandin with a
licensed obstetrician in attendance. 
The Global Fee payment is compensation for pregnancy and maternity care
services, professional services provided to the mother for delivery including
prenatal and postnatal physician’s office visits, other covered professional
services and covered outpatient services. PARTICIPATING MEDICAL GROUP shall
bill BLUE CROSS for a Global Fee within twelve (12) months of “delivery”.

 

18.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, is hereby amended to add Section 7.08 to read:

 

INSURED
SERVICES, as defined
in this Agreement, shall include each of the services and benefits set forth in
this Section 7.08. which shall be provided according to the AIM Benefit
Agreement and paid directly by PARTICIPATING MEDICAL GROUP.  Except as stated below, reimbursement to
PARTICIPATING MEDICAL GROUP for the following Insured Services shall be made by
BLUE CROSS in accordance with the lesser of (i) actual billed charges; (ii) the
fee schedule set forth in Exhibit E; (iii) the rate negotiated between BLUE
CROSS and the provider of service: or (iv) the amount actually paid by
PARTICIPATING MEDICAL GROUP, within forty-five (45) working days following
receipt of a clean, undisputed claim as follows, on the condition that such
claim shall be submitted to BLUE CROSS no later than twelve (12) months after
the date of service:

 

A.                                   Chemotherapy   drugs,
intravenously administered exclusive of professional charges. 

 

B.                                     Durable medical equipment and prosthetic
devices.

 

C.                                     Mammography. 
Reimbursement for routine mammograms shall be limited to *** per AIM
Program Member per calendar year.

 

D.                                    Pregnancy and maternity services.  Reimbursement shall equal the Global Fee ***
as set for in Section 7.07 above.

 

E.                                      Professional hemodialysis services.

 

F.                                      Hepatitis B vaccine and gamma globulin.

 

G.                                     Pediatric immunization serums.

 

19.                                 Article VII, COMPENSATION TO PARTICIPATING
MEDICAL GROUP, is hereby amended to add Section 7.09 to read:

 

The
provider of Insured Services may bill BLUE CROSS directly, in which case, BLUE
CROSS shall reimburse said provider within forty-five (45) working days
following receipt of a clean, undisputed claim accompanied by an Authorization
from PARTICIPATING MEDICAL GROUP. This section shall only apply for the
following Insured Services: DME, prosthetics and chemotherapy
drugs.

 

BLUE
CROSS shall pay contracting providers at the rate negotiated between BLUE CROSS
and said provider.  In the case of
non-contracting providers, BLUE CROSS shall pay the lesser of the actual billed
charges, or the maximum allowable rate according to the BLUE CROSS Customary
and Reasonable Charges, or the rate arranged for by a CALIFORNIACARE Case
Manager.

 

5

 

20                                    Article VIII, ENROLLMENT PROTECTION.
Section 8 01 shall be amended to add the following sentence

 

Sections
8.02, 8 03, and 8.04 shall not apply to BLUE CROSS’ AIM Program.

 

21.                                 Article VIII, ENROLLMENT PROTECTION.
Section 8.03.1 is hereby added to read:

 

The
liability of PARTICIPATING MEDICAL GROUP for expenses for AIM Capitation
Services rendered to any single Member enrolled in BLUE CROSS’ AIM Program
shall be limited to the first Six Thousand Dollars ($6,000.00) of such expenses
during the mother’s enrollment and each calendar year of the infant’s
enrollment if PARTICIPATING MEDICAL GROUP elects Enrollment.  Protection as set forth in Exhibit K-1 herein.

 

22.                                 Article VIII, ENROLLMENT PROTECTION.
Section 8.05.1 is hereby added to read:

 

The
total expenses of PARTICIPATING MEDICAL GROUP for AIM Capitation Services
rendered to any single Member during the mother’s enrollment and each calendar
year of the infant’s enrollment shall be calculated according to the fee
schedule set forth in Exhibit E. In the event the foregoing calculation for any
given procedure results in a figure greater than the actual cost of the
procedure as billed by a third party then the actual cost for that procedure
shall be deemed to be the amount actually paid by PARTICIPATING MEDICAL GROUP.

 

23.                                 Article VIII, ENROLLMENT PROTECTION.
Section 8.06.1 is hereby added to read:

 

Expenses
in connection with the following services shall not be included as AIM
Capitation Services expenses incurred by PARTICIPATING MEDICAL GROUP in
reaching the AIM Enrollment Protection level:

 

A.                                   Pregnancy and maternity services covered by
the Global Fee under Section 7.08 herein.

 

B.                                     Services rendered to infants for treatment of
Complications pursuant to Sections 7.01.1E and F.

 

C.                                     Services rendered in connection with Workers’
Compensation cases.

 

D.                                    Services for which payment is obtained from
third-party sources.

 

E.                                      Services for which payment is obtained from
BLUE CROSS through any coverage other than the AIM Program.

 

All
copayments applicable for AIM Capitation Services rendered to Members shall be
subtracted from AIM Capitation Services expenses.  When the PARTICIPATING MEDICAL GROUP is capitated by two
coverages for one Member, the PARTICIPATING MEDICAL GROUP agrees to coordinate
all related copayments under the Coordination of Benefits rules in the Member’s
Benefit Agreement.

 

24.                                 Article VIII, ENROLLMENT PROTECTION.
Section 8.07.1 is hereby added to read:

 

PARTICIPATING
MEDICAL GROUP shall maintain records necessary to evidence having reached the
AIM Enrollment Protection level.  After
reaching the AIM Enrollment Protection level with regard to any AIM Program
Member, during the remainder of a mother’s enrollment or the remainder of the
calendar year of an infant’s enrollment, PARTICIPATING MEDICAL GROUP shall bill
BLUE CROSS

 

6

 

for
one hundred percent (100%) of services rendered, or provided, to that Member by
PARTICIPATING MEDICAL GROUP, calculated in accordance with Sections 8.03.1,
8.05.1, and 8.06.1.  Reimbursement to
PARTICIPATING MEDICAL GROUP shall be made by BLUE CROSS in accordance with the
fee schedule set forth in Exhibit E, on a monthly basis, within forty-five (45)
working days of submission of complete and accurate documentation by
PARTICIPATING MEDICAL GROUP. Services which are not set forth in Exhibit E
shall be reimbursed by BLUE CROSS at the actual charges paid by PARTICIPATING
MEDICAL GROUP.

 

25.                                 Article VIII, ENROLLMENT PROTECTION, Section
8.08 shall be deleted and Section 8.08 is hereby restated in full to read:

 

PARTICIPATING
MEDICAL GROUP and BLUE CROSS acknowledge and agree that PARTICIPATING MEDICAL
GROUP’s limitations of liability as set forth in this Article VIII shall be
conditioned upon submission of clean undisputed claims to BLUE CROSS no later
than twelve (12) months after the date of the service rendered to Members or
AIM Program Members. Any claims under the Enrollment Protection programs under
Article VIII hereof which would otherwise be the responsibility of BLUE CROSS
under this Agreement shall be the financial responsibility of PARTICIPATING
MEDICAL GROUP if a clean undisputed claim is not submitted within twelve (12)
months of the date of service. For the purpose of this Agreement, a clean claim
shall mean a claim that meets all BLUE CROSS requirements with respect to
back-up information.

 

26.                                 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

  	
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
  STARCARE MEDICAL GROUP

    D.B.A., GATEWAY MEDICAL GROUP, INC.

  
	
   

  	
   

  
	
  Signature:

  	
  /s/ Barry Ford

  	
   

  	
  Signature:

  	
  /s/ Marlean Free

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Barry Ford

  	
   

  	
  Name:

  	
  MARLEAN FREE

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
  Vice President

  Network Development & Management

  	
   

  	
  Title

  	
  DIRECTOR

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  1-4-2000

  	
   

  	
  Date:

  	
  12/27/99

  	
   

  

 

7

 

EXHIBIT A (2)-

AIM

DIVISION OF FINANCIAL RESPONSIBILITY

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  CHEMOTHERAPY
  DRUGS (intravenously administered) 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial
responsibility have been deleted.

 

1

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  EMERGENCY ROOM:
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  EMPLOYMENT
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial
responsibility have been deleted.

2

 

 

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (1)

  	
  HEALTH EVALUATIONS /
  PHYSICALS

  (required by third party or outside
  agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HEARING
  SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient /
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HEPATITIS B
  VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HOME HEALTH
  (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  HOSPICE (in lieu
  of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(1)          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 government authority, or at the request of a third party such as
a school, camp or sport affiliated organization be covered.

*** All reference to the
division of financial responsibility have been deleted.

 

3

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  IMMEDIATE CARE -
  Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  IMMUNIZATION
  SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  IMMUNIZATION
  SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial responsibility have been
deleted.

 

4

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  INFANT APNEA MONITOR
  (DME)

  (in conjunction with or concurrent with
  authorized inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (2)

  	
  MAMMOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  MENTAL HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  NUTRITIONIST/
  DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(2)          Limited to $75.00 per member per year

*** All reference to the division of financial
responsibility have been deleted.

 

5

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OBSTETRICAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (3)

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (4)

  	
  Outpatient
  (non-hospital facility) 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)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(3)          Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery. 

(4)          Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery

*** All reference to the
division of financial responsibility have been deleted.

 

6

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Emergency
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Obstetrics /
  Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Pulmonary
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial
responsibility have been deleted.

7

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  PREGNANCY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (5)

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  PROSTHETIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  RADIATION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Outpatient
  Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(5)          Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.

*** All reference to the division of financial
responsibility have been deleted.

 

8

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial
responsibility have been deleted.

 

9

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*** All reference to the division of financial
responsibility have been deleted.

 

10

 

EXHIBIT K-1

 

AIM PROGRAM CAPITATION

 

I.                                         Mother With Enrollment Protection Provided by
BLUE CROSS

 

	
  1.

  	
  Non-Pregnancy and
  Non-Maternity

  	
   

  	
  *** per month from
  enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
  Pregnancy and Maternity

  	
   

  	
  Global Fee applies per
  Section 7.09

  

 

Child
With Enrollment Protection Provided by BLUE CROSS

 

	
  1.

  	
  Age 0 - 1 year

  	
   

  	
  *** per month from birth
  through first birthday

  
	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
  Age 1 - 2 years

  	
   

  	
  *** per month from 13
  through 24 months

  
	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
  Complications for infants

  	
   

  	
  Exhibit E rates apply per
  Sections 7.01.1E and F

  

 

II.                                     Mother Without Enrollment Protection Provided
by BLUE CROSS

 

	
  1.

  	
  Non-Pregnancy and
  Non-Maternity

  	
   

  	
  *** per month from
  enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
  Pregnancy and Maternity

  	
   

  	
  Global Fee applies per
  Section 7.09

  

 

Child
Without Enrollment Protection Provided by BLUE CROSS

 

	
  1.

  	
  Age 0 - 1 year

  	
   

  	
  *** per month from birth
  through first birthday

  
	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
  Age 1 - 2 years

  	
   

  	
  *** per month from 13
  through 24 months

  
	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
  Complications for infants

  	
   

  	
  Exhibit E rates apply per
  Sections 7.01.1E and F

  

 

*** Confidential Treatment Requested

 

1

 

PARTICIPATING MEDICAL GROUP
agrees to accept risk under either Subsection A or Subsection B as indicated
below.

 

A.                                   PARTICIPATING MEDICAL GROUP agrees to
participate in Article VIII, Enrollment Protection as set forth in Sections
8.01, 8.03.1, 8.05.1, 8.06.1, 8.07.1 and 8.08.1 of this Agreement; or

 

B.                                     PARTICIPATING MEDICAL GROUP, at it sole
expense, agrees to obtain and maintain stop loss insurance for all expenses
incurred under this Agreement in amounts acceptable to BLUE CROSS.  Upon request, PARTICIPATING MEDICAL GROUP
shall provide BLUE CROSS with copies of its stop loss insurance policy
referenced in this Subsection B.

 

PARTICIPATING MEDICAL GROUP hereby elects to accept risk pursuant to

 

Subsection     o
A.   or   ý
B.     (check one)

 

2Exhibit 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

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00067-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00067-of-00352.parquet"}]]