Page 26 - QCS.19 SPD - HSA

SECTION 5 - ADDITIONAL COVERAGE DETAILS

What this section includes:

· Covered Health Care Services for which the Plan pays Benefits.

This section supplements Section 4, Schedule of Benefits.

While the table provides you with Benefit limitations along with Copayment, Coinsurance and Annual Deductible
information for each Covered Health Service, this section includes descriptions of the Benefits. These
descriptions include any additional limitations that may apply. The Covered Health Care Services in this section
appear in the same order as they do in the table for easy reference. Services that are not covered are described
in Section 6, Exclusions: What the Plan Will Not Cover.

Ambulance Services
Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance) to the
nearest Hospital where the required Emergency Health Care Services can be performed.
Non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as
we determine appropriate) between facilities only when the transport meets one of the following:

· From an out-of-Network Hospital to the closest Network Hospital when covered Health Care Services are
required, or

· To the closest Network Hospital that provides the required Covered Health Care Services that were not
available at the original Hospital.

· From a short-term acute care facility to the closest Network long-term acute care facility (LTAC), Network
Inpatient Rehabilitation Facility, or other Network sub-acute facility where the required Covered Health
Care Services can be delivered.
For the purpose of this Benefit the following terms have the following meanings:

· "Long-term acute care facility (LTAC)" means a facility or Hospital that provides care to people with
complex medical needs requiring long-term Hospital stay in an acute or critical setting.

· "Short-term acute care facility" means a facility or Hospital that provides care to people with medical
needs requiring short-term Hospital stay in an acute or critical setting such as for recovery following a
surgery, care following sudden Sickness, Injury, or flare-up of a long term Sickness.

· "Sub-acute facility" means a facility that provides intermediate care on short-term or long-term basis.
Cellular and Gene Therapy

Cellular and Gene Therapy received on an inpatient or outpatient basis at a Hospital or on an outpatient basis at
an Alternate Facility or in a Physician's office. Benefits for CAR-T therapy for malignancies are provided as
described under Transplantation Services.
Clinical Trials

Routine patient care costs incurred while taking part in a qualifying clinical trial for the treatment of:

· Cancer or other life-threatening disease or condition. For purposes of this Benefit, a life-threatening
disease or condition is one which is likely to cause death unless the course of the disease or condition is
interrupted.

· Cardiovascular disease (cardiac/stroke) which is not life threatening, when we determine, the clinical trial
meets the qualifying clinical trial criteria stated below.
· Surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, when we
determine, the clinical trial meets the qualifying clinical trial criteria stated below.
· Other diseases or disorders which are not life threatening when we determine, the clinical trial meets the
qualifying clinical trial criteria stated below.

Page 21 Section 5- Additional Coverage Details
HSA - 2017