Further Information Regarding Georgia Health Insurance Benefits

Physical Therapy, Occupational Therapy
Services by a Physician, a registered physical therapist (R.P.T.), a licensed occupational therapist (O.T.), limited to a combined total maximum visits per calendar year as outlined in the Summary of Benefits. All services rendered must be within the lawful scope of practice of, and rendered personally by, the individual provider. No coverage is available when such services are necessitated by Developmental Delay.

Physician Services
In-Network visits to a Physician's office are subject to the per visit Copayment indicated in the Summary of Benefits.

Preventive Care (In-Network)
The following services are Covered Services only if performed In-Network by your Primary Care Physician or by an obstetrician or gynecologist who is a Network Physician:

• Visits to a Physician's office are subject to the per visit Copayment indicated in the Summary of Benefits. Covered Services in the Physician's office include, but are not limited to:
• • Treatment or preventive services including periodic health examinations for adults and well-child care services for Dependent children under the age of 19.
  • Family planning services and services for infertility subject to listed exclusions.
  • Immunizations in accordance with established age appropriate preventive health guidelines, exclusive of immunizations suggested for travel or required for employment.
  • Prenatal care visits. Only one (1) Copayment for all visits combined will be charged.
  • Benefits will be provided for one mammogram and one pap smear tissue examination per year, or more often when ordered by a Physician.
  • Benefits will be provided for annual prostate specific antigen tests for covered males who are 45 years of age of older; or covered males who are 40 years of age or older if ordered by a Physician.
  • Benefits will be provided for one annual chlamydia screening test for covered females who are not more than 29 years old.

Primary Care Physician (PCP)
All In-Network Care must be received from or coordinated through your Primary Care Physician (PCP). A Participant has Direct Access to some specified In-Network Providers without a Primary Care Physician Referral. Such Providers include a gynecologist for obstetrical or gynecological-related conditions, a dermatologist; and an optometrist or ophthalmologist for medical conditions only.

PCPs are required to provide or arrange for on-call coverage 24 hours a day, 7 days a week. If a Participant becomes sick or is injured after the PCP's regular office hours, the Participant should:

• call the PCP's office; and
• identify himself or herself as a Participant; and
• follow the PCP's or covering Physician's instructions.

If the Participant's Injury or illness is a Medical Emergency, the Participant should follow the procedures outlined under the Medical Emergency Care section.

Payment terms apply to all Covered Services. The following services are covered, if Medically Necessary. Please refer to the Summary of Benefits for payment explanations.

Prosthetic Appliances
Prosthetic devices to improve or correct conditions resulting from an Accidental Injury or illness are covered if Medically Necessary and ordered by a Physician.

The following items related to prosthetic devices include artificial limbs and accessories, artificial eyes, lenses for eyes used after surgical removal of the lens(es) of the eye(s), arm braces, leg braces (and attached shoes), and external breast prostheses used after breast removal.

The following items are excluded: corrective shoes; dentures; replacement of teeth or structures directly supporting teeth except to correct traumatic injuries; electrical or magnetic continence aids (either anal or urethral); hearing aids or hearing devices; or implants for cosmetic purposes except for reconstruction following a mastectomy.

Pulmonary Rehabilitation
Programs require prior authorization and Individual Case Management.

Reconstructive Surgery
Pre-certification is required. Reconstructive Surgery does not include any service otherwise excluded in this SPD Booklets. (See "Exclusions".)

Reconstructive Surgery is covered only to the extent Medically Necessary:

• To restore a function of any body area which has been altered by disease, trauma, congenital/developmental anomalies or previous therapeutic processes;
• To correct congenital defects of a dependent child that lead to functional impairment; and
• To correct medical complications or post-surgical deformity, unless the previous surgery was not a Covered Service.

Registered Nurse First Assistant
Covered Services are provided for eligible registered nurse first assistants. Benefits are payable directly to a registered nurse first assistant if such services are payable to a surgical first assistant and such services are performed at the request of a Physician and within the scope of a registered nurse first assistant's professional license. No benefits are payable to a registered nurse first assistant who is employed by a Physician or a Hospital.

Second Medical Opinion
Covered Services include a second medical opinion by a Network Physician with respect to any proposed surgical intervention or, when pre-certified by the Claims Administrator, any medical care that is a Covered Service.

Skilled Nursing Facility Care
Benefits are provided as outlined in the Summary of Benefits. This care must be ordered by the attending Physician. All Skilled Nursing Facility admissions must be pre-certified. Claims will be reviewed to verify that services consist of Skilled Convalescent Care that is medically consistent with the diagnosis. This benefit is available only if the patient requires a Physician's continuous care and 24-hour-a-day nursing care.

Skilled Convalescent Care during a period of recovery is characterized by:

• A favorable prognosis;
• A reasonably predictable recovery time; and
• Services and/or facilities less intense than those of the acute general Hospital, but greater than those normally available at the patient's residence.

Covered Services include:

• Semiprivate or ward room charges including general nursing service, meals, and special diets. If a Participant stays in a private room, this Plan pays the Semiprivate Room rate toward the charge for the private room;
• Use of special care rooms;
• Pathology and Radiology;
• Physical or speech therapy;
• Oxygen and other gas therapy;
• Drugs and solutions used while a patient;
• Gauze, cotton, fabrics, solutions, plaster and other materials used in dressings, bandages, and casts.

Benefits will not be provided when:

• A Participant reaches the maximum level of recovery possible and the care no longer requires continuous care by a Physician or is no longer considered in lieu of a Hospital stay;
• Care is primarily Custodial Care, not requiring definitive medical or 24-hour-a-day nursing service;
• Care is for mental illness including drug addiction, chronic brain syndromes and alcoholism, and no specific medical conditions exist that require care in a Skilled Nursing Facility;
• A Participant is undergoing senile deterioration, mental deficiency or retardation, and has no medical condition requiring care;
• The care rendered is for other than Skilled Convalescent Care.

Specialist Physician
Your Primary Care Physician will refer you to a Specialist for appropriate care when necessary.

The specialist Physician will need to coordinate continuing care with your Primary Care Physician if either of the following two recommendations is made after your visit:

• Additional care by the Specialist Physician is required;
• A Referral for another type of care is indicated.