Page 14 - QCS.19 SPD - HSA

When services or supplies are received from a Out-of-Network provider, you are responsible for obtaining the
prior authorization. Services and supplies for which you are responsible for obtaining prior authorization are listed
below.

Note that your obligation to obtain prior authorization is also applicable when an Out-of-Network provider
intends to admit you to a Network facility or refers you to other Network providers. Once you have
obtained the authorization, please review it carefully so that you understand what services have been
authorized and what providers are authorized to deliver the services that are subject to the authorization.

Failure to obtain prior authorization will result in a reduction of benefits. Reduced benefits will be 50% of Allowed
Amounts. Obtaining prior authorization does not guarantee payment. Please see the Prior Authorization provision
for more information.

To obtain prior authorization, call the telephone number on your ID card. This call starts the utilization review
process.

Covered Health Care Services Which Require Prior Authorization

Ambulance, non-emergency
You must obtain authorization for non-emergency ambulance transportation as soon as possible prior to
transport.

Cellular and Gene Therapy
For Network and Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a
Cellular or Gene Therapy arises.

At the time you seek to obtain prior authorization for a Cellular or Gene Therapy, we will discuss with you the
health care and financial advantages of using the services of a Designated Provider.

Clinical Trials
You must obtain prior authorization as soon as the possibility of participation in a clinical trial arises.

Dental Services - Accident Only
For network and out-of-network benefits, you must obtain prior authorization 5 business days before follow up
(post-emergency) treatment begins. You do not have to obtain prior authorization before the initial emergency
treatment.
Diabetes Equipment
For out-of-network benefits, you must obtain prior authorization before obtaining any equipment, for the
management and treatment of diabetes, that exceeds $1,000 in cost (either retail purchase cost or cumulative
retail rental cost of a single item).

Durable Medical Equipment
For out-of-network benefits, you must obtain prior authorization before obtaining any durable medical equipment
that exceeds $1,000 in cost (either retail purchase cost or cumulative retail rental cost of a single item).

Gender Dysphoria
For Out-of-Network Benefits for surgical treatment, you must obtain prior authorization as soon as the possibility
of surgery arises and you must contact us 24 hours before admission for an Inpatient Stay.

For Out-of-Network Benefits for non-surgical treatment, depending upon where the Covered Health Care Service
is provided, any applicable prior authorization requirements will be the same as those stated under each Covered
Health Care Service category in this Schedule of Benefits.

Habilitative Services
For out-of-network Benefits for a scheduled admission, you must obtain prior authorization five business days
before admission, or as soon as is reasonably possible for non-scheduled admissions.

Home Health Care
For out-of-network benefits, you must obtain prior authorization 5 business days before receiving home health
care services, or as soon as reasonably possible.
Hospice Care - Inpatient
For out-of-network benefits, you must obtain prior authorization 5 business days before admission for an inpatient
stay in a hospice, or as soon as reasonably possible.

Page 9 Section 4 - Schedule of Benefits
HSA - 2017