Unity Health Plans Insurance Corporation HMO BENEFIT PLAN .


Unity Health Plans Insurance CorporationHMO BENEFIT PLANCERTIFICATE OF COVERAGEUH00174 (rev 08 16)

TABLE OF CONTENTSARTICLE I: DEFINITIONS .AARTICLE II: OBTAINING SERVICES .Prior Authorization.Primary Care Physician .Referrals and Standing Referrals .Behavioral Health .Non-Emergency Care .Emergency Care .Urgent Care .Emergency Inpatient Admissions .Special Provisions Relating to Full-Time Students .Behavioral Health and Chemical Dependency Benefits .Dependents Attending School Outside Unity’s Service Area .Students on Medical Leave .BB-1B-1B-1B-2B-2B-2B-2B-2B-3B-3B-3B-3ARTICLE III: COVERED SERVICES .Professional & Related Services .Ambulance Services .Anesthesia Services .General Anesthesia .Dental Anesthesia .Autism Spectrum Disorder .Behavioral Health and Chemical Dependency Services .Breast Reconstruction .Chiropractic Services.Clinical Trials.Diabetic Self-Management Education .Diagnostic Services .Drugs and Biologicals .Durable Medical Equipment (DME) and Medical Supplies .Emergency Services .Extraction and Replacement of Sound Natural Teeth Because of Accidental Injury .Habilitative Services .Home Health Care Services .Hospice Care .Immunization and Allergy Injections .Maternity Services .Nurse Practitioner and Physician Assistant Services .Oral Surgery Services .Ostomy Supplies .Radiation Therapy and Chemotherapy .Routine Foot Care .Second Opinion.Surgical Services .Temporomandibular Joint Treatment .Therapy Services .Outpatient Physical, Occupational, Speech and Hearing Therapy .Cardiac Rehabilitation Therapy .Inpatient Therapy .Post Cochlear Implant Aural Therapy .Transplant Services and Related Surgical Services .CC-1C-1C-1C-1C-2C-2C-3C-4C-4UH00174 (rev 08 Unity Customer Service: (800) 362-3310unityhealth.com

TABLE OF CONTENTS, Cont.Donor Services .Special Exclusions and Limitations Applicable to Transplant Services .Urgent Care Services .Vision Services .Hospital Services Benefit .Inpatient Care .Hospitals and Specialty Hospitals .Licensed Skilled Nursing Facility .Nervous and Mental Disorders and Alcoholism and Drug Abuse Confinements .Outpatient Care .Emergency Room .Ambulatory Surgical Care .Behavioral Health (Mental Health) Services .Diagnostic Testing .Clinic Visits .C- 13C-13C-13C-14C- 14C-14C-14C-14C-15C-15C-15C-15C-15C-15C-15ARTICLE IV: EXCLUSIONS AND LIMITATIONS .Exclusions .Surgical Services .Medical Services .Ambulance Services .Therapies .Oral Surgery and Dental Services .Transplants .Reproductive Services .Hospital Inpatient Services .Outpatient Prescription Drugs .Durable Medical Equipment (DME) and Disposable Medical Supplies .General .Limitations .Major Disaster or Epidemic .Circumstances Beyond the Control of Unity .Treatment of Growth Retardation .Proof of Claim .Emergency Services .Urgent Care Services .Primary Care Physician Selection .Specialty Providers .Changing Your Primary Care Physician During the Contract Year.Out-of-Pocket Costs .Other Limitations .DD-1D-1D-1D-2D-2D-2D-2D-2D-3D- 3D-4D-4D-6D-6D-6D-6D-7D-7D-7D-7D-7D-8D-8D-8ARTICLE V: COORDINATION OF BENEFITS .Definitions .Effect of Benefits.Order of Benefit Determination .Non-Dependent/Dependent .Dependent Child/Parents Not Separated or Divorced .Dependent Child/Separated or Divorced Parents .Active/Inactive Employee .Longer/Shorter Length of Coverage .Continuation of Coverage .Right to Receive and Release Necessary Information .Coordination of Benefits with Medicare.EE-1E-1E-2E-2E-2E-2E-3E-3E-3E-3E-3UH00174 (rev 08 16)iiiUnity Customer Service: (800) 362-3310unityhealth.com

TABLE OF CONTENTS, Cont.Facility of Payment .Right to Recovery .E- 3E- 4ARTICLE VI: ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE .Employee Coverage .Eligibility .Enrollment and Effective Date .New Entrant .Late Applicant .Late Applicant/Special Enrollment .Late Applicant/Special Enrollment for Loss of Other Coverage.Dependent Coverage .Eligibility .Enrollment and Effective Date .Late Applicant .Newborn Effective Date of Coverage .Adopted Child Effective Date of Coverage .Changes to Enrollment Form .Termination of Coverage .Right to Continue Group Medical Coverage .Medical Conversion Privilege.Disenrollment From the Plan .Extension of Coverage Due to Total Disability .FF- 1F- 1F- 1F- 1F- 1F- 1F-1F- 2F- 2F- 3F- 3F- 4F- 4F- 4F- 4F- 4F- 6F- 6F- 7ARTICLE VII: COMPLAINT AND GRIEVANCE PROCEDURE .

Behavioral Health (Mental Health) and Chemical Dependency (Substance Use Disorder) Services The treatment of psychiatric Illness or alcoho