More Definitions Regarding Georgia Health Insurance

Effective Date
The date for which the Plan Administrator approves an individual application for coverage. For individuals who join this Group after the first enrollment period, the Effective Date is the date the Plan Administrator approves each future Participant according to the normal procedures.

Elective Surgical Procedure
A surgical procedure that is not considered to be an emergency, and may be delayed by the Participant to a later point in time.

Eligible Charges
Those charges for services and supplies (a) defined as Covered Services and not excluded under the Participant's Plan; (b) that are Medically Necessary; and (c) that are provided in accordance with the Participant's Plan. For In-Network services, Eligible Charges are determined by: (a) BCBSHP's negotiated arrangements; (b) pre-determined fee schedules; and (c) the applicable Reimbursement Rate. For Out-of-Network services, Eligible Charges are determined by: (a) BCBSHP's Usual, Customary and Reasonable (UCR) Fees; (b) a provider's contracted fee schedule; (c) the applicable Reimbursement Rate; and or (d) negotiated fees. All payment determinations for Hospital Services are based on the applicable Reimbursement Rate. Reimbursement for Out-of-Network, Participating and Non-Participating Providers is based on Eligible Charges for the type of service a Participant receives, for example, Hospital or Physician services.

Employee
A person who is engaged in active employment with the Group and is eligible for Group coverage with the Plan Sponsor under the employment regulations of the Group.

Employer
An Employer who has allowed its Employees to participate in the Plan by acting as the Plan Sponsor or adopting the Plan as a participating Employer by executing a formal document that so provides.

Experimental or Investigational
Services which are considered Experimental or
Investigational include services which (1) have not been approved by the Federal Food and Drug Administration or (2) for which medical and scientific evidence does not demonstrate that the expected benefits of the proposed treatment would be greater than the benefits of any available standard treatment and that adverse risks of the proposed treatment will not be substantially increased over those standard treatments. Such determination must result from prudent professional practices and be supported by at least two documents of medical and scientific evidence. Medical and scientific evidence means:

1. Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
2. Peer-reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institute of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medikus (EMBASE), Medline, and MEDLARS data base or Health Services Technology Assessment Research (HSTAR);
3. Medical journals recognized by the United States Secretary of Health and Human Services, under Section 18961(t)(2) of the Social Security Act;
4. The following standard reference compendia: the American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information;
5. Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the Federal Agency for Health Care Policy and Research, National Institute of Health, National Cancer Institute, National Academy of Sciences, Health Care Financing Administration, and any National board recognized by the National Institutes of Health for the purpose of evaluating the medical value of heath services; or
6. It meets the Technology Assessment Criteria as determined by the Claims Administrator as outlined in the Definitions section of this SPD Booklet.

Formulary, BCBSHP Formulary, Preferred Drug Formulary or Drug Formulary
A document setting forth certain rules relating to the coverage of pharmaceuticals by the Claims Administrator that may include but not be limited to (1) a listing of preferred prescription medications that are covered and/or prioritized in order of preference by the Claims Administrator, and are dispensed to Participants through pharmacies that are Network Providers, and (2) pre-certification rules. This list is subject to periodic review and modification by the Claims Administrator, at the Claims Administrator's sole discretion. Charges for medications may be Ineligible Charges, in whole or in part, if a Participant selects a medication not included in the Formulary.

Freestanding Ambulatory Facility (Surgi-Center)
A facility, with a staff of Physicians, at which surgical procedures are performed on an outpatient basis--no patients stay overnight. The facility offers continuous service by both Physicians and registered nurses (R.N.s). It must be licensed by the appropriate state agency. A Physician's office does not qualify as a Freestanding Ambulatory Facility.

Generic Drugs
Prescription Drugs that are not Brand Name Drugs but which are made up of equivalent ingredients.

Group
The Employee's Employer, which has entered into the Health Plan Document with the Claims Administrator. The Group shall act only as an agent of Participants who are Participants of the Group and their eligible Dependents.

Home Health Care
Care, by a state-licensed program or provider, for the treatment of a patient in the patient's home, consisting of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the patient's attending Physician.

Home Health Care Agency
A provider which renders care through a program for the treatment of a patient in the patient's home, consisting of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the patient's attending Physician. It must be licensed by the appropriate state agency.

Hospice
A provider which provides care for terminally ill patients and their families, either directly or on a consulting basis with the patient's Physician. It must be licensed by the appropriate state agency.

Hospice Care Program
A coordinated, interdisciplinary program designed to meet the special physical, psychological, spiritual and social needs of the terminally ill Participant and his or her covered family members, by providing palliative and supportive medical, nursing and other services through at-home or Inpatient care. The Hospice must be licensed by the appropriate state agency and must be funded as a Hospice as defined by those laws. It must provide a program of treatment for at least two unrelated individuals who have been medically diagnosed as having no reasonable prospect of cure for their illnesses.

Hospital
An institution licensed by the appropriate state agency, which is primarily engaged in providing diagnostic and therapeutic facilities on an Inpatient basis for the surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of Physicians duly licensed to practice medicine, and which continuously provides 24-hour-a-day nursing services by registered graduate nurses physically present and on duty. "Hospital" does not mean other than incidentally:

• An extended care facility; nursing home; place for rest; facility for care of the aged;
• A custodial or domiciliary institution which has as its primary purpose the furnishing of food, shelter, training or non-medical personal services; or
• An institution for exceptional or handicapped children.