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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
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