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Benefits under this provision include fees for services provided by a Physician surgical assistant and/or a
non–Physician surgical assistant. When multiple surgical procedures are done at the same time, Covered Health
Care Services will include the Allowed Amount for the first or major procedure and one-half of the Allowed
Amount for each additional procedure. For a Physician surgical assistant, payment is limited to 20% of the
Allowed Amount for the first or major surgical procedure and 10% of the Allowed Amount for additional
procedures. For a non-Physician surgical assistant, payment is limited to 10% of the Allowed Amount for the first
or major procedure and 5% of the Allowed Amount for each additional procedure.

Benefits also include anesthesia services.
Benefits are not payable for incidental surgical procedures, such as an appendectomy performed during gall
bladder surgery.

Physician's Visit - Sickness and Injury

Services provided by a Physician for the diagnosis and treatment of a Sickness or Injury received on an outpatient
or inpatient basis. Benefits are provided under this section regardless of whether the service is rendered in a
clinic, Skilled Nursing Facility, Alternate Facility or Hospital.

Covered Health Care Services include medical education services that are provided in a Physician's office by
appropriately licensed or registered healthcare professionals when both of the following are true:

· Education is required for a disease in which patient self-management is a part of treatment; and
· There is a lack of knowledge regarding the disease which requires the help of a trained health
professional.

Covered Health Care Services include Genetic Counseling. Benefits include genetic testing which results in
available medical treatment options and is determined to be Medically Necessary following genetic counseling
when ordered by the Physician and authorized in advance by us.

For purposes of this Benefit, "genetic testing" is the examination of the genetic information in a person's cells that
may show an increased risk for developing a specific disease or disorder or in the management of certain
diseases.

Covered Health Care Services for Preventive Care provided in a Physician's office are described under
Preventive Care Services.

Benefits also include a second opinion.
Each Physician who gives a second opinion:

· Must be a specialist for the Injury or Sickness; and
· Cannot be financially connected with the other Physician(s).

Preventive Care Services

Benefits are provided for services for preventive medical care provided on an outpatient basis at a Physician’s
office, an Alternate Facility or a Hospital for:
· Items or services that have an A or B rating in current recommendations of the United States preventive
Services Task Force;
· Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for
Disease Control and Prevention;

· Evidence-informed preventive care and screenings for infants, children, and adolescents as provided for
in the comprehensive guidelines supports by the Health Resources and Services Administration (HRSA);
and

· Additional preventive care and screening, with respect to women, provided for in guidelines supported by
HRSA.

Benefits defined under this requirement include one breast pump per Pregnancy in conjunction with childbirth. If
more than one breast pump can meet your needs, Benefits are available only for the most cost effective pump.
We will determine the following:

· Which pump is the most cost effective.

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PPO - 2017