0578033714752

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 Non-Discrimination Notice
for MVP Commercial Plans
MVP Health Care® complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. MVP Health Care does not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex.

What MVP Health Care Provides Multi-Language Interpreter Services

Free aids and services to people with disabilities Español (Spanish)
to communicate effectively with us, such as: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia
• Qualified sign language interpreters linguística. Llame al 1-844-946-8010 (TTY: 1-800-662-1220).
• Written information in other formats
䷩橼ᷕ㔯 (Chinese)
(large print, audio, accessible electronic
㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ⃵屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣ġ
formats, other formats)
1-844-946-8010炷TTY烉1-800-662-1220炸ˤ
Free language services to people whose primary
language is not English, such as: Русский (Russian)
• Qualified interpreters ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-844-946-8010 (телетайп: 1-800-662-1220).
• Information written in other languages
Kreyòl Ayisyen (French Creole)
If You Need These Services ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou.
If you need these services, contact Jane Strange Rele 1-844-946-8010 (TTY: 1-800-662-1220).
at 1-844-946-8009 (TTY: 1-800-662-1220). 䚐ạ㛨 (Korean)
㨰㢌aG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘U
How to File a Grievance or Complaint 1-844-946-8010 (TTY: 1-800-662-1220) ⶼ㡰⦐G㤸䞈䚨G㨰㐡㐐㝘.
If you believe that MVP has not given you these
services or has treated you differently because Italiano (Italian)
of race, color, national origin, age, disability, or ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza
sex, you can file a grievance with MVP by: linguistica gratuiti. Chiamare il numero 1-844-946-8010 (TTY: 1-800-662-1220).
Mail: ATTN: JANE STRANGE zjdja (Yiddish)
CIVIL RIGHTS COORDINATOR
MVP HEALTH CARE
625 STATE ST
SCHENECTADY NY 12305 (Bengali)
Phone: 1-844-946-8009
(TTY/TDD: 1-800-662-1220)
Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy
In person: 625 State Street, Schenectady, NY językowej. Zadzwoń pod numer 1-844-946-8010 (TTY: 1-800-662-1220).
Email: civilrightscoordinator@
mvphealthcare.com (Arabic)
You can also file a civil rights complaint with the
U.S. Department of Health & Human Services
Français (French)
Office for Civil Rights by:
ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés
Online: ocrportal.hhs.gov gratuitement. Appelez le 1-844-946-8010 (ATS : 1-800-662-1220).
Mail: US DEPT OF HEALTH & HUMAN SRVS
200 INDEPENDENCE AVE SW (Urdu)
HHH BLDG ROOM 509F
WASHINGTON DC 20201
Tagalog (Tagalog-Filipino)
Phone: 1-800-368-1019 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
(TTY/TTD: 1-800-537-7697) tulong sa wika nang walang bayad. Tumawag sa 1-844-946-8010 (TTY: 1-800-662-1220).
Complaint forms are available by visiting
hhs.gov and selecting Laws & Regulations, λληνικά (Greek)
then Complaints & Appeals, then Civil Rights: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
How to file a complaint. υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-844-946-8010 (TTY: 1-800-662-1220).

Shqip (Albanian)
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa
pagesë. Telefononi në 1-844-946-8010 (TTY: 1-800-662-1220).
MVP_AR44_NDN_R1 MVPCORP0021 (05/2017)
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 Benefit Highlights

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 Pharmacy Benefits
MVP Health Care ® pharmacy benefits cover thousands of medications on the MVP approved drug
list. Choose from a selection of participating pharmacies, or take advantage of convenient mail
and specialty pharmacy services through CVS Caremark®. Generally, benefits are available for up
to a 30-day supply of medically necessary prescription medications at a participating local retail
pharmacy and may allow up to a 90-day supply through the CVS Caremark Mail Service Pharmacy.

Prescription Drug Formulary Specialty Medications

The MVP Formulary is our approved list of covered CVS Specialty® dispenses injectable and oral
medications that are proven safe and effective, and medications that treat specialty conditions, or are
provide clinical value to treat your condition. The high-cost, and provide the following valuable services:
Formulary also lists medications that require prior • Pharmacy-trained clinical teams, which include
authorization, are subject to step therapy* or quantity pharmacists and nurses, offer support, and answer
limits, or are available through mail delivery. patient and physician questions about medications
for complex medical conditions
Formulary Co-pays
• Ancillary supplies, such as syringes and needles,
The Formulary is divided into tiers to make it easier for are provided at no additional cost
you and your doctor to choose the most appropriate,
lowest cost drug. Check your prescription drug rider, To learn how to order a prescription or to see if
schedule of benefits, or summary plan description to a medication is available through the specialty
find your co-pay for each tier. pharmacy, visit mvphealthcare.com/prescriptions.
You can also check with your local retail CVS Pharmacy®
• Tier 1—With the lowest co-pay, drugs in Tier 1
to see if your specialty medication is available.
generally include FDA-approved generic drugs
that are as safe and effective as their brand-name
counterparts
Mail Service Pharmacy
• Tier 2—At a mid-range co-pay, these are preferred If your benefit allows, maintenance medications that
brand-name drugs and also may include generic are taken on a regular basis are available by mail service.
drugs Save time and money when you buy these drugs in
• Tier 3—This highest co-pay tier includes brand-name larger quantities and have them delivered to your door.
drugs and new drugs that are in the review process Your co-pay for a 90-day supply of medication will
generally be less than going to a local retail pharmacy
Brand / Generic Difference Program monthly for the same amount of medication.
FDA-approved generic drugs have a lower co-pay
and offer the same clinical benefits as the Questions about your pharmacy benefit?
brand-name drug. If you and your doctor determine Visit mvphealthcare.com/prescriptions for the
that you must use the brand-name drug, you may current Formulary and Preventive Drugs list. Or, call
be responsible for the generic co-pay plus the the MVP Customer Care Center at the number on
difference in cost between the generic and the the back of your MVP Member ID card.
brand-name drug.

*Step Therapy: In some cases, MVP may require you to first try one drug to treat your medical condition before covering another drug for that condition.
This is a summary of certain general aspects of MVP Health Care Prescription Drug Benefits, which may vary by employer plan, product, or service area. Check with
your employer for details. Consult your plan documents for a complete list of covered benefits, limitations, and exclusions. Formulary information is available by
calling the MVP Customer Care Center. Pharmacies and providers participating in our network and mail order vendors are independent contractors and are neither
employees nor agents of MVP Health Care or its affiliates. This summary is not an offer of coverage. If there are any differences between the information contained
herein and a specific plan document, the plan document will be controlling.
CVS Caremark employees are trained regarding the appropriate way to handle your private health information. 106-52484A 081120.
MVPCOMM0035 (09/2023) Commercial ©2023 MVP Health Care

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 Save at CVS Pharmacy
The CVS Caremark® Cost Saver™
This program makes sure you get the lowest Start Saving Today
possible cost for medications covered under your
No sign-up or registration need. All you need is
plan. Just present your MVP Member ID card when
your MVP Member ID card to start saving on your
you pick up your prescriptions. We’ll manage the
medications today. Just show it to your pharmacist
rest by automatically applying the lowest available
and we’ll take it from there.
discount price.
Powered by GoodRx, Cost Saver benefits include:
• Best available prices for many commonly Don’t forget to use your CVS ExtraCare ®
prescribed, non-specialty generic drugs card or number to earn 2% back in
• Automatically applying your out-of-pocket costs ExtraBucks Rewards when you shop
to your deductible and out-of-pocket thresholds at CVS Pharmacy or CVS.com.
• Delivering a seamless experience that avoids
wasted time shopping around for the lowest price

Online and On-the-Go with MVP and CVS Caremark

Your MVP membership comes with a variety of online tools to help you with your prescription drug benefits.
Sign in to Gia® at my.mvphealthcare.com and select My Plan, then Manage Prescriptions. Stay up to date on
medication costs, manage your personal health and wellness information, and search for generic medication
alternatives to save money.

Find Ways to Save

From using generic medicines to setting up mail Download the CVS Caremark
order service for maintenance medications, you can Mobile App
choose the right ways to save money based on your
plan and prescriptions. • Refill and renew mail
service prescriptions
Order Prescriptions • Indentify unknown
Purchase qualified maintenance drugs—at a savings pills using the Pill
to both you and MVP—and have them delivered Identifier
to your door. To locate participating pharmacies • Check for drug
near your home or within a specific zip code, visit interactions among
mvphealthcare.com/prescriptions and select medications
Find a Pharmacy. • Check order status
and prescription
Get Information About Medications
history
Learn more about specific drug interactions and
• Check drug coverage
possible side effects.
and costs
An Easy Way to Organize Your Prescriptions • Find local pharmacies
Take advantage of PillPack, available with free
shipping to your home. Get 30-day supplies of eligible Visit caremark.com/mobile for
medications prepared in one personalized box, more information.
sorted and labeled by dose, day, and when to take.
Other pharmacies are available in our network. You are not obligated to fill your prescriptions at CVS Pharmacy by using the ExtraCare Health Benefit.
Health benefit plans are issued or administered by MVP Health Plan, Inc.; MVP Health Insurance Company; MVP Select Care, Inc.; and MVP Health Services Corp.,
operating subsidiaries of MVP Health Care, Inc. Not all plans available in all states and counties.

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 2023 Annual Notices
for MVP Health Care Members* ®

The Rights and Responsibilities of MVP Members

MVP encourages members to learn and exercise their rights options not covered by the plan. You have the right to receive
and responsibilities. This policy outlines what members can information necessary for you to be able to give informed
expect from MVP and what MVP expects from members. consent prior to the start of any procedure or treatment. The
Listed below are the MVP Member Rights and Responsibilities information will be made available to an appropriate person
that all Commercial MVP members receive. acting on your behalf, should you not be able to receive the
information. You also have the right to ask for a second opinion
MVP Member Rights before you get any non-emergency treatment or care. No
You have the right to receive information about MVP, its information that could have any bearing on the treatment you
services, and providers. You also have the right to receive receive should be kept from you. You may refuse treatment to
a copy of MVP’s Member Rights and Responsibilities and the extent permitted by law and have the right to be informed
to make recommendations to the policy. of the medical consequences should you choose that option.
As a member you should have received a Certificate of You have the right to voice complaints or appeals about
Coverage or contract. This document outlines important the organization or the care it provides.
information about your benefits and how to use them.
MVP works hard to make sure you receive the health
If your plan requires you to select a Primary Care Provider care services you need and excellent service. If you are
(PCP), you may change your selection at any time by calling not fully satisfied with the medical or administrative
the MVP Customer Care Center at the phone number services provided by MVP, you have the right to a thorough
listed on the back of your MVP Member ID card or visiting investigation of the complaint or appeal by qualified and
mvphealthcare.com. Information available on the MVP impartial staff. If you come across a situation that causes
website includes an updated list of Participating Providers, concern, please call the MVP Customer Care Center. If the
their specialties, locations, and more. Customer Care representative cannot satisfactorily respond
You have the right to be treated with respect and dignity, to your concerns or you are unhappy with our response to
and you have the right to your privacy. your issues, you have the right to file a formal complaint.
Normally, complaints are investigated and responded to in
You have the right to be treated with dignity. You have the
writing within 30 calendar days of receipt.
right to receive quality medical services, in a professional
and courteous manner, regardless of your race, sex, religion, If you do not agree with a previous decision associated with
age, or sexual orientation. a denial of services or benefits, you have the right to access
MVP’s two-step appeal process. Appeals are handled in a
All information concerning your medical history and
timely manner and are based on your health care needs.
enrollment file is privileged and confidential. MVP will not
The investigation and decision of the appeal is completed
release information regarding any member’s care without a
within 15 calendar days of receipt.
written statement or release signed by the member, except
as required by law. Details of the complete complaint and appeals process can
You have the right to participate with providers in making be found in the Certificate of Coverage section within the
decisions about your health care. This includes the MVP Member Guide and is also available upon request from
right to have a candid discussion about appropriate or the MVP Customer Care Center.
medically necessary treatment options for your condition, You have the right to receive medically necessary
regardless of cost or benefit coverage. specialty care.
Your health care provider is required to tell you, in terms If a provider with an appropriate specialty is not available
you will understand, all treatment options, including those in MVP’s network to treat a medical condition, you have the
*May not apply to self-funded plan members. right to request out-of-network services.
MVPCOMM0005 (02/2023) ©2023 MVP Health Care

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 Annual Notices for MVP Health Care Members Page 2

You have the right to receive reasonable and timely access You also have the responsibility to understand your health
to medically necessary health care services and access to issues and participate in developing mutually agreed-upon
your medical records. treatment goals, to the best degree possible.
MVP sets high standards for our health care professionals and You should ask your provider about any aspects of your illness,
continually monitors the medical care you receive. Often, one injury, or condition that you do not understand so that you
phone call is all you will need to access treatment quickly. can better understand the treatment plan or instructions and
You also have the right to your medical records, including how they will impact your health issues.
diagnosis, treatments, and prognosis. If you would like to see You have a responsibility to treat all personnel with
your records, please check with your provider office. They will
courtesy and dignity.
be able to give you these records. If you need copies of these
records, some offices charge on a per-page basis. When it is not When you are treated with respect, you are more likely
advisable to share this information with you, the information to return that respect. It is your right to expect courtesy.
will be shared with the person acting on your behalf. It is your responsibility to act with courtesy toward your
You have the right to formulate Advance Directives providers, the providers’ office staff, and MVP staff, including
regarding your care and Health Care Proxy. Customer Care representatives.

Advance Directives are documents that detail the care you You have a responsibility to notify MVP of any changes in
wish to receive if you are unable to explain those wishes to your status, such as adding or deleting dependents, change
your doctor (e.g., you are in a coma). Advance Directives can in marital status, etc. It is important for you to give your
be filled out and given to your doctor at any time. health care provider an honest description of your current
symptoms, effects of medication, or results of treatment.
You may choose a Health Care Proxy who can make decisions
for you if you cannot make decisions for yourself. These Always provide your medical history. This may include
decisions may include termination or withholding of life any relevant medical records, including x-rays or other
support systems, artificial nutrition, and hydration. The diagnostic tests.
proxy document may include special instructions, limits of
authority, and an expiration date. You have a responsibility to participate in your health care.

You have the right to make recommendations regarding You have a responsibility to follow the plans and instructions
MVP’s member rights and responsibilities policies. for care that you have agreed to with your providers. You also
have a responsibility to participate in developing mutually
To make a recommendation, you can call the MVP Customer
agreed-upon treatment goals, to the best degree possible.
Care Center at the phone number listed on the back of your
MVP Member ID card. You have a responsibility to select a PCP.
You have a responsibility to select a participating PCP for
MVP Member Responsibilities yourself and your dependents to coordinate your medical care.
You have a responsibility to supply information (to the Some plans such as Exclusive Provider Organization (EPO)
best extent possible) that MVP and its Participating and Preferred Provider Organization (PPO) do not require you
Providers need to provide care.
to select a PCP. See your Certificate of Coverage or contract
You have a responsibility to pay all applicable co-payments, for details.
co-insurance, and deductibles to your health care
You have a responsibility to identify yourself as an
providers, as specified in your Subscriber Contract or
MVP Health Plan member when receiving care.
Certificate of Coverage.
You need to pay your health care provider any co-pay(s) due. You always have a responsibility to carry your MVP Member ID
MVP is billed directly for the rest of the charges. You may be card and never permit anyone else to use it.
asked to pay the entire bill at the time of service if you get care
from an out-of-network provider. Simply send an original How to Contact MVP
itemized bill with proof of payment to MVP for processing.
With extended hours and email access, MVP makes it easy
You have the responsibility to follow the plans and to contact the MVP Customer Care Center when you have
instruction for care that you agreed to with your provider. questions or need help. We are easy to reach 24 hours a day at
Your provider will make recommendations to help you recover mvphealthcare.com. You can also call MVP Monday–Friday,
fully or to manage a chronic condition. By adhering to his or 8 am–6 pm Eastern Time. Call the MVP Customer Care Center
her instructions and recommendations, you are avoiding toll-free at the phone number listed on the back of your MVP
additional discomfort or an extended recovery period. Member ID card.

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 Annual Notices for MVP Health Care Members Page 3

MVP has interpreters in many languages if you do not speak apply to your specific health plan. To access your Member
English. If you are hearing impaired, TTY users may call a relay Guide, visit my.mvphealthcare.com and sign in to your MVP
operator at 711 for assistance with their calls to MVP. online member account . Select My Plan and then My Benefits.
You can request a printed copy by calling the MVP Customer
24 / 7 Nurse Advice Line Care Center at the phone number listed on the back of your
The 24 / 7 Nurse Advice Line is staffed by registered nurses MVP Member ID card.
available to answer health-related questions and offer Your MVP Member ID card is an easy reference tool for
guidance 24 hours per day, seven days per week. It offers information about your co-payments for doctor visits with
members access to an audio health library of more than 400 your PCP or a specialist, and inpatient and emergency room
recorded messages on a wide range of general medical topics. hospital care. On the back of your MVP Member ID card, you will
Members should first try to consult with their PCP on any find toll-free phone numbers to call if you have any questions
medical issues, but if the PCP is unavailable, members have about your health care benefits, including emergency care,
the option of calling the Nurse Advice Line by calling the MVP hospital admissions, mental health/substance use disorder
Customer Care Center at the phone number listed on the back services, receiving care from providers who are not part of the
of your MVP Member ID card. TTY users may call 711 for a relay MVP Participating Provider network, and locating participating
operator who can assist with their call. Members may also pharmacies (if your MVP plan includes pharmacy benefits).
choose to contact the 24 / 7 Nurse Advice line using our secure
online form by visiting my.mvphealthcare.com. Sign In to When you receive covered health care services from
your MVP online member account and select Get Care, then Participating Providers, you must pay the designated
24/7 Nurse Advice Line, then complete and submit the Contact amounts for these services as listed in your Certificate of
a Nurse form. Coverage or any applicable riders. Other than the designated
amounts, you should not have to pay for covered services
How to Contact the MVP Utilization that you receive from Participating Providers. In the rare
Management Department instance that this may occur, please send the claim (itemized
bill) to MVP. Include your name, address, MVP Member ID
You may reach the Utilization Management Department number, provider, date of service, and diagnosis. Keep a copy
regarding authorizations for care during working and after of the claim for your records and send the original to MVP.
working hours by calling the MVP Customer Care Center at
the phone number listed on the back of your MVP Member If you receive a bill for any services covered by MVP, forward it
ID card. to MVP for processing. You can submit your claim to MVP via
mail, email, fax, or online.

MVP Quality Improvement Program Mail completed claims to:

MVP is dedicated to providing quality health care and services ATTN: CLAIMS SUBMISSION
to its members. Our Quality Improvement (QI) program sets MVP HEALTH PLAN
standards for the care and services that are provided to our PO BOX 2207
members by MVP and by Participating Providers. MVP reports SCHENECTADY NY 12301-2207
on its progress toward achieving the QI program goals in the Email completed claims to
Quality Improvement Annual Report. [email protected].
You are welcome to participate in the development, Fax completed claims to 518-395-1395.
implementation, or evaluation of the QI program and/or you
may comment on the MVP Quality Improvement process. If To submit your claim online, visit my.mvphealthcare.com
you are interested in participating or commenting, please call and sign In to your MVP online member account. Select
the MVP Accreditation and Quality Regulatory Compliance Payments and Claims and then Submit a Claim. Only current
MVP members over the age of 18 may submit claims online.
Department at 518-991-3609. To receive a summary of the QI
Annual Program Description and / or the Executive Summary Also available online is the MVP Prior Authorization (PA)
of the QI Annual Report, please call the MVP Accreditation and Guide for Members, a convenient explanation and listing
Quality Regulatory Compliance Department at 518-991-3609. of procedures, services, and prescription drugs that
require approval from MVP in order to be covered by MVP’s
How to Obtain Services fully-insured and self-insured plans. The PA Guide is available
by visiting mvphealthcare.com/priorauth and selecting
Coverage, Payment, and General Information Services that Require Prior Authorization—A Guide for Members.
Your Member Guide and Certificate of Coverage provide To request a printed copy of the PA Guide, call the MVP
detailed information about your MVP benefits, including Customer Care Center at the phone number listed on the
covered services, access to care, and any restrictions that may back of your MVP Member ID card.

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 Annual Notices for MVP Health Care Members Page 4

Protection From Surprise Bills Your MVP Subscriber Contract or Certificate of Coverage, and
any pertinent rider(s), control your MVP benefits, coverage,
In accordance with the federal No Surprises Act, your MVP
and any other terms of your coverage.
heath plan includes protection from out-of-network “surprise”
medical bills. In-Area Emergencies
A surprise bill is one you receive for covered services performed The hospital emergency room or other medical facility will
by a non-Participating Provider in certain circumstances. You charge your normal emergency room co-payment (this
are not responsible for surprise, non-Participating Provider amount is printed on your MVP Member ID card). Please
charges that exceed your in-network co-payment, deductible, contact your PCP as soon as possible following the emergency
or co-insurance. so that he or she can coordinate any follow-up care that you
may need.
Protection under this Act does not apply when a Participating
Provider is available, but you choose to receive services from
Out-of-Area Emergencies
a non-Participating Provider.
Your MVP benefits provide coverage for non-emergency care
For more information about the No Surprises Act, call the that you receive from providers who practice within the MVP
MVP Customer Care Center at the phone number listed on Participating Provider network. You are also covered when
the back of your MVP Member ID card. Members can also visit you need emergency care outside of the MVP service area. If
mvphealthcare.com/NoSurprises. an emergency occurs while you are away from home, go to
the nearest provider or hospital for treatment. Please notify
Your Primary Care Provider MVP of the emergency within 48 hours or as soon as possible,
When you joined MVP, you and your covered dependents so that we can arrange for any follow-up services outside the
may have selected PCPs from those in the MVP Participating MVP service area.
Provider network. Your PCP gives you care, such as routine
well care, preventive care, and basic health screening MVP Referral Requirements
services, and coordinates any scheduled hospital care that
MVP no longer requires PCP referrals for specialty care. This
you might require. In some cases, your PCP must get prior
change in the MVP referral policy does not affect services that
authorization from MVP before you can receive some referrals
require prior authorization. MVP Participating Providers will
and treatments.
continue to be responsible for obtaining prior authorization
Specialist as PCP for inpatient admissions and select procedures and services.

If you have a life-threatening, disabling, or degenerative Members should seek the specialty care services of an MVP
disease, you can have your specialist or specialty care Participating Provider to receive the maximum benefit level.
center act as your PCP. The specialist or specialty care If MVP determines that the care you received did not meet the
center will take over coordination of all your primary care criteria below, MVP will not pay for the care.
services. They will also approve visits for other specialty
You do not need a referral from your PCP or prior authorization
care, lab work, hospitalization, and all other health services.
from MVP to get emergency medical care if you believe
Advanced cancer care, HIV disease, and severe heart
that not getting immediate attention for your emergency
conditions are examples of cases where a specialist might
condition would:
act as your PCP. MVP must approve this arrangement.
• Place your physical or mental health in serious jeopardy
If you believe that your specialist should become your PCP, • Seriously impair your bodily functions
ask your current PCP to contact MVP. You and your PCP will
• Cause serious dysfunction of any organ or body part
be notified of MVP’s decision in writing.
• And, in New York State, result in disfigurement
Emergency Care Policy
If you or a member of your family has an emergency that Formulary and Exceptions Policy
requires immediate medical care, you should go to the nearest If your MVP benefits include prescription drug coverage, that
hospital emergency room or medical facility or call your local coverage is subject to the MVP Prescription Drug Formulary,
emergency number for medical assistance. MVP follows the our list of covered drugs. Depending on the benefit design,
prudent layperson standard when paying for emergency care. non-formulary drugs might require prior authorization or be
available at a higher co-payment.
If you are unsure if your condition is an emergency, call your
PCP for guidance and to coordinate your medical care. Your Before MVP will cover a newly introduced prescription drug, a
PCP (or a covering physician) is on call 24 hours per day, committee of MVP physicians and pharmacists reviews the
including weekends and holidays. available data concerning the effectiveness and safety of the

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new drug to determine if the drug represents a significant • Little Footprints for high-risk pregnancies
℠

improvement over existing covered medication. If a drug meets • Case Management Programs for members with complex
the committee’s criteria, MVP approves that drug for coverage. health issues
If a drug is not covered by your prescription drug benefit, and • Social work services that help connect members to
your doctor believes that it is medically necessary for you, community resources and services
your doctor can request an exception from MVP. Members
can also initiate an exception request by submitting the How to Obtain Behavioral Health Services
Prescription Drug Formulary Exception form. To download the MVP offers a Behavioral Health Case Management program
form, visit mvphealthcare.com/members and select Forms, that could be beneficial to members who have experienced
then Pharmacy Forms. You can also request the form by a new mental health diagnosis, substance use disorder, or an
calling the MVP Customer Care Center at the phone number acute behavioral health problem. The MVP Behavioral Health
listed on the back of your MVP Member ID card. Case Management program offers licensed clinicians who can
assist in connecting you to appropriate community resources,
To find out if MVP covers a specific drug, or if MVP education on behavioral health diagnoses, medication
covers a drug with certain conditions such as prior management, and developing care plans to improve your
authorization, step therapy, or with quantity limits, visit overall well-being. If you have questions regarding your
mvphealthcare.com/prescriptions or call the MVP mental health and would like access to our Case Management
Customer Care Center at the phone number listed on the program, you, your provider, or a designee can call MVP at
back of your MVP Member ID card. 1-866-942-7966.
It only takes a simple phone call to request to see a psychiatrist,
Care Management psychologist, social worker, or substance use counselor. That
phone call can come from you, the behavioral health provider,
We’re There When You Need Us
or your PCP prior to a behavioral health visit.
Living well can sometimes take an extra helping hand. That is
why MVP has a team of nurses, respiratory therapists, health If at any time you are experiencing thoughts of harming
coaches, social workers, and other health care professionals yourself or others, please call the MVP Crisis Hotline at
to help you. 1-833-787-9687 or text HELLO to 741741 for immediate
support. You can also call the National Suicide Prevention
If you are living with a serious physical or behavioral health Lifeline at 1-800-273-TALK (1-800-273-8255) or call, text, or
concern, you can call MVP at 1-866-942-7966 for help and chat to 988. MVP is here to help you through difficult times
support, and in some situations, MVP may contact you to offer and unsettling circumstances.
assistance. MVP will match you with one of our free programs
or connect you with other wellness resources that can help. Education and Support
Members can speak with an MVP Case Manager who can
How MVP Can Help answer questions and help find community-based resources
When you are faced with a health issue, MVP can point you and health care solutions. MVP Case Managers can offer
to programs and resources that can help you manage or information about healthy eating habits, medication
improve a medical condition, guide you through a medical management, symptom monitoring and management,
event, and learn how to take the best care of yourself. weight monitoring, and fitness activities. Members will also
receive personalized mailings and newsletters with the latest
MVP offers Health Management programs for members
health information.
living with:
• Asthma Health Coaching
• Cardiac Disease (after a heart attack or open-heart surgery) If you need extra help to work through a complex health
• Chronic Obstructive Pulmonary Disorder (COPD) concern or behavioral health issue, you may be matched with
• Depression a personal health coach. Your health coach will work with
• Diabetes you and your doctor to help you set and reach goals that are
important to your treatment plan.
• Heart Failure
• Low Back Pain Self-Care Resources
MVP also offers special programs to help members whose Whether you are researching a health condition or treatment,
health concerns are complicated and can lead to hospital looking for simple answers to your health questions, or
or emergency room visits. If you think that you might benefit reaching your health improvement goals, taking care of
from one of these programs, call MVP at 1-866-942-7966 yourself is easier when you use MVP’s online well-being tools.
for further assistance: MVP’s clinicians can direct you to helpful online resources.

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 Annual Notices for MVP Health Care Members Page 6

Gia and MVP Virtual Care Services

®
Provider Programs
MVP virtual care services, available through Gia, include 24 / 7
primary, urgent, and emergency care. Connect via video chat
Patient-Centered Medical Home Program
anytime, anywhere for: This program recognizes provider practices functioning as
• Preventive care medical homes by using systematic, patient-centered, and
coordinated care management processes.
• Everyday health needs
• Urgent / emergency care
• Complex or chronic conditions Obtaining Additional Information
About MVP Participating Providers
For more information, visit GoAskGia.com.
MVP is committed to providing access to high-quality,
How to Find Out More coordinated care to help you live a healthy life. One way
we do that is by sharing information on health care quality
Not all resources are available to all MVP members. Call
with you. Within the MVP online provider directory, any
1-866-942-7966 for more information or to see if you
provider who has earned one or more certifications from the
qualify. To find detailed information on program offerings
National Committee for Quality Assurance (NCQA) has the
and current programs newsletters, you may also visit
corresponding seal(s) included in provider’s directory profile
mvphealthcare.com/HealthandWellness and select
under Quality Reports.
Connect Now, then Learn About MVP’s Case Management and
Support Programs. We are committed to connecting you with To review the NCQA certifications, visit
the help you need to live well! mvphealthcare.com/findadoctor and look for the Quality
Reports link in the provider profile.
Women’s Health and Cancer Rights Act Both New York State and Vermont also make information
of 1998 available to consumers who would like to know more about
their providers. Visit mvphealthcare.com/findadoctor and
As required by the Women’s Health and Cancer Rights Act select either NY Physician Profiles or VT Physician Profiles.
of 1998, MVP provides benefits for mastectomy-related
services, including reconstruction and surgery to achieve The New York State Physician Profile website was created
symmetry between the breasts, prostheses, and treatment with the passage of the New York Patient Health Information
of complications resulting from a mastectomy, including and Quality Improvement Act of 2000. Using this New York
lymphedema. To obtain a detailed description of the State website, MVP members may find information about the
mastectomy-related benefits available through MVP, call the doctor’s medical education, translation services at the doctor’s
MVP Customer Care Center at the phone number listed on office, and information about legal actions taken against the
the back of your MVP Member ID card. doctor. To see all information that is available for each doctor,
visit nydoctorprofile.com and search on any doctor’s name.
Mental Health Parity and Addiction These websites offer information free to the public. If you do
Equity Act not have internet access and would like to receive a printed
report from any of these sites about a specific provider, call
MVP uses a team of clinical and compliance experts across the MVP Customer Care Center at the phone number listed on
the company to ensure continual compliance with the the back of your MVP Member ID card.
requirements of the Mental Health Parity and Addiction
Equity Act (MHPAEA). MHPAEA is a federal law that prohibits
insurance companies and managed care organizations How MVP Assesses New Technology
from discriminating against individuals with mental health MVP draws upon the knowledge of its medical directors,
conditions (MH) or substance use disorders (SUD). MVP’s Participating Providers, and allied health professionals to
MHPAEA compliance program ensures that MVP uses financial research new technologies, medical products, behavioral
requirements/quantitative treatment limits (FR / QTLs) and health treatments, and pharmaceuticals for inclusion as
non-quantitative treatment limits (NQTLs) in a way that benefits covered by MVP.
complies with parity. Parity requires each of these managed
MVP regularly assesses new technologies and new applications
care practices to meet specific tests to assure that they are
of existing technologies for inclusion as covered benefits.
not being implemented in a discriminatory manner. MVP
analyzes each FR / QTL / NQTL on an annual basis and updates The research process includes a review of information
the analysis as a part of any mid-year changes. If you have any from appropriate government regulatory bodies as well as
questions or concerns about MVP’s parity compliance, call published scientific evidence. Benefit policies are examined
the MVP Customer Care Center at the phone number listed on by physicians of various specialties and other health care
the back of your MVP Member ID card. professionals across the MVP service area, as well as by

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staff in several MVP departments, to decide whether the Member Complaints, Appeals,
technologies will be included as covered benefits. The MVP
Quality Improvement Committee provides final approval.
and Grievances
MVP wants to solve any problems you may have with us in a
MVP’s technology policies are reviewed at least annually, with
fair and friendly manner. Call the MVP Customer Care Center
comprehensive updates triggered more often by changes in
at the phone number listed on the back of your MVP Member
published medical evidence. By carefully considering new
ID card if you have a concern with MVP. A Customer Care
technologies before approving them for coverage, MVP assures
representative can often resolve your problem, immediately.
our members that they are receiving safe, effective, and
MVP has interpreters if you do not speak English.
high-quality care.
If the MVP Customer Care representative cannot resolve your
problem, you or your representative may file a complaint,
Transition of Care appeal, or grievance by submitting it to the Member Appeals
If your provider leaves the MVP Participating Provider network, department at:
MVP will send you a letter to notify you. If you are undergoing
ATTN: MEMBER APPEALS DEPARTMENT
treatment for a life-threatening, disabling, or degenerative
MVP HEALTH PLAN
condition, you may be able to continue to see that provider
PO BOX 2207
for covered services for up to 90 days from the effective date
SCHENECTADY NY 12301-2207
of the provider’s termination. If you are pregnant, you may
continue to receive care from your provider throughout your A complaint is a written or verbal expression of dissatisfaction.
pregnancy, delivery, and through the completion of your Examples of complaints are problems scheduling
postpartum care directly related to your pregnancy. appointments with providers or timeliness of claim payment
issues. An appeal (or grievance) is a request from a member
You cannot continue to see a provider that has left the MVP
for MVP to change a decision it has made. It may concern
network if the provider was removed from the network for
whether a requested service is a benefit covered by MVP or
the following reasons:
the way a complaint has been resolved.
• Concern of imminent harm to patients
• A determination of fraud Medical complaints and first level appeals are handled
by a licensed health care professional who is qualified to
• A final disciplinary action by a state licensing board that
review the issue. In an appeal (or grievance), the reviewer
impairs the provider’s ability to practice
must not have been involved in making MVP’s original
Transition of Care also applies when you are a new member. decision. If your complaint, appeal, or grievance concerns
If you are seeing a non-Participating Provider when you join an administrative matter, it will be handled by a member of
MVP, you must switch to a Participating Provider. However, the senior administrative staff with the necessary education
if you have a life-threatening, disabling, or degenerative and background to resolve the matter. Under select member
condition, you may be able to continue to see that provider contracts, a second level appeal or grievance is available
for covered services for 60 days from your date of enrollment. (please refer to your contract or Certificate of Coverage).
If you are in your second or third trimester of pregnancy, you Second level appeals and grievances are reviewed by the
may continue to receive care from your provider throughout MVP Second Level Appeals Committee.
your pregnancy, delivery, and through the completion of your
MVP will never retaliate or take any discriminatory action
postpartum care directly related to your pregnancy.
against a member who files a complaint or appeal.
In either situation, the provider must agree to:
If you are covered under a New York State or Vermont
• Accept the MVP reimbursement or payment in full Subscriber Contract or Certificate of Coverage and have been
• Agree to adhere to the MVP Quality Improvement denied coverage on the basis of medical necessity or because
requirements the service is deemed experimental or investigational, you
• Adhere to MVP policies and procedures have the right to request a review by a state-approved external
• Provide MVP with medical information related to your care appeal agent. You may obtain an external appeal application
by calling the MVP Customer Care Center at the phone number
If the provider will not agree to these terms, MVP cannot offer
listed on the back of your MVP Member ID card.
you transitional care.
If you are covered under a New York State Subscriber
MVP will also provide transition of care support if your benefits
Contract or Certificate of Coverage you may also contact
have been exhausted or you are terminated from MVP. An MVP
the New York State Department of Financial Services at
clinician will review your case to identify ongoing needs and
1-800-400-8882 or dfs.ny.gov.
will either work with your PCP or provide you with community
resources to assist in providing ongoing treatment. You will be If you are covered under a Vermont Subscriber Contract or
notified regarding plans for future unmet needs. Certificate of Coverage you may also contact the Health Care

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 Annual Notices for MVP Health Care Members Page 8

Advocate Program. The Office of Health Care Advocate is a Customer Care Center at the phone number listed on the back
statewide program operated by Vermont Legal Aid, Inc. Full- of your MVP Member ID card.
time health care counselors staff the program to help Vermont
residents resolve problems and complaints with their health
insurance. The office is in the Burlington office of Vermont
Report Suspected Insurance
Legal Aid and can be reached by calling 1-800-917-7787. Fraud / Abuse
You may also call the Vermont Department of Financial Every year, billions of dollars are spent on fraudulent claims
Regulations at 1-800-631-7788. throughout the insurance industry, translating into escalating
costs and premiums. We all pay for this costly crime. At MVP,
we are committed to providing top-quality, affordable health
MVP Policy for Approving Medically care; that is why we are tough on fraud.
Necessary Health Care
MVP has a dedicated unit called the Special Investigations
MVP supports and encourages the delivery of appropriate
Unit (SIU), which deals exclusively with situations regarding
health care to our members and through our Utilization
potential fraud, waste, and abuse. The SIU works closely with
Management program. Part of that program is to monitor our
federal and state agencies responsible for identifying and
members’ use of health care services to detect and correct
investigating potential insurance fraud, waste, and/or abuse,
potential under- and over-use of health care services.
as well as our Participating Providers and other insurance
The MVP Utilization Management program does not provide companies. We also rely on members like you.
financial incentives to employees, providers, or practitioners
who make utilization management decisions that would Common forms of insurance fraud include:
encourage or create barriers to members getting appropriate • A health care provider bills for services you never received
health care and services. • Payments made for services previously covered by
Our Utilization Management program follows these principles: another insurance carrier
• Payments made to or for someone who was not an
1. Utilization Management decisions are based only on
eligible subscriber or dependent
appropriateness of care and the benefit provisions of the
subscriber’s coverage. • Someone using your MVP Member ID card to obtain
medical care, supplies, or equipment
2. MVP does not reward practitioners, providers, or staff,
including Medical Directors and Utilization Management These are serious crimes and they are punishable by law.
staff, for issuing denials of requested care. Please help us fight insurance fraud by reporting any activities
3. Financial incentives, such as annual salary reviews and / or you suspect. Contact the MVP SIU by calling toll-free at
incentive payments, do not encourage decisions that 1-877-TELL-MVP (1-877-835-5687). As always, your privacy
result in underutilization of health care and services is our top concern. Should you wish to make an anonymous
by members. report, contact EthicsPoint at 1-888-357-2687. Please be
assured that any information you provide will be kept in
Criteria MVP uses to make decisions are available on request.
strict confidence.
The MVP medical staff, comprised of physicians, registered
nurses, and other health care providers, reviews requests for
health care services to determine if the requested service is
medically necessary. The staff uses specific clinical review
criteria including clinical protocols, practice guidelines,
and written policies to make these decisions. You and your
doctor can get copies of these review criteria by calling the
MVP Customer Care Center at the phone number listed on the
back of your MVP Member ID card.

MVP Privacy Notices

To obtain a copy of our HIPAA Privacy Notice or
Nonpublic Personal Financial Information Policy, visit
mvphealthcare.com/privacy-notices. To request a printed
copy of the notice(s), or if you would like to request a copy of
the notice(s) in an alternate language or format, call the MVP

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 Contract
or Certificate of Coverage

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 VERMONT HMO CONTRACT

FRVT HMO STANDARD CTR (2024)

MVP Health Plan, Inc.

625 State Street
Schenectady, New York 12305

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 (800) 777-4793

THIS IS YOUR CONTRACT

Issued by
MVP Health Plan, Inc.
625 State Street, Schenectady, New York 12305
(800) 777-4793

This Contract ("Contract") describes the benefits available to you under a Contract between MVP
and your Group or MVP and you directly, depending upon whether you purchase this contract
through your employer or as an individual. Amendments, Summary of Benefits and Coverage (SBC),
riders and/or endorsements may be delivered with this Contract or added thereafter. You must make
sure you understand and comply with all of the terms and conditions herein.

The terms We, Us, and Our mean MVP, or any designated agents of MVP.

The terms You and Your mean the Enrollee and his or her Dependents Covered under this
Contract unless otherwise specified.

THIS CONTRACT IS AVAILABLE FOR SALE THROUGH THE VERMONT HEALTH CONNECT
EXCHANGE.

READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND

THE TERMS AND CONDITIONS IN THIS CONTRACT. YOU SHOULD KEEP THIS CONTRACT
WITH YOUR OTHER IMPORTANT PAPERS SO THAT IT IS AVAILABLE FOR YOUR FUTURE
REFERENCE.

By:

Christopher Del Vecchio,

Chief Executive Officer
MVP Health Plan, Inc.

MVP Health Plan, Inc. is a not-for-profit health maintenance organization certified in Vermont.

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 TABLE OF CONTENTS

SECTION PAGE

SECTION ONE – INTRODUCTION ............................................................................................................................. 4

SECTION TWO – DEFINITIONS................................................................................................................................... 6
SECTION THREE – ENROLLMENT, ELIGIBILITY AND COVERAGE................................................................ 14
SECTION FOUR - ACCESS TO PROVIDERS.......................................................................................................... 23
SECTION FIVE – MEDICAL NECESSITY .................................................................................................................. 26
SECTION SIX - UTILIZATION MANAGEMENT .................................................................................................... 27
SECTION SEVEN – COVERED HOSPITAL INPATIENT SERVICES .................................................................. 30
SECTION EIGHT – COVERED OUTPATIENT SERVICES .................................................................................... 33
SECTION NINE – COVERED SKILLED NURSING FACILITY SERVICES ......................................................... 35
SECTION TEN – SPECIAL COVERED SERVICES .................................................................................................. 36
SECTION ELEVEN - COVERED EMERGENCY SERVICES AND URGENTLY NEEDED CARE .................. 38
SECTION TWELVE – COVERED PROFESSIONAL CARE AND SERVICES .................................................... 41
SECTION THIRTEEN – PRESCRIPTION DRUG COVERAGE ............................................................................. 59
SECTION FOURTEEN - EXCLUSIONS ..................................................................................................................... 71
SECTION FIFTEEN - TERMINATION OF YOUR COVERAGE ........................................................................... 78
SECTION SIXTEEN - POST TERMINATION CONTINUATION OF COVERAGE; CONVERSION TO
A DIRECT CONTRACT ........................................................................................................ 82
SECTION SEVENTEEN – EFFECT OF MEDICARE ................................................................................................ 87
SECTION EIGHTEEN - COORDINATION OF BENEFITS ................................................................................... 88
SECTION NINETEEN - THIRD PARTY LIABILITY AND RIGHTS OF REPAYMENT .................................... 91
SECTION TWENTY – GRIEVANCES AND INDEPENDENT EXTERNAL REVIEW........................................ 93
SECTION TWENTY ONE - GENERAL PROVISIONS ......................................................................................... 103
IMPORTANT TELEPHONE NUMBERS .................................................................................................................. 112

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 SECTION ONE – INTRODUCTION

MVP is a New York State not-for-profit corporation. MVP is certified as a health maintenance
organization in New York State and the State of Vermont. MVP provides benefits for Enrollees for
comprehensive health services on a prepaid basis. These services are provided by:

(1) physician and physician-hospital organizations;

(2) independent physicians and other health care professionals; and
(3) independent hospitals and other facilities through agreements with MVP.

MVP’s service area includes the geographical area, designated by Us and approved by the State
of Vermont, in which We provide coverage. The MVP service area includes the state of Vermont
and the New York State counties of Albany, Broome, Cayuga, Chemung, Chenango, Clinton,
Columbia, Cortland, Delaware, Dutchess, Essex, Franklin, Fulton, Genesee, Greene, Hamilton,
Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Oneida, Onondaga,
Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Rensselaer, Rockland, Saratoga, Schenectady,
Schoharie, Schuyler, Seneca, Steuben, St. Lawrence, Sullivan, Tioga, Tompkins, Ulster, Warren,
Washington, Wayne, Westchester, Wyoming and Yates.

When you enroll as an MVP Enrollee, you and your covered dependents may choose a Primary
Care Physician (“PCP”) from MVP’s Participating Provider Directory, but you are not required to
do so. All services must be provided by MVP participating providers or providers in our affiliate’s
First Health/MagnaCare Network. The following exceptions apply.

(1) emergency services

(2) services while temporarily outside the service area.
(3) certain gynecological services.
(4) Enrollees with certain serious conditions.
(5) Enrollees in their second or third trimester of pregnancy.
(6) services not available through an MVP provider.

These exceptions are described in detail in Section Four and other sections in this Contract. You
should refer to those sections to ensure that you meet all requirements. To be eligible for benefits
under this Contract, services must also be:

A. Covered Services as defined in this Contract;

B. Medically Necessary as defined in this Contract;
C. For certain services as specified later in this Contract, subject to Pre-Authorization,
and/or concurrent review; and
D. Not subject to the exclusions and limitations described in this Contract.

If you receive services which are not Covered Services, MVP will not pay for those services. You
will be responsible for paying all charges for those services. However, this Contract applies to
benefits only, and does not stop you from receiving services that are not, or might not be, eligible

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 for benefits. You have the right to file grievances with MVP or with the State of Vermont if you
are dissatisfied with our processes, procedures, or benefit decisions. You also have certain rights
to request independent external review of our decisions.

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 SECTION TWO – DEFINITIONS

1. The following terms have special meanings in this Contract.

A. Acute Services means services which, according to generally accepted professional

standards, are expected to provide significant, measurable clinical improvement
within a reasonable and medically predictable period of time, not to exceed two
(2) months.

B. Benefit Year refers to a calendar year. A Benefit Year is the date your Deductibles,
out-of-pocket limits and other totals begin to accumulate. Limits on visits and
other limits also begin to accumulate on the first day of your Benefit Year.

A calendar year is the twelve (12) month period beginning on January 1 and ending
on December 31. If you were not covered under this Contract for this entire period,
calendar year means the period from your effective date until December 31 for the
initial period, and January 1 to December 31 thereafter.

C. Charge means the total amount billed by a provider for a service. A charge is
incurred on the date the service was provided to you.

D. Complications of Pregnancy means conditions requiring hospital admission whose

diagnoses are distinct from pregnancy but are adversely affected by pregnancy or
are caused by pregnancy including, but not limited to:

(1) acute nephritis (4) missed abortion

(2) nephrosis (5) similar medical and surgical conditions of
(3) cardiac decompensation comparable severity

It does not include:

(1) false labor (5) hyperemesis gravidarium

(2) occasional spotting (6) pre-eclampsia
(3) physician prescribed rest (7) similar conditions associated with the
during pregnancy management of a difficult pregnancy
(4) morning sickness not constituting a distinct
complication of pregnancy

This term also includes non-elective cesarean section, ectopic pregnancy, and
miscarriage.

E. Cost Share is the amount that you must pay, in addition to the premium, for
Covered Services. You must pay any cost share directly to the provider. Cost Share
in this Contract refers to any of the following as applicable.

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 x Coinsurance is a dollar amount, expressed as a stated percentage of the charge.
x Copayment is a fixed dollar amount.
x Deductible is a dollar amount which you must pay for Covered Services before
we provide benefits under this Contract. See your Summary of Benefits and
Coverage (SBC) to see if you have an Embedded or an Aggregate Deductible.
These are explained below.

Embedded/Stacked Deductible.
Except where stated otherwise, you must pay the Deductible amount in the SBC
for Covered Services during each Plan Year before We provide coverage. If your
Plan has an Embedded/Stacked Deductible and You have other than individual
coverage, the individual Deductible applies to each person covered under this
Contract. Once a person within a family meets the individual Deductible, no further
Deductible is required for the person that has met the individual Deductible for
that Plan Year. However, after Deductible payments for persons covered under this
Contract collectively total the family Deductible amount in the SBC in a Plan Year,
no further Deductible will be required for any person covered under this Contract
for that Plan Year.

Aggregate Deductible.
Except where stated otherwise, you must pay the Deductible amount in the SBC
during each Plan Year before We provide coverage. If your Plan has an Aggregate
Deductible and You have other than individual coverage you must pay the family
Deductible in the SBC for Covered Services under this Contract during each Plan
Year before We provide coverage for any person covered under this Contract.
However, after Deductible payments for persons covered under this Contract
collectively total the family Deductible amount in the SBC in a Plan Year, no further
Deductible will be required for any person covered under this Contract for that
Plan Year.

x Individual and/or Family Out of Pocket Annual Maximums. These are the
maximum amounts of eligible expenses each Member must pay during any
Contract Year. See your SBC to see if you have an Embedded or Aggregate Out
of Pocket Maximum. These are described below. Some payments do not
count toward Annual Out of Pocket Maximums.

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 Embedded/Stacked Out of Pocket Maximum.
When You have met Your Out-of-Pocket Maximum in payment of Copayments,
Deductibles and Coinsurance for a Plan Year in the SBC, We will provide coverage
for 100% of the Allowed Amount for Covered Services for the remainder of that
Plan Year. If your Plan has an Embedded/Stacked Out of Pocket Maximum and
You have other than individual coverage, once a person within a family meets the
per person in a family Out-of-Pocket Maximum in the SBC, We will provide
coverage for 100% of the Allowed Amount for the rest of that Plan Year for that
person. If other than individual coverage applies, when persons in the same family
covered under this Contract have collectively met the family Out-of-Pocket
Maximums in payment of Copayments, Deductibles and Coinsurance for a Plan
Year in the SBC, We will provide coverage for 100% of the Allowed Amount for the
rest of that Plan Year for the entire family.

Aggregate Out-of-Pocket Maximum.

When You have met Your Out-of-Pocket Limit in payment of Deductibles,
Copayments, and Coinsurance for a Plan Year in the SBC, We will provide coverage
for 100% of the Allowed Amount for Covered Services for the remainder of the
Plan Year. If your Plan has an Aggregate Out of Pocket Maximum and You have
other than individual coverage, you must pay the family Out-of-Pocket Maximum
in the SBC for in-network Services under this Contract during each Plan Year.
However, after the family Out-of-Pocket Maximum for any and all persons covered
under this Contract collectively total the family Out-of-Pocket Maximum, we will
provide coverage for 100% of the Allowed Amount for the rest of that Plan Year.

Cost-sharing for out-of-network services, except for Emergency Services does not
apply toward Your Out-of-Pocket Maximum.

F. Covered Services means the services specified in this Contract as eligible for
benefits. MVP maintains protocols to assist in determining whether a service is a
Covered Service. You may request a copy of MVP’s protocols by calling MVP's
Customer Care Center at 1-888-687-6277.

G. Custodial Services means services primarily for maintenance or designed to help

you in your daily living activities. Custodial Services include, but are not limited to:

(1) assistance in walking, bathing (5) administration of oral medications

and other personal hygiene, (6) routine changing of dressings
toileting, getting in and out of (7) child care
bed (8) adult day care
(2) dressing (9) residential care
(3) feeding (10) care not requiring skilled professionals
(4) preparation of special diets

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 This term also means services which, according to generally accepted professional
standards, are not expected to provide significant, measurable clinical
improvement within a reasonable and medically predictable period of time, not to
exceed two (2) months.

H. Dependent means a person other than the Subscriber, listed on the Subscriber’s
enrollment application who meets all eligibility requirements, and for whom the
required premium has been received by MVP.

I. Diagnostic Services means radiology and imaging services, x-rays, ultrasounds,

diagnostic nuclear medicine, MRIs, CAT scans, electroencephalograms,
electrocardiograms, organ scans, and other medical and surgical diagnostic
services.

J. Domestic Partners means the two individuals in a legal or interpersonal relationship

who live together and share a common domestic life but are neither joined by
marriage nor a civil union.

K. Durable Medical Equipment means equipment which is primarily and customarily

used only for a medical purpose. Such equipment is appropriate for use in the
home, and is designed for prolonged and repeated use. It is generally not useful
to a person in the absence of an illness, injury or condition. Durable medical
equipment includes, but is not limited to wheelchairs, hospital beds, walkers,
traction equipment, and respirators.

L. Effective Date means the date your coverage under this Contract begins.

M. Enrollee means the person to whom this Contract is issued, who meets and
continues to meet all eligibility requirements, and for whom the required premium
has been received. The words “you” and “your” refer to the Enrollee and his or her
eligible dependents.

N. Experimental or Investigational Services means services that are either generally

not accepted by informed health care providers in the United States as effective in
treating the condition, illness or diagnosis for which their use is proposed, or are
not proven by medical or scientific evidence to be effective in treating the
condition, illness or diagnosis for which their use is proposed.

O. External Prosthetic Devices are devices that replace all or some of the functions of
a permanently inoperative and/or malfunctioning external body part. Examples of
such devices are artificial limbs and breast prostheses.

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 P. Habilitation Services: Health care services that help a person keep, learn or
improve skills and functioning for daily living. Habilitative Services include the
management of limitations and disabilities, including services or programs that
help maintain or prevent deterioration in physical, cognitive, or behavioral
function. These services consist of physical therapy, occupational therapy and
speech therapy.

Q. Health Care Facility: means all institutions, whether public or private, proprietary or
nonprofit, which offer diagnosis, treatment, inpatient or ambulatory care to two or
more unrelated persons, and the buildings in which those services are offered. A
Health Care Facility is not a facility operated by religious groups relying solely on
spiritual means through prayer or healing.

R. Mental Health Condition means a condition or disorder involving mental illness or

alcohol or substance abuse that falls under a diagnostic category listed in the
mental disorders section of the international classification of disease, as
periodically revised.

S. MVP Direct means individuals who enroll directly through MVP and not through
Vermont Health Connect. This is a direct to MVP enrollment for individuals who do
not receive cost share reductions.

T. Non-participating Provider means a Provider who does not have an agreement

with MVP to provide Covered Services to Enrollees.

U. Participating Provider means a Provider who has an agreement with MVP to

provide Covered Services to Enrollees.

V. Primary Care Physician means a Participating Provider who has an agreement with
MVP to provide covered primary health care services to Enrollees.

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 W. Provider means a properly licensed and/or certified:

(1) physician (11) free standing ambulatory surgery center, free

(2) hospital standing radiology/imaging center, free
(3) approved facility for the standing dialysis center, and free standing
treatment of mental health laboratory facility
conditions (12) athletic trainer
(4) approved institution for the (13) advanced practice registered nurse who is
treatment of alcohol or certified as a nurse midwife
substance dependency (14) naturopath
(5) skilled nursing facility (15) DME provider
(6) home care agency (16) chiropractor
(7) health care professional (17) podiatrist
(8) licensed midwife (18) mental health provider
(9) audiologist (19) DDS (dentist)
(10) hearing aid dispenser acting
within the scope of their
license

The provider must provide health care services within the scope of his or her
practice, and must charge and bill patients for such services.

Y. Qualified Health Plan or QHP means a health insurance plan that is certified by the
Department of Financial Regulation and selected for offering through the Vermont
Health Connect, provides essential health benefits, follows established limits on
cost-sharing (like deductibles, copayments, coinsurance, and out-of-pocket
maximum amounts), and meets other requirements.

Z. Relevant document, record or other information means, that a document, record

or other information shall be considered relevant if such document, record or other
information was relied upon in making the benefit determination or the
determination of a grievance, or was submitted, considered or generated in the
course of making the benefit determination or the determination of a grievance,
without regard to whether such document, record or other information was relied
upon in making the benefit determination or the determination of a grievance.

AA. Resident means a person who is domiciled in Vermont. It means the person
intends to maintain a principal dwelling place in Vermont indefinitely. It also
means that the person intends to return to Vermont if temporarily absent. One
must act consistent with that intent.

BB. Spouse means the Enrollee’s spouse under a legally valid marriage or civil union as
defined by Vermont law.

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 CC. Summary of Benefits and Coverage (SBC). The document attached to this Contract
that describes Cost Share (Copayments, Deductible, Coinsurance), Annual Out of
Pocket Maximums, Annual Benefit Maximums, Lifetime Benefit Maximums and
similar information.

DD. Store and Forward means an asynchronous transmission of medical information to

be reviewed at a later date by a health care provider at a distant site who is trained
in the relevant specialty and by which the health care provider at the distant site
reviews the medical information without the patient present in real time.

EE. Surgery means generally accepted invasive, operative, and cutting procedures
including, but not limited to specialized instrumentation, endoscopic examinations,
and correction of fractures and dislocations, and the pre- and post-operative care
usually rendered in connection with such procedures.

FF. Telemedicine means the delivery of health care services such as diagnosis,
consultation, or treatment through the use of live interactive audio and video over
a secure connection that complies with the requirements of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).

GG. Therapeutic Services means:

a. Chemotherapy means prevention of the development, growth, or

multiplication of malignant diseases by chemical or biological agents, and
includes growth cell stimulating factor injections, and oral medications
taken as part of a chemotherapy regimen;

b. Dialysis means removal of waste materials when an Enrollee has acute

kidney failure or chronic, irreversible kidney deficiency, and the use of
equipment and disposable medical supplies.

c. Infusion Therapy means treatment of disease by continuous injection of

curative agents; and

d. Inhalation Therapy means inhalation of medicine, water vapor and/or gases

to treat impaired breathing.

e. Radiation Therapy means the use of x-ray, gamma ray, accelerated particles,
mesons, neutrons, radium or radioactive isotopes for treatment of disease;

HH. Therapy Services means Acute Services, limited to physical therapy, occupational
therapy, speech therapy, and habilitative therapy.

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 II. Totally Disabled or Total Disability means incapable of engaging in any
employment or occupation for which the person is or becomes qualified by reason
of education, training or experience. Such person must not, in fact, engage in any
employment or occupation for wage or profit.

JJ. VHC means Vermont Health Connect or the Exchange.

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 SECTION THREE – ENROLLMENT, ELIGIBILITY AND COVERAGE

A. Who is Covered Under this Contract.

You, the Subscriber to whom this Contract is issued, are covered under this Contract. You must
live, work or reside in Vermont to be covered under this Contract if you have coverage through
your employer. You must live in Vermont to be covered under this Contract if you have Individual
or MVP Direct coverage. Members of your family may also be covered depending on the type of
coverage You selected

B. Types of Coverage.
We offer the following types of coverage:

1. Individual. If You selected individual coverage, then You are covered.

2. Individual and Spouse. If You selected individual and Spouse coverage, then You and
Your Spouse are covered.

3. Parent and Child/Children. If You selected parent and child/children coverage, then You
and Your Child or Children, as described below, are covered.

4. Family. If You selected family coverage, then You and Your Spouse and Your Child or
Children, as described below, are covered.

C. Children Covered Under this Contract.

If You selected parent and child/children or family coverage, Children covered under this Contract
include Your natural Children, legally adopted Children, step Children, and Children for whom You
are the proposed adoptive parent without regard to financial dependence, residency with You,
student status or employment. A proposed adopted Child is eligible for coverage on the same
basis as a natural Child during any waiting period prior to the finalization of the Child’s adoption.
Coverage lasts until the end of the year in which the Child turns 26 years of age. Coverage also
includes Children for whom You are a legal guardian if the Children are chiefly dependent upon
You for support and You have been appointed the legal guardian by a court order. Foster Children
and grandchildren are not covered.

Any unmarried dependent Child, regardless of age, who is incapable of self-sustaining

employment by reason of mental illness, developmental disability, or physical handicap and who
became so incapable prior to attainment of the age at which the Child’s coverage would otherwise
terminate and who is chiefly dependent upon You for support and maintenance, will remain
covered while Your insurance remains in force and Your Child remains in such condition. You
have 31 days from the date of Your Child's attainment of the termination age to submit an
application to request that the Child be included in Your coverage and proof of the Child’s
incapacity. We have the right to check whether a Child is and continues to qualify under this
section.

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 We have the right to request and be furnished with such proof as may be needed to determine
eligibility status of a prospective or covered Subscriber and all other prospective or covered
Members in relation to eligibility for coverage under this Contract at any time.

D. When Coverage Begins----This Section Applies If You Have Coverage Through Your
Employer or Direct Through MVP.
Coverage under this Contract will begin as follows if you have coverage through your employer
or Direct Through MVP:

1. If You, the Subscriber, elect coverage before becoming eligible, or within 30 days of
becoming eligible for other than a special enrollment period, coverage begins on the date
You become eligible, or on the date determined by Your Group. Groups cannot impose
waiting periods that exceed 90 days.

2. If You, the Subscriber, do not elect coverage upon becoming eligible or within 30 days of
becoming eligible for other than a special enrollment period, You must wait until the
Group’s next open enrollment period to enroll, except as provided below.

3. If You, the Subscriber, marry while covered, and We receive notice of such marriage within
30 days thereafter, coverage for Your Spouse and child starts on the first day of the month
following such marriage. If We do not receive notice within 30 days of the marriage, You
must wait until the Group’s next open enrollment period to add Your Spouse or child.

4. If You, the Subscriber, have a newborn child, your newborn child will be covered for the
first 60 days from the moment of birth. Your adopted newborn child will be covered for
60 days from the moment of birth if You take physical custody of the infant as soon as the
infant is released from the Hospital after birth. Your newborn will be subject to their own
Cost-Sharing for Covered services beginning on their date of birth, whether or not you
add your newborn to coverage permanently. Coverage is limited to benefits for otherwise
covered services for injury, sickness, necessary care and treatment of medically diagnosed
congenital defects or birth abnormalities, or any combination of these, and well child care.
However, We will not provide Hospital benefits for the adopted newborn’s initial Hospital
stay if one of the infant’s natural parents has coverage for the newborn’s initial Hospital
stay. If You have individual or individual and Spouse coverage, You must also notify Us of
Your desire to switch to parent and child/children or family coverage and pay any
additional Premium within 60 days of the birth or adoption in order for coverage to
continue beyond 60 days. Otherwise, coverage begins on the date on which We receive
notice, provided that You pay any additional Premium when due.

5. To continue the child’s coverage beyond 60 days, You must complete and return an
enrollment form, any requested documentation, and the required premium. If You do so
within 60 days of the date of birth, adoption, placement for adoption, legal guardianship,
legal custody, or within 60 days of the date the child became Your step child, Your child

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 will be added to Your coverage and will be covered effective as of the date of birth,
adoption, placement for adoption, or legal guardianship, legal custody, or as of the date
the child became Your step child. If You do not do so within 60 days of the events
described, You will not be able to add Your child to Your coverage until the first day of the
month following the next premium due date after the next open enrollment period when
We get the completed form, requested documents, and premium. Remember, a newborn
child is always covered for the first 60 days. If You belong to a Small Group with no open
enrollment period, Your child will be added to Your coverage as of the date MVP receives
Your completed enrollment form, any requested documents and premium. If You do not
notify us, we will not provide coverage for the child beyond the first 60 days.

E. Special Enrollment Periods---This Section Applies When You Have Coverage Through
Your Employer or Direct Through MVP.
You, Your Spouse or child, can also enroll for coverage within 60 days of the occurrence of one
(1) of the following events if your current coverage is through your employer or was purchased
direct through MVP:

1. You or Your Spouse or child loses minimum essential coverage, which includes the
termination of employer contributions for You or Your Dependents’ coverage;
2. Your enrollment or non-enrollment in another qualified health plan was unintentional,
inadvertent or erroneous and was the result of the error, misrepresentation, or inaction of
an officer, employee, or agent of VHC, or a non VHC entity providing enrollment assistance
or conducting enrollment activities, as evaluated and determined by VHC;
3. You adequately demonstrate to VHC that another qualified health plan in which You were
enrolled substantially violated a material provision of its contract;
4. You gain a Dependent or become a Dependent through marriage, birth, adoption,
placement for adoption or foster care, or through a child support order or other court
order, however, foster children are not covered under this Contract;
5. You lose a Dependent or are no longer considered a Dependent through divorce, legal
separation, or upon the death of You or Your Dependents;
6. You become eligible for new qualified health plans because of a permanent move and
You, Your Spouse or Child either had minimum essential coverage for one (1) or more days
during the 60 days before the move or were living outside the United States or a United
States territory at the time of the move;
7. If You are an Indian, as defined in 25 U.S.C. 450b(d), You and Your Dependents may enroll
in a qualified health plan or change from one qualified health plan to another one time
per month;
8. You demonstrate to VHC that You meet other exceptional circumstances as VHC may
provide;
9. You are a victim of domestic abuse or spousal abandonment, including a Dependent or
unmarried victim within a household, are enrolled in minimum essential coverage, and You
and Your Dependents seek to enroll in coverage separate from the perpetrator of the
abuse or abandonment;

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 10. You, Your Spouse or child apply for coverage during the annual open enrollment period
or due to a qualifying event, are assessed by VHC as potentially eligible for Medicaid or
Children’s Health Insurance Plan, but are determined ineligible for Medicaid or Children’s
Health Insurance Plan after open enrollment ended or more than 60 days after the
qualifying event;
11. You, Your Spouse or child apply for Medicaid or Children’s Health Insurance Plan coverage
during the annual open enrollment period and are determined ineligible for Medicaid or
Children’s Health Insurance Plan coverage after open enrollment has ended; or
12. You, Your Spouse or child adequately demonstrate to VHC that a material error related to
plan benefits, service area, or premium influenced Your decision to purchase a qualified
health plan through VHC.

We must receive notice and Premium payment within 30 days of one of these events. If You enroll
because You lost minimum essential coverage, your coverage will begin on the first day of the
month following Your loss of coverage. If You, Your Spouse or child enroll because You gain a
Dependent through adoption or placement for adoption, your coverage will begin on the date of
the adoption or placement for adoption. If You, Your Spouse or child enroll because of a court
order, your coverage will begin on the date the court order is effective. If You, Your Spouse or
child enroll because of the death of You or Your Dependents, your coverage will begin on the first
day of the month following Your application.

In all other cases, the effective date of Your coverage will depend on when We receive Your
application. If Your application is received between the first and fifteenth day of the month, your
coverage will begin on the first day of the following month. If Your application is received between
the sixteenth day and the last day of the month, your coverage will begin on the first day of the
second month.

In addition, You, Your Spouse or child can also enroll for coverage within 60 days of the occurrence
of one of the following events:
1. You or Your Spouse or child loses eligibility for Medicaid or Children’s Health Insurance
Plan; or
2. You or Your Spouse or child becomes eligible for Medicaid or Children’s Health Insurance
Plan.

We must receive notice and Premium payment within 60 days of one of these events. The effective
date of Your coverage will depend on when We receive Your application. If Your application is
received between the first and fifteenth day of the month, your coverage will begin on the first
day of the following month. If Your application is received between the sixteenth day and the last
day of the month, your coverage will begin on the first day of the second month.

F. Special Enrollment Periods---This Section Applies When Your Current Coverage is

Through VHC.

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 Outside of the annual open enrollment period, You, Your Spouse, or Child can enroll for coverage
within 60 days prior to or after the occurrence of one (1) of the following events if you purchased
your coverage through VHC:

1. You, Your Spouse or Child involuntarily loses minimum essential coverage, including
COBRA or state continuation coverage; including if You are enrolled in a non-calendar year
group health plan or individual health insurance coverage, even if You have the option to
renew the coverage;
2. You, Your Spouse or Child are determined newly eligible for advance payments of the
Premium Tax Credit because the coverage You are enrolled in will no longer be employer-
sponsored minimum essential coverage, including as a result of Your employer
discontinuing or changing available coverage within the next 60 days, provided that You
are allowed to terminate existing coverage;
3. You, Your Spouse or Child loses eligibility for Medicaid coverage, including Medicaid
coverage for pregnancy-related services and Medicaid coverage for the medically needy,
but not including other Medicaid programs that do not provide coverage for primary and
specialty care;
4. You, Your Spouse or Child become eligible for new qualified health plans because of a
permanent move and You, Your Spouse or Child had minimum essential coverage for one
(1) or more days during the 60 days before the move; or
5. You, Your Spouse or Child are no longer incarcerated.

Outside of the annual open enrollment period, You, the Subscriber, Your Spouse, or Child can
enroll for coverage within 60 days after the occurrence of one (1) of the following events:

1. You, Your Spouse or Child’s enrollment or non-enrollment in another qualified health plan
was unintentional, inadvertent or erroneous and was the result of the error,
misrepresentation, or inaction of an officer, employee, or agent of VHC, or a non-VHC
entity providing enrollment assistance or conducting enrollment activities, as evaluated
and determined by VHC;
2. You, Your Spouse or Child adequately demonstrate to VHC that another qualified health
plan in which You were enrolled substantially violated a material provision of its contract;
3. You gain a Dependent or become a Dependent through birth, adoption or placement for
adoption or foster care, or through a child support order or other court order, however,
foster Children and Children for whom You are a legal guardian are not covered under this
Contract;
4. You gain a Dependent or become a Dependent through marriage and You or Your Spouse
had minimum essential coverage for one (1) or more days during the 60 days before the
marriage;
5. You lose a Dependent or are no longer considered a Dependent through divorce, legal
separation, or upon the death of You or Your Dependents;
6. If You are an Indian, as defined in 25 U.S.C. 450b(d), You and Your Dependents may enroll
in a qualified health plan or change from one (1) qualified health plan to another one (1)
time per month;

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 7. You, Your Spouse or Child demonstrate to VHC that You meet other exceptional
circumstances as VHC may provide;
8. You, Your Spouse or Child were not previously a citizen, national, or lawfully present
individual and You gain such status;
9. You, Your Spouse or Child are determined newly eligible or newly ineligible for advance
payments of the Premium Tax Credit or have a change in eligibility for Cost-Sharing
Reductions;
10. You are a victim of domestic abuse or spousal abandonment, including a Dependent or
unmarried victim within a household, are enrolled in minimum essential coverage, and You
and Your Dependents seek to enroll in coverage separate from the perpetrator of the
abuse or abandonment;
11. You, Your Spouse or Child apply for coverage during the annual open enrollment period
or due to a qualifying event, are assessed by VHC as potentially eligible for Medicaid or
Children’s Health Insurance Plan, but are determined ineligible for Medicaid or Children’s
Health Insurance Plan after open enrollment ended or more than 60 days after the
qualifying event;
12. You, Your Spouse or Child apply for Medicaid or Children’s Health Insurance Plan coverage
during the annual open enrollment period and are determined ineligible for Medicaid or
Children’s Health Insurance Plan coverage after open enrollment has ended; or
13. You, Your Spouse or Child adequately demonstrate to VHC that a material error related to
plan benefits, service area, or premium influenced Your decision to purchase a qualified
health plan through VHC.

VHC must receive notice and any Premium payment within 60 days of one (1) of these events.

If You, Your Spouse or Child are applying due to a permanent move or marriage, You, Your Spouse
or Child can meet the requirement to demonstrate coverage in the 60 days prior to the permanent
move or marriage by having minimum essential coverage for one (1) or more days during the 60
days before the move or marriage; living in a foreign country or in a United States territory for
one (1) or more days during the 60 days before the move or marriage; You are an Indian as defined
in 25 U.S.C. 450b(d); or You lived for one (1) or more days during the 60 days before the move or
marriage in a service area where no qualified health plan was available through VHC.

G. Effective Dates of Coverage for Special Enrollment Periods.

If You, Your Spouse or Child enroll because You are losing minimum essential coverage within the
next 60 days, You are determined newly eligible for advance payments of the Premium Tax Credit
because the coverage You are enrolled in will no longer be employer-sponsored minimum
essential coverage, or You gain access to new qualified health plans because You are moving, and
Your selection is made on or before the triggering event, then Your coverage will begin on the
first day of the month following Your loss of coverage.

If You, Your Spouse or Child enroll because You got married, your coverage will begin on the first
day of the month following Your selection of coverage. If You, Your Spouse or Child enroll
because You gain a Dependent through adoption or placement for adoption, your coverage will

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 begin on the date of the adoption or placement for adoption. If You, Your Spouse or Child enroll
because of a court order, your coverage will begin on the date the court order is effective.

If You have a newborn or adopted newborn Child, your newborn child will be covered for the first
60 days from the moment of birth. In order to avoid a gap in your child’s coverage after the first
60 days, you must notify VHC of such birth within the first 60 days after the birth. If notice of the
birth is given to VHC beyond the first 60 days after birth, coverage begins on the date on which
VHC receives notice. We will not provide Hospital benefits for the adopted newborn’s initial
Hospital stay if one of the infant’s natural parents has coverage for the newborn’s initial Hospital
stay. If You have individual or individual and Spouse coverage, you must also notify VHC of Your
desire to switch to parent and child/children or family coverage and pay any additional Premium
within 60 days of the birth or adoption in order for coverage to continue beyond 60 days.
Otherwise, coverage begins on the date on which VHC receives notice, provided that You pay any
additional Premium when due.

If You, Your Spouse or Child enroll because of the death of You or Your Dependents, your
coverage will begin on the first day of the month following Your selection.

In all other cases, the effective date of Your coverage will depend on when VHC receives Your
selection. If Your selection is received between the first and fifteenth day of the month, your
coverage will begin on the first day of the following month, as long as Your applicable Premium
payment is received by then. If Your selection is received between the sixteenth day and the last
day of the month, your coverage will begin on the first day of the second month, as long as Your
applicable Premium payment is received by then.

H. Domestic Partner Coverage.

This Contract covers domestic partners of Subscribers as Spouses if you are covered with VHC or
you purchase coverage direct through MVP. This Contract covers domestic partners of
Subscribers as Spouses if you have coverage with your employer and your employer group allows
coverage of domestic partners. If You selected family coverage, Children covered under this
Contract also include the Children of Your domestic partner. Proof of the domestic partnership
and financial interdependence must be submitted in the form of:

1. Registration as a domestic partnership indicating that neither individual has been

registered as a member of another domestic partnership within the last six (6) months,
where such registry exists; or
2. For partners residing where registration does not exist, by an alternative affidavit of
domestic partnership.
a. The affidavit must be notarized and must contain the following:
x The partners are both 18 years of age or older and are mentally competent to
consent to contract;
x The partners have been living together on a continuous basis prior to the date
of the application;

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 x Neither individual has been registered as a member of another domestic
partnership within the last six (6) months; and
b. Proof of cohabitation (e.g., a driver’s license, tax return or other sufficient proof); and
c. Proof that the partners are financially interdependent. Two (2) or more of the following
are collectively sufficient to establish financial interdependence:
x A joint bank account;
x A joint credit card or charge card;
x Joint obligation on a loan;
x Status as an authorized signatory on the partner’s bank account, credit card or
charge card;
x Joint ownership of holdings or investments;
x Joint ownership of residence;
x Joint ownership of real estate other than residence;
x Listing of both partners as tenants on the lease of the shared residence;
x Shared rental payments of residence (need not be shared 50/50);
x Listing of both partners as tenants on a lease, or shared rental payments, for
property other than residence;
x A common household and shared household expenses, e.g., grocery bills, utility
bills, telephone bills, etc. (need not be shared 50/50);
x Shared household budget for purposes of receiving government benefits;
x Status of one (1) as representative payee for the other’s government benefits;
x Joint ownership of major items of personal property (e.g., appliances, furniture);
x Joint ownership of a motor vehicle;
x Joint responsibility for child care (e.g., school documents, guardianship);
x Shared child-care expenses, e.g., babysitting, day care, school bills (need not
be shared 50/50);
x Execution of wills naming each other as executor and/or beneficiary;
x Designation as beneficiary under the other’s life insurance policy;
x Designation as beneficiary under the other’s retirement benefits account;
x Mutual grant of durable power of attorney;
x Mutual grant of authority to make health care decisions (e.g., health care power
of attorney);
x Affidavit by creditor or other individual able to testify to partners’ financial
interdependence; or
x Other item(s) of proof sufficient to establish economic interdependency under
the circumstances of the particular case.

I. Obligation to Provide Information. You must give us information needed to determine

your initial and continuing eligibility status. This information must be provided within 30
days of our request. We have the right to verify this information.

J. When you, your Spouse or your child is no longer eligible for coverage. You must
immediately notify MVP or VHC of any event that affects your coverage. Such events
include, but are not limited to, divorce or annulment; death of your Spouse; Medicare,

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 Medicaid, or CHIP eligibility; coverage under another policy or contract; a child reaching
the age at which coverage terminates; a change in residency and a change or termination
of any medical support order.

K. If, because of the event, you want to change your coverage tier to one with a lower
premium, (such as a change from family to individual coverage), you must return a
completed change form and any requested documentation to your Group within 30 days
of such event or if your Group does not provide the information to MVP in a timely manner,
so that the change in premium will be effective as of the date of the event. If you do not,
your change in premium will not be effective until the first of the month following the next
premium due date after the form and documentation are received. This paragraph only
involves the effective date of changes in premiums.

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 SECTION FOUR - ACCESS TO PROVIDERS

When you become an Enrollee, you and each member of your family are encouraged but are not
required to pick a Primary Care Provider (PCP).

1. Finding a PCP or a Participating Provider.

Participating Providers can be found on our website at mvphealthcare.com.

2. No Referral Required. MVP does not require that you get a referral from your Participating
Provider for Covered Services from an MVP specialist. However, you are required to take
certain actions before getting the following Covered Services.

A. Non-Emergency In-Patient Hospital Services. You must be admitted by a

Participating Provider. The provider that admits you must get Pre-Authorization
from MVP for your hospital admission.

B. Non-Emergency Care Services From a Non-Participating Provider. An MVP

Participating Provider must submit a Pre-Authorization request on your behalf, and
you must receive prior written approval from MVP’s Utilization Management
Department before you get such services.

Talk to your Participating Provider for all of your health care needs. Even though you
do not need a referral, your Participating Provider should play a central role in your health
care. You should visit your Participating Provider for “Primary Care Services”. These are
routine office visits for well care, preventive care and basic health screenings. Primary Care
Services may not be covered under your contract unless your Participating Provider provides
them.

3. If you need to find other MVP Participating Providers in your area, please visit our Web site
at mvphealthcare.com. Click on “Find a Doctor” on the home page.

4. Use of Non-Participating Providers When Your Provider Leaves the Network.

If You are in an ongoing course of treatment when Your Provider leaves Our network, then
You may continue to receive Covered Services for the ongoing treatment from the former
Participating Provider for up to 90 days from the date Your Provider’s contractual
obligation to provide services to You terminates. If You are pregnant, You may continue
care with a former Participating Provider through delivery and any postpartum care
directly related to the delivery.

The Provider must accept as payment the negotiated fee that was in effect just prior to the
termination of Our relationship with the Provider. The Provider must also provide Us
necessary medical information related to Your care and adhere to our policies and
procedures, including those for assuring quality of care, obtaining Pre Authorization,

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 Referrals, and a treatment plan approved by Us. You will receive the Covered Services as
if they were being provided by a Participating Provider. You will be responsible only for
any applicable In-Network Cost-Sharing.

Please note that if the Provider was terminated by Us due to fraud, imminent harm to
patients or final disciplinary action by a state board or agency that impairs the Provider’s
ability to practice, continued treatment with that Provider is not available.

5. Use of Non-Participating Providers by New Enrollees in a Course of Treatment.

If You are in an ongoing course of treatment with a Non-Participating Provider when Your
coverage under this Certificate becomes effective, You may be able to receive Covered
Services for the ongoing treatment from the Non-Participating Provider for up to 60 days
from the effective date of Your coverage under this Certificate. This course of treatment
must be for a life-threatening disease or condition or a degenerative and disabling
condition or disease. You may also continue care with a Non-Participating Provider if You
are in the second or third trimester of a pregnancy when Your coverage under this
Certificate becomes effective. You may continue care through delivery and any post-
partum services directly related to the delivery.

In order for You to continue to receive Covered Services for up to 60 days or through
pregnancy, the Non-Participating Provider must agree to accept as payment Our fees for
such services. The Provider must also agree to provide Us necessary medical information
related to Your care and to adhere to Our policies and procedures including those for
assuring quality of care, obtaining Pre Authorization, Referrals, and a treatment plan
approved by Us. If the Provider agrees to these conditions, You will receive the Covered
Services as if they were being provided by a Participating Provider. You will be responsible
only for any applicable in-network Cost-Sharing.

6. Use of Non-Participating Providers when a qualified Participating Provider is not available.

Except as otherwise specifically provided in this Contract, in order for services to be eligible
for benefits under this Contract, services must be provided by a Participating Provider or
a Provider in our affiliate’s First Health/MagnaCare Network. In circumstances where a
qualified Participating Provider is not available to provide Covered Services to an Enrollee,
MVP may provide benefits for Covered Services provided by a Non-Participating Provider.
MVP will work with you or your provider as necessary to find a provider to provide the
services you need. When seeking benefits for using a Non-Participating Provider for your
health care services, some information we will need to know: information regarding your
condition, a medical opinion as to why services cannot be provided by a Participating
Provider, and the name and qualifications of the proposed Non-Participating Provider.
This information is best provided by your primary care physician or other specialty
physician you may be seeing. Your provider can provide this information to MVP by
following the Pre-Authorization requirements set forth in Section Six.

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 7. Use of Non-Participating Providers when an Enrollee is temporarily outside the service
area.

When an Enrollee temporarily lives, works, attends school or otherwise temporarily resides
outside of the service area, requires medically necessary services that would be covered
under the health benefit plan if the Enrollee were able to access care from contracted
providers within the service area, and it is medically necessary that the services be provided
promptly, locally and not delayed until the member's return to the service area, the
managed care organization shall assist the Enrollee in locating a provider in the Enrollee's
location that is contracted, otherwise affiliated or willing to arrange a single case
agreement and that has the appropriate training and experience to provide the services
that are medically necessary to meet the particular health care needs of the Enrollee.
Coverage shall be consistent with the terms and conditions of the Enrollee's Contract for
coverage of services obtained from a contracted provider within the service area. There
shall be no additional liability to the Enrollee.

8. Use of Non-Participating Providers for Emergency Services. We will provide benefits for
emergency services provided by a Participating or Non-Participating Provider for an
Emergency Medical Condition. We will ensure that you are held harmless for any Out-of-
Network Provider charges that exceed your Cost Share.

9. Out-of-Network Providers at Network Facilities. If you receive Medically Necessary,

Covered Services from an Out of Network Provider at a Network facility without your
informed consent, we will cover your care as if you had been treated by a Network
Provider. You must pay any Cost-Sharing amounts required under your Contract, which
will in no event be more than as if you received those services from a Network Provider.
These may include Deductibles, Co-insurance or Co-payments. Under federal law, unless
you give your informed consent, providers are prohibited from billing you for these
services beyond your Cost-Sharing amounts. If the Out of Network Provider requests any
payment from you other than your Cost-Sharing amounts, please contact us at the number
on the back of your ID card so that we can work directly with the Provider to resolve the
request.

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 SECTION FIVE – MEDICAL NECESSITY

1. We will only provide Benefits if a Covered Service is Medically Necessary. Medically

Necessary or Medical Necessity means that a Covered Service is:

A. Appropriate, in terms of type, amount, frequency, level, setting and duration, for
the diagnosis or treatment of your condition;

B. Consistent with generally accepted practice parameters as recognized by health

care providers in the same or similar specialty as typically treat or manage the
diagnosis or condition;

C. Must be informed by the unique needs of each individual patient and each
presenting situation;

D. One which:

i. Helps restore or maintain your health;

ii. Prevents deterioration of or palliate your condition; or
iii. Prevents the reasonably likely onset of a health problem or detect an
incipient problem.

Even though a Provider prescribes, performs, orders, recommends, or approves a service,

that does not mean that the service is Medically Necessary or that we must provide
benefits for the service.

2. MVP maintains protocols to assist in determining whether a service is Medically Necessary.

You may request a copy of such protocols by contacting MVP's Customer Care Center at
1-888-687-6277.

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 SECTION SIX - UTILIZATION MANAGEMENT

This Contract requires concurrent review and Pre-Authorization by MVP before you receive certain
Covered Services. All other services are subject to retrospective review. MVP's approval of services
through concurrent review, or Pre-Authorization are not a guarantee of benefits. MVP may deny
benefits in cases where there is material misrepresentation or fraud by an Enrollee, and as
otherwise permitted by law. Also see Section Thirteen, “Prescription Drug Coverage” for details
about how to get Pre-Authorization for prescription drugs.

1. Urgent Matters. Requests and claims for Retrospective Review are excluded from this
paragraph 1.

A. In cases involving Urgently Needed Care, we will notify you and your Provider, by
telephone, of our decision within 24 hours of the time that the request for
concurrent review and Pre-Authorization is requested. You and your Provider will
be notified, in writing, within 24 hours of the telephone notice.

B. In cases where:

i. application of the time periods described in paragraphs 2 or 3 below:

(a) could, applying the judgment of a prudent layperson with an average

knowledge of health and medicine, seriously jeopardize your life or
health or your ability to regain maximum function; or

(b) in the case of a pregnant woman, could place the health of an unborn
child in serious jeopardy;

(c) would, in the opinion of a physician with knowledge of your medical

condition, subject you to severe pain that cannot be adequately treated
without the requested services; or

ii. a physician with knowledge of your medical condition determines that a

concurrent review or Pre-Authorization request is urgent, if all necessary
information is received at the time of the request, we will notify you and
your Provider, by telephone and in writing, of our decision within 48 hours
after our receipt of the request. If all necessary information is not received
at the time of the request, we will notify you and your Provider within 24
hours after our receipt of the request of any missing information that is
needed to decide the request. You and your Provider will have 48 hours
from the receipt of our notice to provide us with the missing information.
In such cases, we will notify you and your Provider, by telephone and in
writing, of our decision within 48 hours after: (a) our receipt of the missing

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 information; or (b) the expiration of your time to provide the missing
information, whichever is sooner.

2. Pre-Authorization. The approval that your Provider must get from MVP before you receive
certain outpatient, home care, and professional services, and certain prescription drugs.
MVP reviews information about your medical condition and the services in order to
determine whether such services are Medically Necessary Covered Services. It is also the
approval that your Participating Provider must get from MVP before you receive any
services from a Non-Participating Provider.

A. When Pre-Authorization is Required.

i. For In-Network Services. Check with your MVP Participating Provider. He

or she will ask for Pre-Authorization from MVP on your behalf when it is
needed for In-Network services. MVP makes a list of these services
available to Participating Providers. Go to MVP’s website at
mvphealthcare.com if you would like to see the list of In-Network services
that need Pre-Authorization. You may also call MVP’s Customer Care
Center at 1-888-687-6277 to ask if a service is on the list.

ii. For Out-of-Network Services. You must get Pre-Authorization from MVP
for yourself when the services are Out-of-Network. Go to MVP’s website at
mvphealthcare.com for a list of Out-of-Network services that require you
to get Pre-Authorization. You may also call MVP’s Customer Care Center
at 1-888-687-6277 to ask if a service is on the list.

B. If all necessary information is received at the time of the Pre-Authorization request,

we will notify you and your provider, by telephone and in writing, of our decision
as soon as possible but no later than two (2) business days from receipt of the
request. If all necessary information is not received at the time of the Pre-
Authorization request, we will notify you and your Provider of any missing
information that is needed to decide the request. You and your Provider will have
45 days from the receipt of our notice to provide us with the missing information.
MVP will make our decision and notify you and your Provider, in writing, within two
(2) business days of receipt of the information or the expiration of the time allowed
to provide the missing information, whichever is earlier.

3. Concurrent Review. Concurrent review means MVP’s review of a request to extend a

course of treatment beyond the period of time or number of treatments approved under
paragraph 2, to determine whether such services continue to be Medically Necessary
Covered Services. The services reviewed include inpatient services, skilled nursing facility
services, home care services, and ongoing professional care services. Your Provider must
give us the information needed to conduct this review before the end of each period for
which your benefits were approved. If all necessary information is received at the time of

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 the concurrent review, we will notify you and your Provider, in writing and your provider
by telephone, of our decision within 24 hours after the review. If all necessary information
is not received at the time of the concurrent review request, we will contact your Provider
or Facility for any missing information that is needed to conduct the review. If we deny
benefits as a result of our review, we will not provide any benefits after the date that you
receive notice of our decision. If we deny benefits, you must pay all charges.

4. Retrospective Review. Retrospective review means our review, after services have been
provided to you, to determine whether such services are Medically Necessary Covered
Services. We will review information about your medical condition and the services
provided to you. If all necessary information is received at the time of the request for
retrospective review, we will notify you of any adverse determination, in writing, within 30
days after our receipt of the request. If all necessary information is not received at the
time of the request for retrospective review, we will notify you and your Provider within 5
days after our receipt of the request of any missing information that is needed to decide
the request. You and your Provider will have 45 days from receipt of our notice to provide
us with the missing information. In such cases, we will notify you of any adverse
determination, in writing, within 30 days after: (a) our receipt of the missing information;
or (b) the expiration of your time to provide us with the missing information, whichever is
sooner. Except in cases of missing information, MVP's time to conduct retrospective
review shall not exceed a total of thirty (30) days.

5. Emergency or Urgent Care Services. You, your Provider, or a family member or other
representative must contact us at 1-800-348-8515 within 48 hours, or as soon as
reasonably possible, after receiving Emergency Services or Urgent Care Services that result
in an inpatient admission so that MVP can coordinate your follow up care.

6. Right to File a Grievance. If you disagree with our decisions under this section, you may
file a grievance as described in Section Twenty.

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 SECTION SEVEN – COVERED HOSPITAL INPATIENT SERVICES

1. Pre-Authorization and Concurrent Review are required for all Hospital inpatient services.

2. What is a hospital? As used in this Contract, the term “hospital” means a duly licensed,
short-term, acute care facility that primarily provides diagnostic and therapeutic services
for diagnosis, treatment and care of injured and sick persons by or under the supervision
of physicians. Such facility has organized departments of medicine and major surgery and
provides twenty-four (24) hour nursing service by or under the supervision of registered
nurses. The following are not within the definition of Hospital:

x Convalescent homes.
x Convalescent, rest or nursing facilities.
x Facilities primarily affording custodial or educational care.
x Health resorts, spas or sanitariums
x Infirmaries at schools, colleges or camps
x Facilities for the aged.
x Any military or veteran’s hospital or soldiers’ home, or any hospital contracted for or
operated by any national government or agency thereof for the treatment of Enrollees
or ex-Enrollees of the armed forces, except for services rendered for Emergency
Medical Conditions, where a legal liability exists for charges made to the individual for
such services.
x Residential Care Facilities.

3. Inpatient Services. We will provide benefits for the following when provided to you in a
participating Hospital:

x Semi-private room.
x Board and general nursing services.
x Use of operating, recovery, delivery, endoscopic and treatment rooms and equipment.
x Use of intensive care or special care units and equipment.
x Diagnostic and therapeutic items used in and provided by the Hospital, such as
prescribed drugs, medications, sera, biologicals and vaccines, intravenous preparations
and visualizing dyes, and the administration of such items.
x Dressings and casts.
x Diagnostic Services.
x Therapeutic Services.
x Professional services, equipment, and supplies in connection with oxygen, anesthesia.
x Laboratory services.
x Pathology services.
x Medical and surgical supplies.
x Therapy Services.

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 4. Maternity Care. We provide benefits for the inpatient services listed in paragraph 3 to a
covered mother for childbirth for at least 48 hours after a vaginal delivery. The same
benefits are provided for at least 96 hours after a cesarean delivery. The attending
provider, with the mother or mother’s designated representative, may determine to
discharge the mother sooner. In the event the mother elects to leave the Hospital
following delivery and requests a home care visit before the end of the 48-hour or 96-
hour minimum Coverage period, we will Cover a home care visit. The home care visit will
be provided within 24 hours after the mother’s discharge, or at the time of the mother’s
request, whichever is later. Our coverage of this home care visit shall be in addition to
home health care visits under this Contract and shall not be subject to any Cost-Sharing
amounts in the Summary of Benefits and Coverage (SBC) that apply to home care benefits.
We will also provide benefits for these inpatient services for pregnancy and Complications
of Pregnancy. You may get these services from a physician, licensed midwife, or an
advanced practice registered nurse who is certified as a nurse midwife. You may receive
these services in a facility or at your home. To receive Benefits from a midwife, or nurse
midwife, the midwife, nurse midwife and facility must be Participating. Coverage is subject
to the same Cost Share as any other maternity care listed on your SBC.

5. Newborn Care. We will provide benefits for well-baby care and an initial hospital visit for
the baby while the mother is an inpatient. The attending physician, with the newborn’s
mother or the newborn’s designated representative, may determine to discharge the
newborn sooner. Subject to the requirements set forth in Section Three, we will also
provide benefits for a covered newborn from the moment of birth through 60 days or such
other period required by law after birth for Covered Services for sickness, injury, and
medically diagnosed congenital defects or birth abnormalities, or any combination of
these.

6. Breast Cancer Care. We will provide benefits for the inpatient services listed in paragraph
3 in connection with an inpatient hospital stay following a mastectomy, lymph node
dissection or lumpectomy for the treatment of breast cancer, and for physical
complications of mastectomy, including lymphedema. We will also provide benefits for
these inpatient services in connection with an inpatient hospital stay following
reconstruction of the breast on which a mastectomy was performed, and surgery and
reconstruction of the other breast to produce a symmetrical appearance. These surgical
services will be performed in the manner that your attending physician, in consultation
with you, determines is appropriate.

7. Mental Health and Substance Use Care

A. Mental Health Conditions. We will provide benefits for the inpatient services listed
in paragraph 3 for treatment of mental health conditions only when provided in a
mental health facility qualified pursuant to rules adopted by the secretary of human
services or in an institution approved by the secretary of human services, that
provides a mental health treatment program pursuant to a written plan. We will

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 also provide benefits for mental health residential treatment centers. The facility
must also be a Participating Provider.

We will not provide benefits for the following services: adventure-based activities,
wilderness programs residential programs that focus on education, socialization
or delinquency, Custodial Services (see Section Two – Definitions), and we will not
provide benefits for marriage counseling.

B. Alcohol or Substance Use Disorders. We will provide benefits for the inpatient
services listed in paragraph 3 only when provided pursuant to a written treatment
plan in a facility approved by the secretary of human services that provides a
program for the treatment of alcohol or substance use disorders. We will also
provide benefits for substance use residential treatment centers. The facility must
also be a Participating Provider.

We will not provide Benefits for the following services: adventure-based activities,
wilderness programs, residential programs that focus on education, socialization,
or delinquency, and Custodial Services (see Section Two - Definitions).

8. Physical Rehabilitation Care. We will provide benefits for the services listed in paragraph
3 only when such services are Acute Services provided by a participating free standing
facility licensed to provide inpatient physical rehabilitation services or by a unit of a
participating Hospital designated as providing such services.

9. Skilled Nursing Facility Care. Care that is most appropriately provided in a Skilled Nursing
Facility, but at MVP’s discretion is provided on an inpatient basis in a Hospital, may be
covered under your Skilled Nursing Facility benefits.

10. You must pay the Cost Share listed on your SBC for Hospital inpatient services.

11. Gender Reassignment Services for Gender Dysphoria. We will provide benefits for
medically necessary Gender reassignment services.

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 SECTION EIGHT – COVERED OUTPATIENT SERVICES

1. Outpatient Services. We will provide benefits for the following outpatient services. Such
services must be provided to you in the outpatient department of a participating Hospital
or a participating free standing facility:

A. Pre-surgical testing. We will provide benefits for tests given to you before your
admission to a Hospital if:

x Your physician has ordered the tests; and

x An operating room at the hospital has been reserved for surgery.

You must pay the Cost Share listed on your Summary of Benefits and Coverage (SBC).

B. Outpatient Surgery. We will provide benefits for Surgery, abortion services,

sterilizations and one attempt at reversal of sterilization. These services are subject
to Pre-Authorization. You must pay the Cost Share listed on your SBC for each
surgery. Voluntary sterilization procedures for females are covered with no Cost
Share.

C. Therapeutic Services. We will provide benefits for outpatient Therapeutic Services.

You must pay the Cost Share listed on your SBC for each visit.

D. Contraceptive Services. We will provide benefits for outpatient contraceptive

services as per HRSA guidelines for all FDA approved contraceptive methods
including office visits and consultations. We will provide benefits for office visits
associated with insertion, removal, counseling, and monitoring of contraceptive
devices as medically necessary. Contraceptive services are covered in full.

E. Treatment of Mental Health Conditions. We will provide benefits for outpatient

treatment of Mental Health Conditions only when provided by a participating
licensed or certified mental health provider. You must pay the Cost Share listed on
your SBC for each visit. Covered services include outpatient individual, group, and
family therapies, medication management, psychological/neuropsychological
testing, intensive outpatient and partial hospitalization programs, Transcranial
Magnetic Stimulation (TMS), and Electroconvulsive Therapy (ECT).

F. Treatment of Alcohol or Substance Use Disorders. We will provide benefits for

outpatient treatment of alcohol or substance use only when provided by a
participating licensed or certified substance use provider. You must pay the Cost
Share listed on your SBC for each visit. Covered services include outpatient
individual, group, and family therapies, medication management, Medication
Assisted Treatment (MAT), opioid treatment programs, and intensive outpatient
and partial hospitalization programs.

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 G. Mammography Screenings. We will provide the following benefits for outpatient
mammography screening for breast cancer:

(a) for Enrollees under age 40, we will provide benefits for mammography
screening when recommended by a participating physician; and

(b) for Enrollees age 40 and older, we will provide benefits for an annual
mammography screening.

Mammography screenings are covered in full, there is no cost-share for the

Enrollee.

H. Diagnostic Services. We will provide benefits for outpatient Diagnostic Services.

Please refer to your SBC.

I. Laboratory Services. We will provide benefits for outpatient laboratory services.

Please refer to your SBC.

J. Diagnostic and Therapeutic Items. This section includes benefits for items used in
and furnished by the outpatient department or free-standing center. This includes:
drugs, medications, sera, biologicals, vaccines, intravenous preparations and
visualizing dyes administered during the course of receiving Covered Services, and
the administration of such items.

K. Cardiac or Pulmonary Rehabilitation. We cover up to three (3) supervised exercise

sessions per week up to a total of 36 sessions for cardiac or pulmonary
rehabilitation programs. For cardiac rehabilitation, we cover an additional 36
sessions for each new acute cardiac event.

L. Out of Pocket costs for treatment of victims of sexual assault. Treatment and
examinations for victims of sexual assault are covered with no Cost Share.

M. Gender Reassignment Services for Gender Dysphoria. We will provide benefits for
medically necessary Gender reassignment services.

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 SECTION NINE – COVERED SKILLED NURSING FACILITY SERVICES

1. Pre-Authorization and Concurrent Review are required for all Skilled Nursing Facility
services.

2. What is a Skilled Nursing Facility (SNF)? – A skilled nursing facility is a licensed facility that
provides inpatient skilled nursing care and related services. It is certified as a participating
SNF by Medicare or accredited as an SNF by the Joint Commission on Accreditation of
Healthcare Organizations. A SNF is not, other than occasionally, a place that provides
minimal, custodial, ambulatory or part-time care services. The SNF must be a Participating
Provider.

3. Conditions for SNF Services. We will provide benefits for SNF services only if the following
conditions are met:

A. your admission is for ongoing treatment of the condition for which you were
hospitalized;
B. you would otherwise require skilled care as a hospital inpatient if you were not
admitted to the SNF; and
C. you require inpatient skilled nursing or Therapy Services on a daily basis.

4 Skilled Nursing Facility Services. We will provide benefits for the inpatient skilled nursing
facility services listed below up to 60 days per Plan Year for non-custodial care.

x Room and board in a semiprivate room.

x Skilled nursing care.
x Therapy Services.
x Drugs, medications, supplies and equipment used in and furnished by the SNF.
x Other services provided by the SNF that would be covered if you were an
inpatient in a hospital.

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 SECTION TEN – SPECIAL COVERED SERVICES

1. Home Care.

A. Pre-Authorization is required for out of network Home Care Services. Concurrent

Review is required for out of network Home Care Services.

B. What is a home care agency? A home care agency is a hospital or agency licensed
or certified to operate as a home care agency.

C. Conditions for Home Care Services. We will provide benefits for home care services
under the following conditions.

i. The services are supervised by a participating physician under a written

treatment plan.
ii. The services are provided by a participating home care agency.
iii. Without these services you would need to be admitted to a Hospital or
Skilled Nursing Facility.

D. Home Care Services. We will provide benefits for the services listed below.

i. Part time or intermittent skilled nursing care by or under the supervision of

a registered nurse.

ii. Part time intermittent home health aide services, provided that such
services consist primarily of caring for the patient and do not include
custodial care.

iii. Therapy Services if provided by home health agency personnel.

iv. Medical supplies, drugs, the purchase or rental of durable medical

equipment, and laboratory services, to the same extent that such laboratory
services would have been covered if you were an inpatient in a Hospital or
Skilled Nursing Facility.

E. Payment. You must pay the Cost Share listed on your Summary of Benefits and
Coverage (SBC) for each home care visit and for any Durable Medical Equipment.

2. Ambulance Services. We will provide benefits for Hospital, municipal, professional, or

licensed voluntary ambulance services to and from a Hospital, between Hospitals, and
between a Hospital and a Skilled Nursing Facility. These services are subject to Pre-
Authorization. Please refer to your SBC.

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 3. Hospice Services.

A. What is Hospice? Hospice is an organization engaged in providing services to

terminally ill persons. It must be federally certified to provide hospice services or
accredited as a hospice by the Joint Committee of Accreditation of Health Care
Organizations and must be a Participating Provider.

B. Conditions for Hospice Services.

We will provide benefits for Hospice Services under the following conditions.

i. A physician certifies and MVP agrees that your terminal illness has a
prognosis of 6 month life expectancy or less; and
ii. You and your physician consent to a written Hospice care plan.

We Cover inpatient Hospice Services in a Participating Hospice or Participating Hospital

and home care and outpatient services provided by the hospice, including drugs and
medical supplies. We also Cover supportive care and guidance for the purpose of helping
You and Your immediate family cope with the emotional and social issues related to Your
death, either before or after Your death. We do not Cover: funeral arrangements; pastoral,
financial, or legal counseling; or homemaker services, companion care, or unskilled respite
care. You must pay the Copayment, Deductible and/or Coinsurance that applies.

4. Private Duty Nursing

A. You must get Pre-Authorization for private duty nursing.

B. We cover skilled nursing Services by a private-duty nurse outside of a hospital,
subject to these limitations:

i. We limit Benefits for private duty nursing for up to 4 visits per Enrollee, per
year.
ii. We provide Benefits only if you receive Services from a registered or
licensed practical nurse. We do not Cover private duty nursing Services
provided at the same time as home health care nursing Services.

5. Delivery of Covered Services Using Telehealth. If Your Participating Provider offers

Covered Services using telehealth, We will not deny the Covered Services because they are
delivered using telehealth. Covered Services delivered using telehealth may be subject to
utilization review and quality assurance requirements and other terms and conditions of
the Contract that are at least as favorable as those requirements for the same service when
not delivered using telehealth. “Telehealth” means the use of electronic information and
communication technologies by a Participating Provider to deliver Covered Services to
You while Your location is different than Your Provider’s location. “Telehealth” also
includes coverage for all medically necessary, clinically appropriate health care services

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 delivered remotely by audio-only telephone to the same extent covered if they were
provided through in-person consultation. This includes services that are covered when
provided in the home by home health agencies.

6. Telemedicine Program
In addition to providing Covered Services via telehealth, We cover online internet
consultations between You and Providers who participate in our telemedicine programs
for medical conditions that are not an Emergency Condition.

The telemedicine programs are provided pursuant to contracts with Amwell, Galileo, and
UCM Digital Health, and are services that provide Participants with access to a national
network of Providers for medical care in connection with a wide range of conditions and
cases, including some mental health disorders. A member can access these services
through video and/or phone, using either desktop or mobile devices. More information
can be found at StartWithGia.com.

SECTION ELEVEN - COVERED EMERGENCY SERVICES AND URGENTLY NEEDED CARE

1. Emergency Services. We will provide benefits for emergency services provided by a

Participating or Non-Participating Provider only if your condition is an Emergency Medical
Condition.

A. Emergency Condition. A medical or behavioral condition manifesting itself by

acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in:

(1) Placing the health of the person afflicted with such condition (or, with
respect to a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy, or in the case of a behavioral condition placing
the health of such person or others in serious jeopardy;

(2) Serious impairment to such person’s bodily functions;

(3) Serious dysfunction of any bodily organ or part of such person; or

(4) Serious disfigurement of such person.

B. Emergency Services. A medical screening examination that is within the capability

of the emergency department of a Hospital or of an independent freestanding
emergency department, as applicable, including ancillary services routinely
available to the emergency department to evaluate an Emergency Condition; and
within the capabilities of the staff and facilities available at the Hospital or the

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 independent freestanding emergency department, such further medical
examination and treatment as are required to stabilize the patient. Emergency
Services also include items and services for which benefits are provided or covered
that are furnished (regardless of the department of the hospital in which such items
or services are furnished) after the patient is stabilized and as part of outpatient
observation or an inpatient or outpatient stay which respect to the visit in which
the pre-stabilization Emergency Services are furnished.

C. Cost Sharing. Out of Network Emergency Services are subject to the same cost
share as In-Network Emergency Services.

D. Pre-Authorization. Emergency Services are not subject to Pre-Authorization

requirements.

E. You, your Provider, or a member of your family must call MVP at 1-800-348-8515
within 48 hours, or as soon as reasonably possible, after receiving Emergency
services.

F. Your Participating Provider must coordinate your care after you receive Emergency
services.

G. Your Payments. You must pay the Cost Share listed on your Summary of Benefits
and Coverage (SBC) for Emergency services. We will ensure that you are held
harmless for any Out-of-Network Provider charges that exceed your Cost Share.
You will not have to pay the Cost Share for Emergency Services if you are admitted
to a Hospital right away. You will have to pay the Cost Share for Hospital inpatient
services.

2. Urgently-Needed Care. We will provide benefits for Urgently Needed Care provided by a
Participating or a Non-Participating Provider. However, you must first call your Provider
and follow his or her instructions as to what you should do.

A. Urgently-Needed Care provided by a Participating Provider means Medically

Necessary Covered Services to treat an illness or condition that if not treated within
24 hours presents a serious risk of harm.

B. Urgently-Needed Care provided by a Non-Participating Provider means Medically

Necessary Covered Services to screen and stabilize a condition that if not treated
within 24 hours presents a serious risk of harm, so that you can be safely
transported to a Participating Provider; provided that such services were received
because you were unable to receive services from a Participating Provider.

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 C. You, your Provider, or a member of your family must call MVP at 1-800-348-8515
within 48 hours, or as soon as reasonably possible, after receiving Urgently-Needed
Care that results in an inpatient admission.

D. Your Participating Provider must coordinate your care after you receive Urgently-
Needed Care.

E. You must pay the applicable Cost Share listed on your Summary of Benefits and
Coverage (SBC). You will not have to pay the Cost Share for Urgently-Needed care
if you are admitted to a Hospital right away. You will have to pay the Cost Share
for Hospital inpatient services.

3. Ambulance Services. We will provide benefits for ambulance services, when used for an
Emergency Medical Condition. Please refer to your SBC.

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 SECTION TWELVE – COVERED PROFESSIONAL CARE AND SERVICES

1. After Hours Provider Services. Providers must provide or arrange for on-call coverage 24
hours per day, seven 7 days per week. If you become sick or injured outside of the
Provider’s regular office hours, you should call his or her office, identify yourself as an MVP
Enrollee, and follow the Provider or covering physician’s instructions. If you require
Emergency Services or Urgently-Needed Care, you must follow the procedures set forth in
Section Eleven.

2. Covered Services. We will provide benefits for the following professional care and services
at the office of a Participating Provider. Except as otherwise provided, you must pay the
Cost Share listed on your Summary of Benefits and Coverage (SBC) for each visit. You will
be held harmless if a Participating Provider engages services on Your behalf that You could
not reasonably be expected to know were provided by a Non-Participating Provider.

A. Preventive Care Services. These services must be provided by a Participating

Provider but need not be Medically Necessary.

i. Well Child Care. We will provide benefits for Well Child Care for covered
children from the date of birth through attainment of age 19, when
provided by your Participating Provider. Well Child Care means an initial
newborn check-up in the hospital and well child visits. Well child visits
include a medical history, a complete physical examination, developmental
assessment, anticipatory guidance, and laboratory tests ordered at the time
of the visit. Such laboratory tests must be performed in the office or in a
clinical laboratory. All well child visits must be provided in accordance with
the standards and frequency SBC of the American Academy of Pediatrics.
Well Child Care also includes immunizations against diphtheria, pertussis,
tetanus, polio, measles, rubella, mumps, hemophilus influenza type B, and
hepatitis B, and other necessary immunizations.

ii. Periodic Health Evaluations. We will provide benefits for periodic routine
physical examinations and immunizations for covered persons age 19 and
older as determined appropriate by age and sex, when provided by your
Participating Provider.

iii. Gynecological Health Care Services. We will provide benefits for

gynecological health care services provided by a Participating Provider.
Gynecological health care services means preventive and routine
reproductive health and gynecological care, including contraceptive
services. Such services include annual screening, counseling and treatment
of gynecological disorders and diseases in accordance with the most
current published recommendations of the American College of
Obstetricians and Gynecologists. We will also provide benefits for follow-

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 up services required as a result of problems identified during such visits.
For a list of Participating Providers who specialize in obstetrics or
gynecology, contact the Customer Care Center at 1-888-687-6277.

iv. Mammography Screenings. We will provide the following benefits for

mammography screening for breast cancer:

(a) for Enrollees under age 40, we will provide benefits for
mammography screening when recommended by a participating
physician; and

(b) for Enrollees age 40 and older, we will provide benefits for an annual
mammography screening.

v. Screening Colonoscopies and Sigmoidoscopies. This is an Adult Preventive

Care Service. MVP will cover this in-network only as follows:

(a) For Enrollees age fifty (50) and older we will provide benefits for an
annual fecal occult blood test plus one flexible sigmoidoscopy every
five (5) years; or one colonoscopy every ten (10) years or more often
as Medically Necessary.

(1) Colonoscopy means a procedure that enables a physician to

examine visually the inside of a patient’s entire colon and
includes the removal of polyps, biopsy or both.
(2) Sigmoidoscopy means a procedure that enables a physician
to examine visually the inside of the distal portion of a
patient’s colon.

(b) For Enrollees at high risk for colorectal cancer, we will provide
benefits for cancer screening examinations and laboratory tests as
recommended by the treating physician. You are considered to be
at high risk if you have

(1) a family medical history of colorectal cancer or a genetic

syndrome predisposing the individual to colorectal cancer;

(2) a prior occurrence of colorectal cancer or precursor polyps;

(3) a prior occurrence of a chronic digestive disease condition

such as inflammatory bowel disease, Crohn’s disease, or
Ulcerative Colitis; or

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 (4) other predisposing factors as determined by the individual’s
treating physician.

vi. Diagnostic Screening for Prostate Cancer. This is an Adult Preventive Care
Service. You will not be required to make a payment for this service.

We will provide Benefits for diagnostic screening for prostate cancer

subject to the following limits.

(a) Standard diagnostic testing, including a digital rectal examination

and a prostate specific antigen test; and

(b) An annual standard diagnostic examination, including a digital

rectal examination and a prostate specific antigen test for men, in
accordance with the standards set forth by the Centers for Disease
Control.

vii. Items or services with an “A” or “B” rating from the United States Preventive
Services Task Force;

viii. Immunizations pursuant to the Advisory Committee on Immunization

Practices (“ACIP”) recommendations; and

ix. Preventive care and screenings that are provided for in the comprehensive
guidelines supported by the Health Resources and Services Administration
(“HRSA”).

[x.

The preventive services referenced above shall be covered in full when received
from In-Network Providers. Cost Sharing may apply to services provided during
the same visit as the preventive services set forth above. For example, if a service
referenced above is provided during an office visit wherein that service is not the
primary purpose of the visit, the cost-sharing amount that would otherwise apply
to the office visit will still apply.

A list of the preventive services covered under this paragraph is available on our
website at mvphealthcare.com or will be mailed to you upon request. You may
request the list by calling the Customer Care Center at 1-888-687-6277.

B. Participating Provider Office or Home Visits. We will provide benefits for the
examination, diagnosis, and treatment of an injury, illness or condition, and for
prenatal and postpartum care, and laboratory services provided at the time of such
visit. Coverage includes injections given during a covered office visit.

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 C. Health Education and Nutrition Counseling. We will provide benefits for health
education and nutritional counseling when provided by Participating Providers as
part of a medical treatment program. There is no limit on the number of visits for
nutritional counseling. You must receive nutritional counseling from one of the
following Network Providers or we will not provide Benefits:
x medical doctor (M.D.);
x doctor of osteopathy (D.O.);
x registered dietitian (R.D.);
x nutritionist licensed in Vermont;
x certified diabetic educator (C.D.E.);
x naturopathic physician (N.D.); or
x nurse practitioner.

D. Consultations. We will provide benefits for inpatient or office consultations by

Participating Providers when requested by your attending physician for the
evaluation of your condition. A report must be given to your Participating Provider.

E. Second Surgical Opinions. We will provide benefits for a second surgical opinion
when your provider has made a recommendation on the need for covered elective
surgery. You are not required to have a second surgical opinion. The second
opinion must be given by a participating board-certified specialist who examines
you and who, by reason of his or her specialty, is competent to consider the
proposed surgery.

F. Treatment of Mental Health Conditions. We will provide benefits for treatment of

mental health conditions only when provided by a licensed or certified mental
health professional who is a Participating Provider.

G. Treatment of Alcohol or Substance Dependency. We will provide benefits for

treatment of alcohol or substance dependency only when provided by a substance
abuse counselor or other person approved by the secretary of human services who
is a Participating Provider.

H. Chiropractic Treatment. We will provide benefits for clinically necessary

chiropractic services, for treatment of conditions related to subluxations, joint
dysfunctions, and neuromuscular and skeletal disorders, when such services are
provided by a participating licensed doctor of chiropractic (D.C.). We will not
provide benefits for:

(i) adjunctive therapies, except physiotherapy modalities and rehabilitative

exercises when used in conjunction with other, covered, chiropractic
treatment; and
(ii) treatment of any visceral condition arising from problems or dysfunctions
of the abdominal or thoracic organs.

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 I. Diabetes Treatment. We will provide benefits for equipment, supplies, and
outpatient self-management training and education, including medical nutrition
therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes,
gestational diabetes, and non-insulin using diabetes if such equipment, supplies
and training are prescribed by a licensed, participating health care professional
legally authorized to prescribe such items. We will provide benefits for the self-
management training and education, including medical nutrition therapy,
described above only if provided by a participating certified, registered, or licensed
health care professional with specialized training in the education and
management of diabetes. We will provide benefits for Medically Necessary routine
foot care for the treatment of diabetes. You must pay the Cost Share for
prescription drugs set forth on your SBC for diabetic equipment and supplies.
Diabetic treatment services are subject to your medical benefit cost share in your
SBC.

J. Allergy Tests and Treatment. We will provide benefits for diagnosis and treatment
of allergies by Participating Providers, including test and treatment materials. Cost
Share applicable to office visits applies.

K. Inpatient Medical Care. We will provide benefits for medical services rendered
when you are receiving covered inpatient services in: (1) a participating Hospital or
Skilled Nursing Facility; (2) a participating mental health care facility or institution
for the treatment of alcohol or substance dependency; or (3) a participating
physical rehabilitation facility. We will only provide benefits for one visit per day
per Participating Provider. MVP may provide benefits for Covered Services
provided by a Non-Participating Provider when a qualified Participating Provider
is not available (see Section Four). Please refer to your SBC for the required cost-
share.

L. Surgery. We will provide benefits for surgery and surgical care rendered by a
Participating Provider. These services, when provided in the outpatient
department of a hospital or in a free standing ambulatory surgery center, are
subject to Pre-Authorization.

M. Anesthesia Services. We will provide benefits for anesthesia services provided by

a Participating Provider in connection with Covered Services. You must pay the
Cost Share listed on your SBC.

N. Anesthesia for Certain Dental Procedures. We will cover general anesthesia for
certain dental procedures in a hospital or ambulatory surgical center given by a
Participating Provider who is licensed to give anesthesia. You must obtain Pre-
Authorization from MVP before receiving benefits. You must pay the Cost Share
listed on your SBC. Anesthesia services are provided:

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 i. for an Enrollee who, as declared by a licensed dentist, are not able to get
Medically Necessary dental care in an outpatient setting. The treating
Provider must certify that hospitalization and general anesthesia are a must
to treat the patient; or
ii. for an Enrollee with a diagnosed phobia or Mental Health Condition whose
dental needs are significantly complex and urgent such that delaying
treatment can be expected to cause infection, loss of teeth, or other
increased oral or dental morbidity; or for those for whom a good result
cannot be expected from dental care given under local anesthesia and a
better result can be expected if care is given under general anesthesia.
iii. for an Enrollee who has exceptional medical needs or a developmental
disability which place the person at serious risk.

Benefits are only for general anesthesia and any related hospital or facility charges.
Except as specifically provided in Section Twelve, MVP will not provide benefits for
the dental procedure. The anesthesia must be given by a fully accredited specialist
in pediatric dentistry, a fully accredited specialist in oral and maxillofacial surgery
or a dentist who has hospital rights.

O. Laboratory Services. These services must be provided by a Participating Provider.

P. Diagnostic Services. These services must be provided by a Participating Provider.

Q. Therapeutic Services. These services must be provided by a Participating Provider.

R. Casts and Dressings. These services must be provided by a Participating Provider.

S. Medical Foods. We will provide benefits for low protein modified food products,
enteral formulae, and medical foods prescribed by a participating provider for use
under the direction of a participating physician for the medically necessary dietary
treatment of an inherited metabolic disease. A low protein modified food product
must be specifically formulated to have less than one gram of protein per serving.
A medical food means an amino acid modified preparation. You must pay the Cost
Share listed on your SBC.

T. Craniofacial Disorders. We will provide benefits for Participating Provider services

for diagnosis and treatment, including surgical and non-surgical procedures, of a
musculoskeletal disorder that affects any bone or joint in the face, neck or head
provided that such disorder is the result of accident, trauma, congenital defect,
developmental defect, or pathology. Surgical procedures require a second opinion
as set forth in paragraph 2(E) above, and are subject to Pre-Authorization
requirements. We will not provide benefits for the diagnosis and treatment of
dental conditions or disorders or for dental pathology primarily affecting the gums,
teeth, or alveolar ridge. We will also not provide benefits for prescription or non-

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 prescription drugs prescribed or recommended by a dentist. You must pay the
Cost Share applicable to the particular services you receive.

U. Therapy Services. These services must be provided by a Participating Provider.

Benefits for these services are limited to thirty (30) visits for Rehabilitative and thirty
(30) visits for Habilitative Services

V. Durable Medical Equipment. We will provide benefits for the purchase, rental,
procurement, repair or replacement of Durable Medical Equipment authorized by
a Participating Physician and obtained from a Participating Provider. The option
of whether to rent or purchase authorized Durable Medical Equipment is at the
sole discretion of MVP. You must pay the Cost Share listed on your SBC.

We do not Cover equipment designed for Your comfort or convenience (e.g., pools,
hot tubs, air conditioners, saunas, humidifiers, dehumidifiers, exercise equipment),
as it does not meet the definition of durable medical equipment.

In addition to the above items, a listing of non-covered DME items can be found
on Our website at MVP Commercial DME Non-Covered Items. This list will be
updated from time to time based solely on changes made by CMS. We
recommend that you check this list prior to purchasing any DME item to ensure it
is a covered item, and not on the list of Non-Covered items. Some examples of
Non-Covered DME items are hot water bottles, exercise equipment, toilet rails, and
tub stools. This list will be revised from time to time by Us. If you are unable to
access the website or need additional information, call the number on Your MVP
ID card.

W. Disposable Medical Supplies. We will provide benefits for disposable medical

supplies including, but not limited to dressings for cancer or burns, catheters,
colostomy bags and related supplies, oxygen, diapers, chux, sponges, syringes,
needles, diabetic test strips, lancets and glucometers for the treatment of diabetes,
incontinence pads, reagent strips, catheters, elastic support stockings, compressive
garments, dressings, and bandages.

X. Transplant Services/Donor Costs. We will provide benefits for organ and bone
marrow Transplant Services, including transplant surgeries only when such services
are obtained through MVP's Transplant Network. You may obtain a description of
this Network by calling the MVP Customer Care Center at 1-888-687-6277.
Transplant Services are subject to Pre-Authorization. MVP will also provide
benefits for live donor medical expenses up to your coverage limitations and after
payment of your expenses. You must pay the Cost Share amounts applicable to
the particular services you receive.

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 Y. Clinical Trials for Cancer Patients. We will provide benefits, to the extent required
by law, to cover routine costs for patients who participate in an approved cancer
clinical trial. If you participate in a clinical trial administered by a cancer care
provider that is not in our network, your routine follow-up care must be provided
within our network, unless the cancer care provider determines this would not be
in your best interest.

Z. Dental. We will only provide Benefits for dental treatment due to accidental injury
to sound natural teeth within twelve (12) months of the accident and care or
treatment necessary due to congenital disease or anomaly; and for
temporomandibular joint disease or dysfunction where such disease or dysfunction
is medical in nature.

AA. Prosthetics.

1. External Prosthetic Devices.

We Cover prosthetic devices (including wigs) that are worn externally and that
temporarily or permanently replace all or part of an external body part that has
been lost or damaged because of an injury or disease. We Cover wigs only when
You have severe hair loss due to injury or disease or as a side effect of the treatment
of a disease (e.g., chemotherapy). We do not Cover wigs made from human hair
unless You are allergic to all synthetic wig materials. We do not Cover dentures or
other devices used in connection with the teeth unless required due to an
accidental injury to sound natural teeth or necessary due to congenital disease or
anomaly.

x Eyeglasses and contact lenses are not Covered under this section of the
Contract and are only Covered under the Pediatric Vision Care section of this
Contract.
x We do not Cover shoe inserts.
x We Cover external breast prostheses following a mastectomy, which are not
subject to any lifetime limit.
x Coverage is for standard equipment only.
x We Cover the cost of one (1) prosthetic device, per limb, per lifetime. We also
Cover the cost of repair and replacement of the prosthetic device and its
parts. We do not Cover the cost of repair or replacement covered under
warranty or if the repair or replacement is the result of misuse or abuse by
You.

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 2. Internal Prosthetic Devices.
We Cover surgically implanted prosthetic devices and special appliances if they
improve or restore the function of an internal body part which has been removed
or damaged due to disease or injury. This includes implanted breast prostheses
following a mastectomy or partial mastectomy in a manner determined by You and
Your attending Physician to be appropriate.

Coverage also includes repair and replacement due to normal growth or normal
wear and tear. Coverage is for standard equipment only.

BB. Coverage for Diagnosis and Treatment of Early Childhood Developmental

Disorders.
1. Definitions. In this section the following terms have the following
meanings:

a. Applied Behavior Analysis means the design, implementation and

evaluation of environmental modifications using behavioral stimuli
and consequences to produce socially significant improvement in
human behavior. This includes direct observation, measurement
and functional analysis of the relationship between environment
and behavior.

b. Autism Spectrum Disorders means one or more pervasive

developmental disorders as defined in the most recent edition of
the Diagnostic and Statistical Manual of Mental Disorders, including
autistic disorder, pervasive developmental disorder not otherwise
specified, and Asperger’s disorder.

c. Behavioral Health Treatment means evidence-based counseling

and treatment programs, including applied behavior analysis, that
are:

i. necessary to develop skills and abilities for the maximum

reduction of physical or mental disability and for restoration of
an individual to his or her best functional level, or to ensure that
an individual under the age of 21 achieves proper growth and
development;
ii. provided or supervised by a nationally board-certified behavior
analyst or by a licensed provider, so long as the services
performed are within the provider's scope of practice and
certifications.

d. Diagnosis of early childhood developmental disorders means

Medically Necessary assessments, evaluations, or tests to determine

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 whether an individual has an early childhood developmental delay,
including autism spectrum disorder.

e. Early childhood developmental disorder means a childhood mental

or physical impairment or combination of mental and physical
impairments that results in functional limitations in major life
activities, accompanied by a diagnosis defined by the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the
International Classification of Disease (ICD). The term includes
autism spectrum disorders but does not include a learning
disability.

f. Treatment for early developmental disorders means evidence-

based care and related equipment prescribed or ordered for an
individual by a licensed health care provider or a licensed
psychologist who determines the care to be medically necessary,
including:

i. behavioral health treatment;

ii. pharmacy care (medications prescribed by a licensed physician
and any health-related services deemed medically necessary to
determine the need for or effectiveness of a medication);
iii. psychiatric care (direct or consultative services provided by a
licensed physician certified in psychiatry by the American Board
of Medical Specialties;
iv. psychological care (direct or consultative services provided by a
psychologist licensed pursuant to 26 V.S.A. chapter 55.); and
v. therapeutic care (services provided by licensed or certified
speech language pathologists, occupational therapists, or
physical therapists).

2. Benefits.
a. We will provide coverage for the evidence-based diagnosis and
treatment of early childhood developmental disorders, including
applied behavior analysis supervised by a nationally board-certified
behavior analyst, for children, beginning at birth and continuing
until the child reaches age 21.
b. The amount, frequency, and duration of treatment described in this
section shall be based on medical necessity and is subject to Pre-
Authorization.

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 c. We will provide coverage for applied behavior analysis when the
services are provided or supervised by a licensed provider who is
working within the scope of his or her license or who is a nationally
board-certified behavior analyst.

d. We will provide coverage for services under this section delivered

in the natural environment (home or child care setting) when the
services are furnished by a provider working within the scope of his
or her license or under the direct supervision of a licensed provider
or, for applied behavior analysis, by or under the supervision of a
nationally board-certified behavior analyst.
e. Except for inpatient services, if you are receiving treatment for an
early developmental delay, we may require treatment plan reviews
based on your needs, consistent with reviews for other diagnostic
areas and with rules established by the department of financial
regulation. We may review the treatment plan for children under
the age of eight once every six months.
f. Diagnosis and Treatment of Early Childhood Developmental
Disorders are subject to the same Cost Share that is required for the
diagnosis and treatment of other mental health conditions.
g. You must pay the applicable Cost Share listed on your SBC.
h. We will not provide Benefits to an individual for services provided
under an individualized family service plan, individualized education
program, or individualized service program.

CC. Tobacco Cessation Services. We will cover the cost of at least two (2) tobacco
cessation attempts per Enrollee per Benefit Year. We will also cover up to two 3-
month supplies per year of tobacco cessation products including over-the-counter
drugs when prescribed by a Participating Provider.

DD. Weight Loss Services. We will provide Benefits for any Medically Necessary Covered
Services or care set forth in your Contract, or Group Health Plan when rendered in
connection with weight reduction or dietary control, including, but not limited to,
laboratory services, and gastric stapling, gastric bypass, gastric bubble or other
surgery for treatment of obesity.

We will provide Benefits for bariatric surgery only when such surgery is performed
at a participating bariatric center of excellence. You can get a list of participating
centers of excellence by calling the MVP Customer Care Center at 1-888-687-6277.

We will not provide coverage for dietary supplements, exercise classes, or gym
memberships.

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 EE. Infertility Treatment. We cover services for the diagnosis and treatment (surgical
and medical) of infertility when such infertility is the result of malformation, disease
or dysfunction. Infertility is determined by the incapacity to impregnate another
person or to conceive, defined by the failure to establish a clinical pregnancy after
12 months of regular, unprotected sexual intercourse or therapeutic donor
insemination, or after six (6) months of regular, unprotected sexual intercourse or
therapeutic donor insemination for a female 35 years of age or older; or the
inability of an individual to establish a clinical pregnancy due to sexual orientation
or gender identity. Earlier evaluation and treatment may be warranted based on a
Member’s medical history or physical findings.

Such Coverage is available as follows:

a. Basic Infertility Services. Basic infertility services will be provided to a member

who is an appropriate candidate for infertility treatment. In order to determine
eligibility, we will use guidelines established by the American College of
Obstetricians and Gynecologists, the American Society for Reproductive
Medicine, and the State of Vermont.

Basic infertility services include:

x Initial evaluation;
x Semen analysis;
x Laboratory evaluation;
x Evaluation of ovulatory function;
x Postcoital test;
x Endometrial biopsy;
x Pelvic ultrasound;
x Hysterosalpingogram;
x Sono-hystogram;
x Testis biopsy;
x Blood tests; and
x Medically appropriate treatment of ovulatory dysfunction.

Additional tests may be covered if the tests are determined to be Medically

Necessary.

b. Comprehensive Infertility Services. If the basic infertility services do not result

in increased fertility, we cover comprehensive infertility services.

Comprehensive infertility services include:

x Ovulation induction and monitoring;

x Pelvic ultrasound;

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 x Hysteroscopy;
x Laparoscopy; and
x Laparotomy.

c. Exclusions and Limitations. We will not provide benefits for any services for
or related to artificial means to induce pregnancy, including but not limited
to artificial insemination, in vitro fertilization and embryo transplantation,
gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT)
and drugs used in connection with such procedures, cryopreservation and
storage of sperm, eggs or embryos, intracytoplasmic sperm injection (ICSI),
sperm storage, sperm banking, gender selection, donor costs, surrogate
parenting, acrobeads sperm assay, hamster egg penetration test, hypo-
osmotic swelling test, retrieval of sperm through electrostimulation,
preimplantation genetic diagnosis and gender selection.

FF. Pediatric Vision.

i. Exam. We will provide Benefits for one (1) routine eye examination
(refraction) per Covered child every Benefit Year. A vision exam means an
eye care exam for prescribing or determining your need for eyeglasses or
contact lenses, and fittings for the contact lenses. The exam must be
provided by a participating optometrist or ophthalmologist. This Benefit is
per child until the end of the year in which they turn twenty-one (21). Please
see your SBC for your Cost Share obligations.

ii. Eyewear. We will provide Benefits for one (1) pair of prescription eyeglasses
OR for prescription contact lenses. See your SBC for any applicable cost-
sharing. We will provide this Benefit once per enrolled child, until the end
of the year in which they turn twenty-one (21), every Benefit Year. This
Benefit applies to the retail price of lenses and/or frames or the retail price
of contact lenses, material, training, the initial lens care kit and medically
necessary follow-up visits for a period of two months. You may purchase
the eyeglasses or contact lenses from any provider. After you make your
purchase, you must follow the instructions in paragraph iii below to get
reimbursed. We will not provide Benefits for the following:
(1) Repairs to eyeglasses; or
(2) Safety glasses required by employment or sport.
(3) Nonprescription eyewear

iii. Reimbursement. You must pay the provider’s charge for the eyeglasses or
contact lenses at the time of purchase. To get reimbursed up to the
maximum Benefit stated in your SBC, you must send us the original receipt
and a written request for reimbursement for the eyeglasses or contact

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 lenses. Please include your MVP Enrollee Identification Number on your
request. Mail both the receipt and request to the address on the claim form.

GG. Hearing Aid Exam and Devices.

Exam. We will provide benefits for an annual hearing exam for prescribing, fitting,
or determining the need for hearing aids and for hearing therapy or training. A
hearing aid exam is subject to the specialist visit cost share.

External Hearing Aids. We Cover hearing aids required for the correction of a
hearing impairment (a reduction in the ability to perceive sound which may range
from slight to complete deafness). Hearing aids are electronic amplifying devices
designed to bring sound more effectively into the ear. A hearing aid consists of a
microphone, amplifier and receiver.

Covered Services include the hearing aid and the charges for associated fitting
and testing. We Cover a single purchase (including repair and/or replacement) of
hearing aids for one (1) or both ears once every three (3) years. External hearing
aids are subject to the durable medical equipment cost share.

Cochlear Implants. We cover bone anchored hearing aids (i.e., cochlear implants)
when they are Medically Necessary to correct a hearing impairment. Examples of
when bone anchored hearing aids are Medically Necessary include the following:

x Craniofacial anomalies whose abnormal or absent ear canals preclude the use
of a wearable hearing aid; or
x Hearing loss of sufficient severity that it would not be adequately remedied
by a wearable hearing aid.

Coverage is provided for one (1) hearing aid per ear during the entire period of
time that You are enrolled under this Contract, unless more than one is Medically
Necessary. We Cover repair and/or replacement of a bone anchored hearing aid
only for malfunctions. Cochlear implants are internal prosthetic devices. Pre-
Authorization is required.

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 HH. Pediatric Dental.

This Section of the contract describes benefits provided by dentists and dental
hygienist and other licensed professionals who may legally provide covered
services. Pediatric Dental benefits are provided to Enrollees to the end of the year
the member turns 21. Please refer to the SBC for Cost-Sharing requirements that
apply to these benefits. The Allowed Amount for Pediatric Dental Services is a
percentage of billed charges. Whenever the estimated cost of a dental treatment
plan exceeds $200, you must submit your claim for pre-determination of benefits.

Benefits are categorized according to the type of service provided: Diagnostic &
Preventive dental services (Class I), Basic Restorative dental services (Class II), Major
Restorative dental services (Class III) and Orthodontics (Class IV).

i. Diagnostic & Preventive Dental Services (Class I)1

Preventive dental services consist of routine oral exams and dental

prophylaxis (cleaning and scaling teeth) including periodontal prophylaxis
once in any six (6) consecutive month period; fluoride treatments once in
any 12 consecutive month period and bite-wing X-rays as part of a routine
exam (once in any six consecutive month period); X-ray, full mouth x-rays
at thirty-six (36) month intervals, bitewing x-rays at six (6) to twelve (12)
month intervals or panoramic x-rays at thirty-six (36) month intervals, other
x-rays; palliative treatment for dental pain when no other treatment but X-
rays is given; Sealants on unrestored permanent molar teeth. Sealant is
provided only to eligible persons through age (14). The sealant is covered
for the application to caries-free (no decay) and restoration free permanent
molars only and no more than once in a lifetime per tooth. Unilateral and
bilateral space maintainers are covered for placement in a restored
deciduous and/or mixed dentition to maintain space for normally
developing permanent teeth. Space maintainers are covered through age
fifteen (15)

ii. Basic Restorative Dental Services (Class II)

Basic Restorative dental services consist of:

a. Fillings
Silver (amalgam), silicate, plastic, porcelain, and composite and sedative
fillings; reinforced pins.

1
Fluoride supplements for children without fluoridated drinking water in their home are covered
in full with no deductible or other cost-sharing.

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 b. Periodontics / Surgical Dental Services
Periodontics or surgical dental services consist of simple and surgical
extractions and cutting procedures in the mouth (oral surgeries, i.e.:
biopsy of oral tissue, incision and drainage of an intraoral abscess,
Gingival Curettage, Osseous Surgery, Gingivectomy, Apioectomy);
periodontal scaling and root planning; X-rays if performed on the same
day the above procedures are performed; and treatment of jaw
fractures and dislocations; and local anesthetics for oral surgery,
fractures, dislocations and treatment of gums. Extra charges for
removing stitches, exams after surgery is not covered.

General anesthesia, nitrous oxide, intravenous sedation, when

administered in a dental office and in conjunction with: an extraction;
tooth reimplantation; surgical exposure of a tooth; surgical placement
of implant body; biopsy; transseptal fiberotomy; alveoloplasty;
vestibuloplasty; incision and drainage of an abscess; frenulectomy
and/or frenuloplasty.

c. Endodontics
Endodontic services, including procedures for treatment of diseased
pulp chambers and pulp canals, and root canal therapy where
Hospitalization is not required.

d. Fixed Prosthodontics
Fixed Prosthodontics consist of fixed partial denture pontics and fixed
partial denture retainers such as crowns. Fixed partial dentures are
limited to 1 per tooth per 2 years.

e. Other
Prefabricated Crowns limited to 1 per tooth per 2 years.

iii. Major Restorative Dental Services (Class III)

Major Restorative Dental services consists of cast crowns and complete

dentures, immediate dentures, overdentures and partial dentures including
repair pins to replace missing natural teeth. The teeth that are being
replaced must be lost while the person is covered. Crowns are covered
when a tooth cannot be adequately restored with amalgam (silver) or resin
(white) restorations. Also covered are denture adjustments, repairs, rebases
and relines. Immediate dentures are limited to 1 per arch per lifetime.
Denture adjustments and repairs are limited to 1 per denture per 180 days.
Denture rebases and / or relines are limited to 1 per denture per 2 years.
Inlays are not a covered benefit. Removable or fixed partial dentures are
not benefits for patients under the age of twelve (12).

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 iv. Orthodontics (Class IV)

Orthodontic services consist of necessary treatment and procedures

required for the correction of malocclusion.

Pre-Authorization is required for all orthodontic treatment. Patients must

meet one (1) major criteria or two (2) minor diagnostic criteria. Major
criteria include: cleft palate, two (2) impacted cuspids, posterior crossbite
of three (3) or more teeth or severe craniofacial syndrome (treacher-Collins
syndrome, Marfan syndrome, Pierre Robin syndrome, etc.). Minor criteria
are: One (1) impacted cuspid, two (2) blocked cuspids, three (3) congenital
missing teeth, open bite of four (4) or more teeth, crowding, anterior cross
bite of three (3) or more teeth, traumatic deep bite impinging on palate, or
overjet of 8mm.

1. Orthodontic benefit limitations:

(a) For treatment commenced while a patient is eligible for orthodontic

benefits, MVP will initiate payment of its liability up to the Maximum
once bands or orthodontic devices are placed.
(b) For patients who become eligible after orthodontic treatment has
commenced, MVP will pro-rate its liability based on the number of
remaining months of active treatment compared to the total
number of months of active treatment.
(c) Active treatment includes procedures undertaken and appliances
used with those procedures for the purpose of bringing teeth into
proper position and alignment. Active treatment does not include
space maintainers, palate expanders or other devices used to
prepare the patient for services to position and align teeth.

2. Clear orthodontic appliances are included in orthodontic benefits

provided that upon the consulting Dentist’s review of pretreatment
radiographs it is indicated that the patient has full adult dentition. Clear
appliances are subject to all orthodontic limitations and conditions and
are subject to review by a consulting Dentist. Patient is responsible for
any difference between the cost of the clear orthodontic treatment and
the cost of conventional orthodontic procedures.

3. MVP will make one (1) payment at the start of treatment followed by
monthly payments throughout the length of treatment up to a
maximum of twenty-four (24) months for its total liability.

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 4. Placement of an appliance must take place for MVP to make payment
on diagnostic records. Diagnostic casts, photographs and other
diagnostic records are included in the total case fee. If banding does
not take place, MVP has no liability beyond its share of the allowable
fee for a comprehensive oral evaluation.

5. The replacement or repair of an orthodontic appliance is not a covered

benefit if done by the same orthodontist who placed the appliance. If
performed by an orthodontist who did not originally place the
appliance, payment will be made for one repair per lifetime.

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 SECTION THIRTEEN – PRESCRIPTION DRUG COVERAGE

1. Definitions. In this Section, the following terms shall have the meanings set forth below.

A. Covered Drugs in this Section shall mean Medically Necessary Food and Drug
Administration (FDA) approved self-administered prescription drugs under The
Federal Food, Drug, and Cosmetic Act (FFDCA). This includes prescription drugs
for bone mineral density not excluded by the terms and conditions of this Section
of your Contract. Covered Drugs must also be recognized as safe and effective for
treatment of the prescribed indication in prevailing Peer Reviewed Medical
Literature or the Standard Medical Reference Compendia listed below:

x The American Hospital Formulary Service Drug Information); or

x Thomson Micromedex DrugDex with a strength of recommendation at
least Class IIa, Strength of evidence at least Category B and Efficacy at least
Class Iia.
This also includes the routine costs for off-label drugs used in connection with
approved cancer clinical trials.

B. A Participating Pharmacy (this includes Retail, Mail or Specialty Pharmacies) is a

pharmacy within MVP’s Provider Network. You may get a list of Participating
Pharmacies by calling MVP’s Customer Care Center at 1-888-687-6277 or by
viewing the list online at mvphealthcare.com.

C. Allowable Charge or Allowable Amount in this Section is the maximum amount

or benefit that MVP will pay for a Covered Drug. The Allowable Amount shall be
equivalent to the negotiated rate charged to MVP or at the pharmacy's usual and
customary cost, whichever is less. Any Cost Share requirements shall be deducted
from MVP’s Allowable Charge in determining your benefit.

D. Annual Out of Pocket Maximum Expense for Prescription Drugs is the

maximum amount you will pay out of pocket each year for Cost Sharing amounts
for your prescription drug benefit.

Please see your Summary of Benefits and Coverage (SBC) for the current individual
and family out of pocket maximum expense for prescription drugs. You will be
notified of any changes to these amounts annually.

Insulin Drugs. Your total out-of-pocket responsibility for prescription insulin

medications will not be more than $100 per 30-day supply, regardless of the
amount, type, or number of insulin medications being prescribed. This Out-of-
Pocket Maximum will apply even if you have not met your deductible.

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 x If your prescription drug coverage or Contract has a Deductible, the Allowable
Charges that apply to the Deductible will also apply to the Annual Out of Pocket
Maximum Expense for Prescription Drugs.

Only Allowable Charges for prescription drugs will be applied to the Annual Out of
Pocket Maximum Expense for Prescription Drugs. The following do not apply:

x Any Cost Share for Medical expenses,

x Any credit given to you by use of a manufacture’s coupon,
x Any Cost Share related to services not covered by your Contract, and
Amendments and/or SBC.
x Any differences in the cost of the brand prescription drug and the cost of the
generic drug when applicable.

E. Tier Structure. MVP divides prescription drugs into 3 tiers to make it easier for
you and your doctor to choose the most appropriate, lowest cost drug to treat
your condition. Medications are placed into tiers based on their overall value to
treat conditions. Each tier has a payment level for covered prescription drugs
within that tier.

x Tier 1 is the lowest payment choice. It includes drugs selected for their
effectiveness and utilization. Many generic drugs have a Tier-1 cost share.
x Tier 2 is a mid-range payment choice. It includes drugs selected for their
effectiveness and utilization. Many brand drugs have a Tier-2 cost share.
x Tier 3 is the highest payment choice. It includes all other covered prescription
drugs. It also includes those drugs that are not on the prescription drug
formulary and new drugs that are being reviewed for inclusion on the
formulary. This tier also includes all covered compounded prescriptions.

F. Brand/Generic Difference. If you have a covered prescription filled with a brand

name drug, as defined by MediSpan® and there is a generic equivalent drug for
that brand name drug, and you have not obtained an exemption based on the
medical necessity for the brand name drug, you must pay the generic drug cost
share, plus the difference in cost between the generic and the brand name drug,
not to exceed the cost of the drug. The amount you pay for the difference between
generic and brand will not apply to any maximum benefit, out of pocket maximum
or deductible.

G. Value Based Insurance Design (or VBID) Drugs. MVP provides certain
prescriptions at a reduced Cost Share to assist those with chronic conditions to
better manage those conditions. See MVP’s website mvphealthcare.com for a list
of VBID Drugs. See your SBC for your Cost Share for VBID Drugs. VBID prescription
coverage may not be available with your plan. Please refer to your SBC.

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 H. Usual and Customary. The cash price that an individual without insurance would
pay for the drug and quantity prescribed, as determined by the pharmacy.

2. Conditions of Coverage. MVP will cover Covered Drugs, subject to the terms, conditions,
and limits set forth in your Contract, that are:

A. Prescribed by a Provider who is authorized to write prescriptions; AND

B. Obtained from an MVP Participating Retail Pharmacy except that:

(i) You may get prescription drugs listed on MVP’s Mail Order List at either an
MVP Participating Retail Pharmacy or at MVP’s Mail Order Pharmacy. You
or your prescribing provider may get a copy of MVP’s Mail Order List or ask
if a prescription drug is available through MVP’s mail order pharmacy
program by calling MVP’s Customer Care Center at 1-888-687-6277 or by
contacting us online at mvphealthcare.com and following the instructions.

(ii) You must get prescription drugs listed on MVP’s Specialty Pharmacy List at
MVP’s Specialty Pharmacy Vendor, upon Pre-Authorization from MVP. You
or your prescribing provider may ask if a drug is listed on MVP’s Specialty
Pharmacy List by calling MVP’s Customer Care Center at 1-888-687-6277.
You can also view the list online. Go to mvphealthcare.com and follow
the instructions.

3. Benefits Available. Prescription drugs other than contraceptives are covered up to a thirty
(30) day supply (“Standard Supply”). You may get two vacation supplies per Benefit Year.
This means that you may get up to an additional 30 day supply for vacation periods two
times per Benefit Year. You must pay the applicable multiple payments for a vacation
supply. Prescription contraceptive drugs and devices approved by the FDA are covered
subject to any applicable Cost Share as per HRSA guidelines, and may be covered up to a
12 month supply.

MVP will permit prescriptions to be filled by such retail pharmacy in the same manner and
at the same level of reimbursement as they are filled by mail order pharmacies with respect
to the quantity of drugs or days’ supply of drugs dispensed under each prescription.

A. Retail Pharmacy Benefit. For covered prescription drugs that you get at an MVP
Participating Retail Pharmacy, MVP will provide coverage subject to our Allowable
Charge for up to a thirty (30) day supply per dispensing (Standard Supply) and
subject to the Cost Share requirements set forth on your SBC. For any prescription
drugs that you get at an MVP Participating Retail Pharmacy which are also included
on MVP’s Mail Order Pharmacy Benefit List, MVP will provide coverage for up to a
90-day supply per dispensing by the Participating Retail Pharmacy, subject to the
same Allowable Charge and Cost Share requirements as detailed in the Mail Order

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 Pharmacy Benefit below. Note that mail order prescriptions may not be available
at all MVP Participating Retail Pharmacies.

Mail Order Pharmacy Benefit. For covered prescription drugs listed on MVP's Mail
Order List and that you get through MVP's Mail Order Pharmacy MVP will provide
coverage subject to our Allowable Charge for up to a ninety (90) day supply per
dispensing (Standard Mail Order Supply) and subject to the Cost Share
requirements set forth on your SBC. You or Your prescribing Provider may get a
copy of MVP’s mail order list or ask if a prescription drug is available through MVP’s
mail order pharmacy program by calling MVP’s Customer Care Center at 1-888-
687-6277 or by contacting us online at mvphealthcare.com and following the
instructions.

How to Use the Mail Order Program Through CVS/Caremark Mail.

1. New Prescriptions. You must fill out a Mail Order Pharmacy Form. You may
ask for a copy of the Form by calling MVP’s Customer Care Center at 1-888-
687-6277. You may also visit MVP’s web site at mvphealthcare.com to
download the Form or ask for a copy. Complete and sign the Form and
attach the 90-day prescription with your check or credit card number for
your payment. Then, mail everything to the address listed on the Form.

2. Refills. When you need to refill a prescription, you may:

(i) Refill By Phone. Call the number listed on your order form. Have
your prescription number, name, address and credit card
information ready to make your payment.

(ii) Refill By Mail. Fill out the order form enclosed with your most recent
delivery form and, if your health has changed, update your health
profile. Fill out the refill section, enclose your check or credit card
number for your payment and mail it to the address listed on the
delivery form.

(iii) Refills on line. You can order refills online at mvphealthcare.com.

3. Getting the Mail Order Drug List. You may only get drugs approved by
MVP for mail order through the mail order pharmacy program or at
approved retail pharmacies. You may get a copy of the list of drugs
approved for mail order or ask whether a drug is an approved maintenance
drug by calling MVP’s Customer Care Center at 1-888-687-6277. You may
also visit MVP’s web site at mvphealthcare.com and enter the name of a
drug to find out if it is approved for mail order or to ask for a copy of the
list of drugs approved for mail order.

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 4. Changes to the Mail Order Drug List. MVP notifies Providers, in writing,
when we add new drugs to the list of drugs approved for mail order or
delete previously approved drugs from the list of drugs approved for mail
order. MVP gives at least 90 days prior written notice to Enrollees who use
a drug on the list when we delete the drug they use from the list. MVP also
gives notice of new drugs added to the list in MVP’s member newsletter or
other communication. You may also file a claim for Mail Order benefits by
following the instructions in Paragraph 8 of this Section.

B. Specialty Pharmacy Benefit. This is not the same as the mail order benefit. For
covered prescription drugs listed on MVP's Specialty Pharmacy List that are
obtained through an MVP Specialty Pharmacy Vendor, MVP will provide coverage
subject to our Allowable Charge for up to a thirty (30) day supply per dispensing
(Standard Supply) and subject to the Cost Share by tier as set forth in the
Formulary.

How to Use the Specialty Pharmacy Vendor Program.

a. New Prescriptions. If your prescription is on the Specialty Pharmacy Drug

List, your doctor should provide the Specialty Pharmacy Vendor with your
prescription by telephone, fax or mail. Once the vendor gets your
prescription, an account will be set up. The vendor may call you for
shipping and billing information or you may also contact the vendor.

2. Refills. When you need to refill a prescription, you may call the Specialty
Vendor to arrange for a refill and provide updated shipping and billing
information. For details on how to refill by phone go to
mvphealthcare.com. The Specialty Pharmacy Vendor may also proactively
contact you with refill reminders.

3. Getting the Specialty Pharmacy Drug List. At any time, you may get a copy
of the list of drugs that you must get through MVP’s Specialty Pharmacy
Vendor or ask whether a drug must be obtained through MVP’s Specialty
Pharmacy Vendor by calling MVP’s Customer Care Center at 1-888-687-
6277. You may also visit MVP’s web site at mvphealthcare.com and enter
the name of a drug to find out if you must get it through MVP’s Specialty
Pharmacy Vendor or to ask for a copy of the list of drugs that you must get
through MVP’s Specialty Pharmacy Vendor.

You will be notified of changes to those drugs as described in paragraph 4.

4. Changes to the Specialty Pharmacy Drug List. MVP lets Providers know
when we add new drugs to the list of drugs that you must get through

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 MVP’s Specialty Pharmacy Vendor and when we delete drugs from the list.
MVP gives at least 90 days prior written notice to Enrollees who use a drug
on the list when we are going to delete the drug they use from the list.
MVP also gives notice of new drugs added to the list in MVP’s member
newsletter or similar communication.

4. MVP Prescription Drug Formulary.

MVP's Pharmacy and Therapeutics Committee, which includes physicians, pharmacists,

and other health care professionals, evaluates FDA approved drugs and devices and
determines which drugs MVP will approve for coverage, their Tier status and any utilization
management requirements. The list of approved drugs is called the Formulary. Drugs that
MVP has not approved for coverage are called Non-Formulary Drugs. MVP’s Pharmacy
and Therapeutics Committee reviews and must approve new drugs prior to such new
drugs being added to the Formulary.

A. Getting Formulary Information. At any time, you may get a copy of the Formulary,
ask whether a drug is listed on the Formulary, or ask if a drug requires Pre-
Authorization by calling MVP’s Customer Care Center at 1-888-687-6277. You may
also visit MVP’s web site at mvphealthcare.com and enter the name of a drug to
find out if it is listed on MVP’s Formulary or to ask for a copy of the Formulary.

B. Changes to the Formulary. MVP lets Providers know, in writing, when we add new
drugs to the Formulary, or make changes to the tier status of a drug on the MVP
Formulary. MVP gives at least 90 days prior written notice to Enrollees who use a
drug on the Formulary when we are going to change the tier status of the drug
they use on the Formulary. MVP also gives notice of new drugs added to the
Formulary in MVP’s member newsletter or similar communication.

5. Pre-Authorization Requirements. In some cases, MVP may require that your prescribing
provider satisfy MVP Pre Authorization Requirements before a prescription is filled at the
pharmacy. Drugs that must be Pre-Authorized before they are filled are identified on the
Formulary. They are also listed by therapeutic categories on our Formulary. MVP notifies
Providers, in writing, when we change these requirements. New FDA approved
prescription medications are subject to Pre-Authorization for a minimum of six (6) months.
All compounded prescriptions over $100 require Pre-Authorization. Compounds
containing non-FDA approved drugs may also require Pre-Authorization.

A. Changes to Pre-Authorization Requirements or Quantity Limits. MVP lets Providers

know, in writing, when we change Pre-Authorization or quantity limit requirements
for a Formulary Drug. MVP gives at least 90 days prior written notice to Enrollees
who use a drug that requires Pre-Authorization or has quantity limits when we are
going to change the requirements or limits to such Formulary Drug. MVP also
provides such notice in MVP’s member newsletter or similar communication.

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 B. When Pre-Authorization is required, your provider must submit a request for
coverage to MVP that includes what is being requested, the intended use, and
clinical information relating to your treatment of the requested use. Forms for this
are available to your provider on the MVP website. Pre-Authorization and
prescription drug override requests can be submitted via fax to 1-800-376-6373,
or submitted online at mvphealthcare.com.

C. If MVP does not provide the required 90-day prior written notice, the prescription
remains valid; and if it is not possible to timely obtain a prescription consistent with
the changed requirement, coverage will be provided for an interim supply of the
drug and, if relevant, any additional supply for the number of days that is medically
necessary to safely discontinue the drug for no more than ninety (90) days or until
the prescribing provider can order a new prescription; or, if necessary, until the
grievance and independent review process can be initiated and completed. A
managed care organization shall not be required to cover an interim supply if:

(i) Enrollee's prescribing provider explicitly consents to the change; or

(ii) the drug has been determined to be unsafe for the treatment of the
Enrollee's disease or medical condition, has been discontinued from
coverage for safety reasons or cannot be supplied by or has been
withdrawn from the market by the drug's manufacturer.

You may also file a claim for benefits by following the instructions in Paragraph 7 of this
Section.

D. As long as a drug continues to be prescribed for an Enrollee and is considered safe

for the treatment of the Enrollee's condition, an Enrollee who has previously been
prescribed an otherwise covered drug that is the subject of Pre Authorization, other
review and/or denial shall be entitled to coverage for a supply of the drug sufficient
to continue treatment through the following time periods, as well as any additional
supply that is medically necessary to safely discontinue the drug if the denial is
ultimately upheld:
(i) until the Pre-Authorization or other review process has been completed;
(ii) if applicable, until all required internal expedited grievances have been
exhausted; and
(iii) until the independent external review decision is issued, if expedited
independent external review is requested within twenty-four (24) hours of
the receipt of the final grievance decision and notice of appeal rights by
the Enrollee, and expedited independent external review is conducted in
accordance with the time frames specified by law.

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 E. MVP will grant an exception to a pharmacy requirement and will provide coverage
on the same terms as if the pharmacy requirement was not in place if your
prescribing health care provider certifies, based on relevant clinical information
about you and sound medical or scientific evidence or the known characteristics of
the drug, that the alternative treatment:
(i) has been ineffective or is reasonably expected to be ineffective or
significantly less effective in treating your condition such that an exception
is medically necessary; or
(ii) has caused or is reasonably expected to cause adverse or harmful reactions
to you.

F. If MVP denies the request related to a prescribed drug you will be notified in
writing with a detailed explanation of:
(i) the information required to meet MVP policy criteria and, if necessary, to
file an appeal of the decision by you or your provider;
(ii) how to request an appeal and provide clinical or other required information
to MVP;
(iii) where information must be submitted, including telephone, fax and other
contact information for MVP;
(iv) under what circumstances and how an interim supply of medication may
be obtained; and
(v) the fact that a denial of a request for coverage is a determination subject
to independent external review under Vermont law, and any applicable
notice required by the state of Vermont with a reference to descriptions of
the independent external review process.
G. Exception to a Pharmacy Requirement. If a Prescription Drug is not on our
Formulary, you, your designee or your prescribing Health Care Professional may
request a Formulary exception for a clinically-appropriate Prescription Drug. The
request should include a statement from your prescribing Health Care Professional
that all Formulary drugs will be or have been ineffective, would not be as effective
as the non-formulary drugs, or would have adverse effects. If coverage is denied
under our standard or expedited Formulary exception process, you are entitled to
an external appeal as outlined in the External Appeal section of this Contract. Visit
our website at mvphealthcare.com or call the number on your ID card to find out
more about this process. Please see your SBC for any limits and cost-sharing that
applies to this benefit.
Standard Review of a Formulary Exception. We will make a decision and notify
you or your designee and the prescribing Health Care Professional no later than

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 72 hours after Our receipt of Your request. If We approve the request, we will cover
the Prescription Drug, including any refills.
Expedited Review of a Formulary Exception. If you are suffering from a health
condition that may seriously jeopardize your health, life or ability to regain
maximum function or if you are undergoing a current course of treatment using a
non-Formulary Prescription Drug, you may request an expedited review of a
Formulary Exception. The request should include a statement from your
prescribing Health Care Professional that harm could reasonably come to you if
the requested drug is not provided within the timeframes for our standard
Formulary exception process. We will make a decision and notify you or your
designee and the prescribing Health Care Professional no later than 24 hours after
Our receipt of your request. If we approve the request, we will cover the
Prescription Drug while you suffer from the health condition that may seriously
jeopardize your health, life or ability to regain maximum function or for the
duration of your current course of treatment using the non-Formulary Prescription
Drug.

6. Exclusions. In addition to all other terms, conditions, and limits in this Contract, MVP will
not provide benefits for the following items:

A. Non-Medically Necessary drugs.

B. Experimental or Investigational Drugs (unless directed to be covered pursuant to

Independent External Appeal). This term means drugs that are either not generally
accepted by informed health care providers in the United States as effective in
treating the condition, illness or diagnosis for which their use is proposed, or are
not proven by medical or scientific evidence to be effective in treating the
condition, illness or diagnosis for which their use is proposed. However, we will
provide benefits, to the extent required by law, to cover routine costs for off-label
drugs used in connection with approved cancer clinical trials. See paragraph 1.A
within this Section Thirteen.

C. Compounded prescriptions (prescriptions that require the mixing of two or more

ingredients but do not contain at least one legend ingredient with a valid NDC
number) or other drug formulations compounded, for which compounding is not
Medically Necessary or for which commercially available products are available.

D. Drugs that require a prescription but have an exact equivalent that is available over
the counter, unless the prescription is Medically Necessary.

E. Drugs used in connection with a medical service that is not covered under your
Contract.

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 F. Refills of prescription drugs (or other covered items) that exceed the Standard
Supply or Mail Order Supply limitations. For example, refills requested because
the Covered Person lost or misused his or her supply of prescription drugs will not
be covered.

G. Nutritional Supplements (prescription or over the counter).

H. Medications which are primarily intended to improve your appearance or lifestyle,

subject to Medical Necessity review, including but not limited to:

(1) Rogaine and other products for hair growth and/or restoration;
(2) Retinoic acid and similar products for the prevention of the wrinkling of the
skin; and
(3) Agents affecting the color, tone, pigmentation or texture of the skin.
(4) Caffeine cessation products.

I. Vaccines, immunizations, and medications received by injection that are not self-
administered, except as determined otherwise by MVP (see your Contract for
covered vaccines and immunizations).

J. Prescription drugs not approved by the FDA of the United States for the indication
prescribed and/or the duration, frequency or dosage prescribed and/or not
recommended in the below established reference compendia. MVP, however, will
not exclude coverage of drugs approved by the FDA for the treatment of certain
types of cancer on the basis that such drug has been prescribed for the treatment
of a type of cancer for which the drug has not been approved by the FDA.
Provided, however, that such drug has been recognized for treatment of the
specific type of cancer for which the drug has now been prescribed in the below
established reference compendia. MVP will also evaluate coverage for medications
for Non-FDA approved indications if the drug has been recognized as safe and
effective in the below established reference compendia:

x The American Hospital Formulary Service Drug Information); or

x Thomson Micromedex DrugDex with a strength of recommendation at least

Class IIa, Strength of evidence at least Category B and Efficacy at least Class
Iia.

K. Immunizations, vaccinations, oral drugs or other services taken solely as a

precaution prior to travel within or outside the United States.

L. Any prescription that is illegally obtained.

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 M. FDA approved prescription products that are only approved for relief of symptoms
related to the common cold.

N. Over the Counter medications except in cases in which a prescription is obtained

pursuant to Federal Health Care Reform coverage under the Contract.

O. Drugs entering the market between 1938 and 1962 that were approved for safety
but not effectiveness is called “DESI” drugs. DESI drugs are not covered.

7. How to file a Claim for Retail Pharmacy Benefits, Mail Order Pharmacy Benefits or Specialty
Pharmacy Benefits.

A. STEP ONE: Have your provider write a prescription and complete any required
Pre-Authorization requirements.

B. STEP TWO: Bring your prescription along with your MVP ID Card to an MVP
Participating Retail Pharmacy or, as applicable, complete a Mail Order Pharmacy
Order Form or Specialty Pharmacy Order Form and mail the completed order form
along with your prescription to the address listed on the form. If the pharmacist
fills your prescription and charges you in accordance with your prescription drug
benefit, then you will have completed the Claim filing process. If the pharmacist
does not fill your prescription or in your opinion has not properly applied your
benefit, then you must proceed to STEP THREE to complete the Claim filing
process.

C. STEP THREE: If the pharmacist does not fill your prescription or in your opinion
has not properly applied your benefit, then you may do the following:

(1) You may decline to have the pharmacist fill your prescription and submit a
Pre-Authorization request directly to MVP, or

(2) You may elect to have the prescription filled (pay the full pharmacy charges)
and submit a Claim for benefits. In this case, if the claim is approved, you
will be reimbursed up to the allowed amount under your pharmacy benefit
minus any cost share requirements. Claims will be subject to all formulary
utilization rules, including Pre-Authorization, step therapy and quantity
limits.

8. How to file a Claim for Mail Order Pharmacy Benefits. To file a Claim you, your designee
or your prescribing provider, must mail a completed claim form to the address listed on
the form. To complete the form, you must fill in all required information; you must have
the dispensing pharmacist sign the form; and you must attach the original receipt for the
prescription to the form. You may get claim forms by calling MVP’s Customer Care Center
at 1-888-687-6277 or by visiting MVP's website at mvphealthcare.com. Claims must be

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 properly submitted within one (1) year from the date the prescription was filled, or as soon
as reasonably possible thereafter. MVP will make a decision on your Claim within the
timeframe set forth in your Contract.

9. How to file a Pre-Authorization request for Pharmacy Benefits. Generally, Pre-

Authorization requests for Pharmacy Benefits will be considered urgent. To request Pre-
Authorization for a medication, you, your designee or the prescribing provider must fax a
request to MVP at 1-800-280-7346. MVP will make a decision on your Pre-Authorization
request within the timeframe set forth in your Contract.

10. How to file an Urgent Pre-Authorization request for Pharmacy Benefits. To file an Urgent
Pre-Authorization request you, your designee or your prescribing provider must mark the
faxed request “Urgent”. MVP will make a decision on your Urgent Care Claim within the
timeframe set forth in your Contract. See “Urgent Matters” in Section Six “Utilization
Management” of the Contract.

11. Restricted Enrollees. If MVP determines that you have received contraindicated, excessive
or duplicative pharmacy services, MVP may impose one or more of the following
restrictions on the provision of benefits to you under your Contract:

A. MVP will restrict benefits to Covered Drugs obtained from one or more designated
Participating Pharmacies.

B. MVP will restrict benefits to Covered Drugs prescribed by one or more designated
Providers.

Before MVP will impose any of the above restrictions, we will give you at least
ninety (90) days prior written notice. The notice will specify the effective date and
scope of the restrictions, explain the reasons for the restrictions, your right to file
a complaint and/or appeal and the procedures for filing a complaint or appeal.
You may request a copy of MVP’s protocols regarding contraindicated, excessive
or duplicative services by calling MVP’s Customer Care Center at 1-888-687-6277.
Nothing in this Subsection shall limit MVP's ability to terminate your coverage
under your Contract for any of the reasons set forth in your Group Contract or
Contract.

12. Prescriptions cannot be refilled until at least seventy-five percent (75%) of the original
prescription (or a subsequent refill) has been used. Drugs with quantity limits are not
subject to this rule.

13. If your prescribed dosage is not commercially available, you may have to make more than
one payment. For example, if your prescription drug is available only in 20 milligram and
30 milligram doses and your provider prescribes 50 milligrams, you may have to make one
payment for the 20 milligram dose and a second payment for the 30 milligram dose.

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 SECTION FOURTEEN - EXCLUSIONS

In addition to any exclusions and limitations described in other sections of this Contract:

1. We will not provide benefits for the following Hospital and Skilled Nursing Facility services:

A. A private room, unless it is Medically Necessary. If you stay in a private room when
it is not Medically Necessary, you must pay the difference between the charge for
the private room and the charge for a semi-private room, if a semi-private room is
available.

B. Any inpatient days that are for Custodial Services or social programs.

C. Any inpatient days that are for diagnostic purposes, such as x-rays, laboratory tests,
or physical checkups, unless Medically Necessary.

D. An inpatient stay while you are waiting for a different level of care, such as Skilled
Nursing Facility or home care. We will pay for the appropriate level of care,

E. We will not provide benefits for inpatient services for dental services. This also
applies to procedures designed primarily to prepare the mouth for dentures
(including alveolar augmentation, bone grafting, fram implants and ramus
mandibular stapling). However, we will provide benefits for anesthesia for certain
dental procedures in accordance with Section Twelve, Paragraph 2.N. of this
Contract.

F. We will not provide benefits for charges because you did not leave your room at
the discharge time.

G. We will not provide benefits for non-medical or items including, but not limited to,
telephone, television, beauty and barber services, guest trays, guest services and
accommodations.

H. We will not provide benefits for items that you take home from the Hospital.

2. Services Not Covered. We will also not provide benefits for the following:

A. Services Starting Before Coverage Begins. If you are receiving services on the day
your coverage under this Contract begins, we will not provide benefits for any
services you receive:

i. prior to your Effective Date; or

ii. on or after your Effective Date if the service is covered or required to be
covered under any other health benefits Contract, program or plan.

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 If the service is not covered and is not required to be covered under any other
health benefits Contract, program or plan, MVP will provide benefits provided that
you comply with the terms of this Contract.

B. Non-Covered Services. We will not provide benefits for any services not listed in
this Contract as a Covered Service or any service that is related to services not
covered under this Contract. We will not provide Benefits for any services in excess
of any limitations or maximums described in this Contract or in your Summary of
Benefits and Coverage (SBC).

C. Non-Medically Necessary Services. We will not provide benefits for any services
that are not Medically Necessary.

D. Non-Participating Provider Services. Except as specifically provided, we will not

provide benefits for any services from a Non-Participating Provider.

E. Services Not Provided By Your PCP or other Participating Provider. Except as

specifically provided in this Contract, we will not provide Benefits for any services
not provided by your PCP or other Participating Provider.

F. Non-Standard Allergy Services. We will not provide benefits for non-standard

allergy services, including, but not limited to skin titration, cytotoxicity testing,
treatment of non-specific candida sensitivity and urine autoinjections.

G. Alternative Services. We will not provide benefits for alternative or complementary

health services, products, remedies, treatments and therapies including, but not
limited to biofeedback, massage therapy, hypnosis and hypnotherapy,
homeopathy, primal therapy, chelation therapy, carbon dioxide therapy, rolfing,
psychodrama, megavitamin therapy, purging, bioenergetic therapy, aroma
therapy, hair analysis, thermograms and thermography, yoga, meditation, and
recreational therapy and any related diagnostic testing.

H. Bulk immunizations (those provided to a group of people, such as employees in an

office setting) or fluoride treatments performed in school.

I. Blood Products. We will not provide benefits for charges for whole blood, blood
plasma, packed blood cells, or other blood products or derivatives if a volunteer
blood replacement program is available. If a program is not available, we will
provide benefits if billed by a Participating Provider. We will provide benefits for
autologous blood donations when they are medically necessary. We will also
provide benefits for administration and processing charges.

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 J. Certification Examinations. Except as specifically provided in Section Twelve,
paragraph 2(A)(ii), we will not provide benefits for any services related to routine
physical examination and/or testing to certify health status, including, but not
limited to, examinations required for school, employment, insurance, marriage,
licensing, travel, camp, sports, or adoption.

K. Conversion Therapy.
We do not Cover conversion therapy. Conversion therapy is any practice by a
mental health professional that seeks to change the sexual orientation or gender
identity of a Member under 18 years of age, including efforts to change behaviors,
gender expressions, or to eliminate or reduce sexual or romantic attractions or
feelings toward individuals of the same sex. Conversion therapy does not include
counseling or therapy for an individual who is seeking to undergo a gender
transition or who is in the process of undergoing a gender transition, that provides
acceptance, support, and understanding of an individual or the facilitation of an
individual’s coping, social support, and identity exploration and development,
including sexual orientation-neutral interventions to prevent or address unlawful
conduct or unsafe sexual practices, provided that the counseling or therapy does
not seek to change sexual orientation or gender identity.

L. Cosmetic Services and Surgery. We will not provide benefits for any services or
surgery which are primarily intended to improve your appearance. We will provide
benefits for services in connection with reconstructive surgery when such service is
incidental to or follows surgery resulting from trauma, infection or other diseases
of the involved part, including breast reconstruction and symmetry surgery as
described in Section Seven, paragraph 6, Section Twelve, paragraph 2(AA))2, and
Section Twenty One, paragraph F. We will also provide benefits for reconstructive
surgery because of congenital disease or anomaly of a covered dependent child
that has resulted in a functional defect.

M. Court-Ordered Services. We will not provide benefits for court-ordered services or

services required as a condition or probation or parole. Such services include, but
are not limited to special medical reports not directly related to treatment and
reports prepared in connection with legal actions unless they are Medically
Necessary Covered Services.

N. Criminal Behavior. We will not provide benefits for any services related to an
intentionally self-inflicted injury or an illness, injury or condition arising out of your
participation in a felony, riot or insurrection. The felony, riot, or insurrection will
be determined by the law of the state where the criminal behavior occurred.
Injuries caused by an act of domestic violence or a medical condition, including
both physical and Mental Health Conditions, are not part of this exclusion.

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 O. Custodial Services. We will not provide benefits for Custodial Services or for bed
rest or convenience reasons.

P. Dental Services. Except as specifically provided, we will not provide benefits for
dental services, including, but not limited to services related to the care, filling,
removal or replacement of teeth and treatment of injuries to or diseases of the
teeth, dental services related to the gums, apicoectomy (dental root resection),
orthodontics, root canal treatment, soft tissue impactions, bony impacted teeth,
alveolectomy, augmentation and vestibuloplasty treatment of periodontal disease,
dental implants, and prosthetic restoration of dental implants. We will also not
provide benefits for temporomandibular joint disease or dysfunction where such
disease or dysfunction is dental in nature. We will also not provide benefits for
inpatient or outpatient hospital services in connection with dental services unless
such services are Medically Necessary and Prior Authorized by MVP.

Q. Dietician Services. Except as specifically provided in Section Twelve, paragraph 2.C,

we will not provide benefits for dietician services. We will not provide benefits for
homemaker services, home delivered meals, or other food or food-related services.

R. Educational Services. We will not provide benefits for services required to

determine appropriate educational placements or services or for other educational
testing. We will also not provide benefits for special education and related services,
and assistive technology devices and assistive technology services determined to
be needed as a result of such educational evaluations, including, but not limited to
therapy services, cognitive retraining and rehabilitation, treatment of behavioral
disorders and behavioral training, services for remedial education, evaluation and
treatment of learning disabilities, interpreter services and lessons in sign language.

S. Employer Services. We will not provide benefits for any services furnished by a
medical department or clinic provided by your employer.

T. Experimental or Investigational Services. Except as specifically provided in this

paragraph, we will not provide benefits for services which we determine are
Experimental or Investigational Services. However, we will provide benefits, to the
extent required by law, to cover routine costs for patients who participate in
approved cancer clinical trials. See Section Thirteen, paragraph 1.A., and also the
Exclusions in Section Thirteen.

U. Exploratory Counseling. We will not provide benefits for exploratory counseling

for personal growth and development or other similar reasons.

V. Family Services. We will not provide benefits for services provided by your
immediate family.

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 W. Foot Care. Unless Medically Necessary for the treatment of diabetes (see section
Twelve, paragraph I), we will not provide benefits for routine or palliative foot care,
including but not limited to any services in connection with corns, callouses, flat
feet, fallen arches, weak feet, toenails, chronic foot strain, or symptomatic
complaints of the feet.

X. Free Services. We will not provide benefits for any services provided to you without
charge or services that would normally be provided without charge.

Y. Government Benefits. We will not provide benefits for any services for which
benefits are available to you under any federal, state, or local government program,
except Medicaid, but including Medicare to the extent it is your primary payor.

Z. Government Hospital. We will not provide benefits for services you receive in any
hospital or other facility or institution which is owned, operated or maintained by
the Veteran’s Administration, the federal government, or any state or local
government, or the United States Armed Forces. However, we will provide benefits
for otherwise covered services in such hospital, facility or institution if the
conditions of coverage described in Section Seven are satisfied or for otherwise
covered services provided for non-military service related conditions.

AA. Home Modifications and Fixtures. We will not provide benefits for the purchase,
rental, repair, replacement or maintenance of home modifications and fixtures
including but not limited to installation of electrical power, water supply or sanitary
waste disposal, elevators, escalators, ramps, seat lift chairs, stair glides, handrails,
swimming pools, whirlpool baths, home tracking systems, exercise or physical
fitness equipment, air or water purifiers, central or unit air conditioners, humidifiers,
dehumidifiers, and emergency alert systems and equipment, and business or
vehicle modifications, or for services for evaluation, fitting or modification of such
modifications and fixtures.

BB. Late Submitted Charges. We will not provide benefits for charges for services
rendered by Participating Providers which are submitted to MVP more than one
hundred eighty (180) days after the date of service, except when coordination of
benefits applies, and MVP is the secondary payor. You will not be responsible for
such charges. We will not provide benefits for charges for services rendered by
Non-Participating Providers which are submitted to MVP more than twenty-four
(24) months after the date of service, except when coordination of benefits applies,
and MVP is the secondary payor. You will not be responsible for such charges.

CC. Military Service-Connected Illnesses, Injuries and Conditions. We will not provide
benefits for any services in connection with any military service-connected illness,
injury, or condition if the Veteran’s Administration is responsible for providing such
services.

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 DD. No-Fault Automobile Insurance. We will not provide benefits for any service which
is covered by mandatory automobile no-fault benefits or applied to the no-fault
deductible. This exclusion applies even if you do not make a proper or timely claim
for benefits available to you under any available no-fault policy or if you fail to
appear at any hearing. We will also not provide benefits even if you bring a lawsuit
against the person who caused your illness, injury or condition and even if you
receive money from that lawsuit and have repaid the medical expenses you
received payment for under the no-fault policy.

EE. Orthotic Devices. We will not provide benefits for orthotic devices, including but
not limited to custom made shoes, orthopedic shoes, arch supports, elastic support
stockings and shoe inserts, or for services for evaluation, fitting, or modification of
such devices.

FF. Personal Hygiene and Comfort and Convenience Items and Services. We will not
provide benefits for the purchase, rental, repair, replacement or maintenance of
personal hygiene or comfort and convenience items or provider services including,
but not limited to, massage services, spa services, and other provider services,
central or unit air conditioners, air or water purifiers, waterbeds, massage
equipment, radio, telephone, television, beauty and barber services, commodes,
hypoallergenic bedding, mattresses, waterbeds, dehumidifiers, humidifiers,
hygiene equipment, saunas, whirlpool baths, exercise or physical fitness
equipment, emergency alert systems and equipment, handrails, heat appliances,
and business or vehicle modifications, or for services for evaluation, fitting or
modification of such items.

GG. Self-Help Education and Training. Except as specifically provided, we will not
provide benefits for self-diagnosis, self-treatment or self-help training.

HH. Special Charges. We will not provide benefits for stand-by services, missed
appointments, new patient processing, interest, copies of provider records or
completion of claim forms.

II. Support Therapies. We will not provide benefits for support therapies including,
but not limited to, marriage counseling, pastoral or religious counseling, sex
counseling, or other social counseling, assertiveness training, dream therapy, music
or art therapy, recreational therapy, and stress management.

JJ. Travel and Transportation Costs. Except as specifically provided, we will not
provide benefits for travel and transportation expenses and related expenses such
as meals and lodging.

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 KK. Unlicensed Provider. We will not provide benefits for services provided by an
unlicensed provider or are outside of a provider's scope of practice.

LL. Vision Examinations, Therapies and Supplies. Except as provided in Section Twelve,
paragraph 2(FF), we will not provide benefits for any services related to eye
examinations for prescribing, fitting, or determining the need for eyeglasses,
lenses, frames, or contact lenses, for vision therapy or training, vision perception
training or orthoptics, or for the correction of refractive errors by means of any
surgical or other procedures, including radial keratotomy, or for services for
disorder of vision correction or accommodations. However, we will provide for
Medically Necessary eye care.

MM. Workers’ Compensation. Except for sole proprietors and partners who are not
voluntarily covered under a workers’ compensation insurance policy, we will not
provide benefits for any service for which you have received or are eligible to
receive benefits under a workers’ compensation act or similar law. This exclusion
applies even if you do not receive such benefits because you did not submit a
proper or timely claim for benefits or because you fail to appear at a hearing. We
will also not provide benefits even if you bring a lawsuit against the person who
caused your illness, injury or condition and even if you receive money from that
lawsuit and you have repaid the medical expenses you received payment for under
the workers’ compensation act or similar law.

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 SECTION FIFTEEN - TERMINATION OF YOUR COVERAGE

This section describes how your coverage may terminate. When your coverage terminates,
benefits stop at 12:00 midnight on the termination date, unless you are eligible for benefits after
termination as described below.

1. Automatic Termination. Your coverage will automatically terminate in the event of any of
the following:

A. Discontinuance of Your Group Membership. If you are covered under this Contract
as a member of a group, your coverage will automatically terminate on the date of
discontinuance of your group membership, or the date to which your premium is
paid, whichever is sooner. See Section Sixteen as to how you may obtain
continuation and conversion coverage.

B. Termination of Group Contract. If the group contract under which this Contract
was issued is terminated, your coverage will automatically terminate as of the date
the group contract terminates. Your group is required to give you prior written
notice if the group contract is terminated.

C. On Your Death. If you have individual coverage, your coverage will automatically
terminate on the date of your death. If you have two person or family coverage,
coverage will automatically terminate on the date of your death, or the date to
which your premium is paid, whichever is sooner. Your Spouse or Dependents
must immediately notify us of your death. However, your Spouse and/or
Dependents may request substantially similar replacement coverage. See Section
Sixteen as to how your Spouse and/or Dependents may obtain continuation and
conversion coverage.

D. Dissolution of Marriage or Civil Union. If you become divorced, or your marriage

or civil union is annulled or otherwise legally dissolved, your Spouse’s coverage will
automatically terminate on the date of dissolution, or the date to which your
premium is paid, whichever is sooner. You must immediately notify us of any such
dissolution. See Section Sixteen as to how your Spouse may obtain continuation
and conversion coverage.

E. Termination of the Domestic Partnership. If the Enrollee's domestic partnership

ends, the domestic partner's coverage will automatically terminate. Coverage will
end on the earlier of the date the domestic partnership ends or the date to which
premium is paid. The Enrollee or domestic partner must notify MVP right away, in
writing, when the domestic partnership ends.

F. Termination of Coverage of a Child. Your child’s coverage under this Contract will
automatically terminate on the last day of the month following the date to which

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 your premium is paid or on the last day of the year following the date the child
reaches age 26, whichever is sooner. If your child is covered pursuant to Section
Three, paragraph 2(D)(iii), the child’s coverage will automatically terminate on the
earliest of the date the child is no longer incapable of self-sustaining employment,
is no longer disabled, or is no longer chiefly dependent upon you for support and
maintenance. You must immediately notify us when your child is no longer eligible
for coverage. See Section Sixteen as to how your child may obtain continuation
and conversion coverage.

i. Special Rule for Children Covered Pursuant to Qualified Medical Support

Orders. We will not terminate the coverage of a child required to be
covered pursuant to a qualified medical support order until we are provided
satisfactory written evidence that:

(a) the order is no longer in effect, or

(b) the child is or will be enrolled in comparable coverage through

another insurer which will take effect not later than the date
coverage under this Contract would terminate.

You must immediately notify us of these circumstances. In such instances,

the child's coverage will terminate on the last day of the month following
the date of the event described in subparagraph (a) or (b), or the date to
which your premium is paid, whichever is sooner

2. MVP’s Termination of Your Coverage. MVP may terminate your coverage for the following
reasons. We will give you 30 days prior written notice:

A. Fraud or Misrepresentation. MVP will immediately terminate your coverage for any
fraud or intentional misrepresentation of material fact made by you when you
enrolled or when you filed any claim under this Contract. The termination will be
effective as of the date of the fraud or intentional misrepresentation and MVP shall
be entitled to all remedies provided for in law and equity, including but not limited
to recovery from you for the charges for benefits provided, attorneys fees, costs of
suit, and interest.

B. Discontinuance of Class of Contract. We discontinue the entire class of Contracts

to which this Contract belongs. We will offer you coverage under a replacement
plan. We will give you 90 days prior written notice.

C. Residency. If you are no longer a resident of Vermont as otherwise provided in

this Contract.

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 D. Regulatory. Any reason found to be acceptable to the Department of Financial
Regulation (DFR) authorized by the Health Insurance Portability and Accountability
Act of 1996, as amended, and regulations thereunder.

E. Ineligibility, You are no longer eligible for Coverage in a QHP through the VHC.

F. Non-payment of Premiums and

i. the three month grace period required for Enrollees receiving advance
payments of the premium tax credit has been exhausted; or

ii. any other applicable grace period not described by this section has been
exhausted.

G. Your Qualified Health Plan terminates or is decertified by the VHC.

H. You change from one MVP QHP to another plan’s QHP during an annual open
enrollment period or special enrollment period.

3. Your Option to Terminate Coverage.

A. You may terminate your coverage at any time by giving us fourteen (14) days’ prior
written notice.

B. If you demonstrate to Vermont Health Connect (VHC) you attempted to terminate

coverage but experienced a technical error, you may request retroactive
termination within 60 days of discovering the technical error. The termination date
will be no sooner than 14 days after the date you previously contacted VHC to
terminate the enrollment.

C. If you demonstrate enrollment in a qualified health plan through VHC was

unintentional, inadvertent or erroneous and was the result of the error or
misconduct of an officer, employee, or agent of VHC or the Department of Health
and Human Services, or an entity providing enrollment assistance, you must
request retroactive termination within 60 days of discovering the enrollment. The
cancellation or termination date will be the original coverage effective date or a
later date if determined appropriate by VHC depending on the circumstances.

D. If you demonstrate to VHC that you were enrolled in a qualified health plan without
your knowledge or consent by a third party, including third parties who have no
connection with VHC, and request cancellation within 60 days of discovery of the
enrollment. The cancellation date or termination date will be the original coverage
effective date or a later date if determined appropriate by VHC depending on the
circumstances.

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 4. Obligations on Termination. Except as specifically provided in paragraph 5 below, once
your coverage ends, MVP will not provide any more benefits except for Covered Services
received before termination.

5. Benefits After Termination. If you are Totally Disabled on the date your coverage
terminates, and such Total Disability occurred before your coverage terminated, we will
continue to provide benefits for otherwise covered services which are directly related to
the illness, injury or condition causing the Total Disability. This extension of benefits will
continue until the earliest of: (1) the date you are no longer Totally Disabled; or (2) twelve
months from the date your coverage would otherwise have terminated. However, we will
not provide more benefits than would otherwise have been provided if your coverage
under this Contract had not been terminated and we will not provide benefits for any
services covered or required to be covered under any other insurance plan or Contract.

If you have coverage other than individual coverage under this Contract, this extension of
benefits covers only the Enrollee with the Total Disability. Coverage of other family
members who were covered under this Contract will terminate as of the termination date.

6. MVP’s Right to Recover. If we incorrectly provide benefits after your coverage or this
Contract has been terminated, MVP may recover from you the charges for benefits
provided, and any attorneys’ fees, costs, and interest.

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 SECTION SIXTEEN - POST TERMINATION CONTINUATION OF COVERAGE; CONVERSION
TO A DIRECT CONTRACT

If your coverage under this Contract terminates under the circumstances described below, you
may be able to continue coverage in some circumstances or to purchase a new contract available
to non-group Enrollees. Continuation and/or conversion coverage is not available for individual
Enrollees.

1. Continuation Coverage:

A. Under Federal COBRA Law. Under the continuation of coverage provisions of the
Federal Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA), most
employer sponsored group health plans must offer: (1) employees and (2) their
spouses and dependents, as those terms are defined by federal law, the
opportunity for continuation of health insurance coverage when their coverage
would otherwise end. This means that: (1) civil union spouses and dependents and
(2) domestic partners and their dependents are not eligible for COBRA coverage
unless such spouses/partners and dependents meet the federal law definition of
spouse or dependent or unless your Group has elected to extend COBRA coverage
beyond that required by law. Enrollees should call or write your Group or us to
find out if your employer offers COBRA and, if so, whether you are eligible for
COBRA coverage.

B. Under Vermont Law. If your employer does not have to offer COBRA coverage as
set forth above, you, your Spouse and your Dependents may be able to get
continuation of coverage under state law. If your Group is an employer group and
your coverage would end because of the occurrence of a qualifying event, you may
be able to continue your coverage under this Contract, subject to the terms of your
Group’s contract. Enrollees should call or write your Group or us to find out if your
employer offers state continuation coverage and, if so, whether you are eligible for
such coverage.
A qualifying event is:
i. loss of employment, including a reduction in hours that results in ineligibility
for employer-sponsored coverage;
ii. divorce, dissolution, or legal separation of the covered employee from the
employee's spouse or civil union partner;
iii. a dependent child ceasing to qualify as a dependent child under the generally
applicable requirements of the policy; or
iv. death of the covered employee or member.

Such coverage will not be available to you if:

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 i. the deceased or terminated Enrollee was not covered under this Contract on
the date of the qualifying event;
ii. the Enrollee seeking continuation coverage is covered by Medicare;
iii. the Enrollee is covered as an employee, enrollee or dependent by any other
insured or uninsured arrangement which provides dental coverage, hospital,
surgical or medical coverage for individuals in a group under which the Enrollee
was not covered immediately prior to the qualifying event, and no preexisting
condition exclusion applies; provided, however, that the person shall remain
eligible for continuation coverages which are not available under the insured
or uninsured arrangement; or
iv. the Enrollee’s termination of employment was due to misconduct as defined
by Vermont law.

1. Written Request for Continuation:

(a) An Enrollee who wishes to elect continuation coverage must notify

the insurer, or the policyholder, or the contractor, or agent for the
group if the policyholder did not contract for the policy directly with
the insurer of such election in writing within 60 days after receiving
notice of the qualifying event. The Enrollee’s applicable premium
contribution must be included with this election which shall include
payment for the period from the qualifying event through the end
of the month in which the election is made.

(b) Contributions shall be due on a monthly basis in advance to the

insurer or the insurer's agent, and shall not be more than 102
percent of the group rate for the insurance being continued under
the group policy on the due date of each payment

2. Termination: Vermont Continuation Coverage shall terminate upon the

occurrence of any of the following:

(a) 18 months after the date the Enrollee’s benefits under this Contract
would otherwise have terminated because of the qualifying event;
or

(b) the end of the period for which premium payments were made, if
the Group or the Enrollee fails to make timely payment of a required
premium payment; or

(c) the Enrollee is covered by Medicare; or

(d) the person is covered by any other group insured or uninsured

arrangement that provides dental coverage or hospital and medical

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 coverage for individuals in a group, under which the person was not
covered immediately prior to the occurrence of a qualifying event,
and no preexisting condition exclusion applies; provided, however,
that the person shall remain eligible for continuation coverages
which are not available under the insured or uninsured
arrangement; or

(e) the date on which the group’s contract with MVP is terminated or,
in the case of an employee, the date the decedent's or terminated
employee's employer terminates participation under the group
policy. However, in such event, if coverage is replaced by similar
coverage under another Group Contract:

(i) The Enrollee shall have the right to become covered under
the replacement Group Contract for the balance of the
period that he would have remained covered under the prior
Group Contract;
(ii) The minimum level of benefits provided by the replacement
Group Contract shall be the applicable level of benefits of
the prior Group Contract, reduced by any benefits payable
under that prior Group Contract; and
(iii) The prior Group Contract shall continue to provide benefits
to the extent of its accrued liabilities and extension of
benefits as if the replacement had not occurred.

2. Conversion to a Direct Contract: Any person whose insurance under the group policy would
terminate because of the death or loss of employment of the employee or member shall
be entitled to have a converted policy issued to him by the insurer under whose group
policy he was insured, without evidence of insurability.

3. Circumstances Under Which Conversion is Not Available. MVP is not required to provide
Conversion Coverage if: (1) the Enrollee was not entitled to or did not properly elect
Continuation Coverage; (2) the person is covered by Medicare; (3) the person is covered for
similar benefits by another individual contract or policy; or (4) the person is or could be
covered for similar benefits under any insured or self-insured group arrangement, or by
reason of any state or federal law, and together with this Conversion Coverage, would result
in overinsurance according to MVP’s standards.

4. Supplementary Suspension, Continuation and Conversion Coverage. To the extent

required by law, if you, the Enrollee, enter active duty but the Group does not voluntarily
maintain your coverage, your coverage shall be suspended unless you elect in writing to
the Group, within 60 days of being ordered to active duty, to continue coverage under this
Contract for yourself and eligible Dependents. Such continued coverage shall not be

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 subject to evidence of insurability. You must pay the required Premium in advance to the
Group, but not more frequently than once a month.

A. This paragraph applies only to the extent required by law and only if you are a
member of a reserve component of the Armed Forces of the United States,
including the National Guard, you serve no more than five (5) years of active duty,
and you either:

i. voluntarily or involuntarily enters upon active duty (other than for the
purpose of determining your physical fitness and other than for training);
or
ii. have your active duty voluntarily or involuntarily extended during the
period when the President in office authorized to order units of the ready
reserve or members of the reserve component to active duty; provided that
such additional duty is at the request and for the convenience to the
Federal Government.

B. Supplementary continuation shall not be available to any person who is covered

by Medicare or any other group coverage. Coverage available through the Federal
government for active duty members of the armed forces shall not be considered
group coverage for the purposes of this paragraph.

C. In the event that you are reemployed or restored to participation in the group upon
return to civilian status after the period of continuation coverage or suspension,
you (and your covered dependents if other than individual coverage applies), shall
be entitled to resume coverage under this Contract. If coverage has been
suspended, resumed coverage will be retroactive to the date of termination of
active duty provided the applicable premium has been paid from that date. No
exclusion or waiting period shall be imposed in connection with resumed coverage
except regarding:

i. A condition that arose during the period of active duty and that has been
determined by the U.S. Secretary of Veteran’s Affairs to be a condition
incurred in the line of duty; or

ii. A waiting period imposed that had not been completed prior to the period
of suspension. The sum of the waiting periods imposed prior and
subsequent to the suspension shall not exceed eleven months.

In the event that you are not reemployed or restored to participation in the
Group upon return to civilian status, you may, within 31 days of the
termination of active duty, or discharge from hospitalization incident to
active duty which continues for a period of not more than one year, submit
a written request for Continuation Coverage to the Group, or a request for

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 Conversion Coverage directly to MVP, as described elsewhere in this
Contract.

D. The maximum period of Supplementary Continuation Coverage for the Enrollee

and his or her Dependents shall be the lesser of: (1) the 18 month period beginning
on the date on which the Enrollee's absence begins; or (2) the day after the date
on which the Enrollee fails to apply for or return to a position of employment, as
determined by federal law.

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 SECTION SEVENTEEN – EFFECT OF MEDICARE

1. When you become covered by Medicare, you must notify MVP in writing and Medicare
then becomes your Primary Plan. We will reduce our benefits by the amount Medicare
paid for the services or care.

2. Eligibility for Medicare By Reason of End-Stage Renal Disease. You are entitled to benefits
under Medicare by reason of end-stage renal disease, and there is a waiting period before
Medicare coverage becomes effective. We will not reduce this Contract’s benefits, and we
will provide benefits before Medicare pays, during the waiting period (this means that
Medicare is the Secondary Plan during this waiting period). We will also provide benefits
before Medicare pays during the coordination period with Medicare. After the waiting
period, Medicare will pay its benefits before we provide benefits under this Contract (this
means that Medicare is the Primary Plan after this waiting period).

3. Recovery of Overpayment. If we provide more benefits than we should have, we have the
right to recover the overpayment from you or from any other person, insurance company,
agency or organization. You must cooperate with us to recover the overpayment.

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 SECTION EIGHTEEN - COORDINATION OF BENEFITS

This Section applies only if you have other group health benefits with another group health plan.

1. When You Have Other Health Benefits. You may be covered by two or more health plans
which provide similar benefits. If you receive a service which is covered at least in part by
any of the plans involved, we will coordinate our benefits with the benefits under the other
plan. This prevents overpayment or duplicate payments for the same service. One plan
(called the Primary Plan) will pay benefits (up to the limits of its policy). The other plan
(called the Secondary Plan) will pay benefits (up to the limits of its policy) if the benefits of
the Primary Plan do not fully cover your expenses. The benefits of the Secondary Plan will
be reduced to cover only those expenses which were not covered by the Primary Plan.

2. The following are considered to be health plans:

A. Any group or blanket insurance contract, plan or policy, including HMO and other
prepaid group coverage, except that blanket school accident coverages or such
coverages offered to substantially similar groups (e.g. Boy Scouts, youth groups)
shall not be considered a health insurance contract, plan or policy;

B. Any other service type group plan;

C. Any self-insured or noninsured plan, or any other plan arranged through any
employer, trustee, union, employer organization, or employee benefit
organization;

D. Any coverage under governmental programs, or any coverage required or

provided by any statute. However, Medicaid and any plan whose benefits are, by
law, excess to those of any private insurance plan or other non-governmental plan
shall not be considered health insurance policies; and

E. Medical benefits coverage in group and individual mandatory automobile “no-

fault” and traditional “fault” type contracts.

3. Rules to Determine Payment. In order to determine which plan is the Primary Plan, certain
rules have been established:

A. If your other plan does not have a provision like this one which coordinates benefits
it will always be the Primary Plan.
B. If you are covered under one plan as an Enrollee and under the other plan as a
dependent, the plan which covers you as an Enrollee is the Primary Plan.
C. If you are covered as a dependent under two plans, then the rules are as follows:
(i) the coverage of the parent whose birthday is first in a year will be primary and
the parent whose birthday is later in the year will be secondary; (ii) if both parents

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 have the same birthday, the benefits of the plan in effect longer will be primary;
(iii) if the other plan does not have this rule, but instead has a rule based upon the
parents gender; and if as a result, the plans do not agree on the order of benefits,
then the rule in the other plan will determine the order of benefits.

D. There are special rules for a child of separated or divorced parents:

(1) if the terms of a court decree specify which parent is responsible for the
health care expenses of the child, and that parent’s plan has actual
knowledge of the court decree, then that parent’s plan shall be primary

(2) if no such court decree exists or if the Plan of the parent designated under
such a court decree as responsible for the child’s health care expenses does
not have actual knowledge of the court decree, benefits for the child are
determined in the following order:

a. first, the Plan of the parent with custody of the child;

b. then, the Plan of the spouse of the parent with custody of the child;

c. finally, the Plan of the parent not having custody of the child.

E. A plan which covers you as an active employee or that employee’s dependent is

primary; a plan which covers you as a laid off or retired employee (or as that
employee’s dependent) is secondary. If the other plan does not have this rule and
if, as a result, the plans do not agree on which plan is primary, this subsection 2(E)
is ignored.
F. If none of the above rules determines the order of benefits, the benefits of a plan
which covered you longer is primary.

The above rules apply whether or not you actually make a claim under both Contracts or
policies.

4. MVP as Secondary Plan. In the event that MVP is considered to be the secondary payor,
you are required to follow the rules and procedures of the primary plan before MVP will
make payment. If MVP is to make payment on a secondary basis, the rules and procedures
of MVP as otherwise stated in this Contract must also be followed. When MVP is the
Secondary Plan, benefits under this Contract will be reduced so that the total benefits
payable under the Primary Plan and MVP do not exceed your expenses for an item of
service. However, we will not pay more than we would have paid if MVP was the Primary
Plan. We count as actually paid by the Primary Plan any items of expense that would have
been paid if you had made the proper claim.

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 5. Recovery of Overpayment. If we provide benefits greater than we should have under this
provision, we have the right to recover the overpayment from you or from any other
person, insurance company, or organization which may have gained from our
overpayment. When the overpayment includes services which you received under this
Contract, the amount of the overpayment will be based on prevailing rates for those
services. You agree to do whatever is necessary to help us to recover our excess payment,
including but not limited to: (1) agreeing to complete and file claim forms with other
organizations or insurance companies and endorsing checks over to us, and (2) authorizing
MVP to complete and file claim forms with other organizations or insurance companies on
your behalf. Whether MVP is the primary or secondary plan, you will be responsible for all
applicable Cost Share.

In the event that you receive benefits or services under this Contract, including but not
limited to coverage for drugs (prescription or otherwise), after coverage has lapsed or has
been terminated, MVP is entitled to recover payment for such services through any and
all reasonable means, including but not limited to, the collections process.

4. Cost Share When You are Enrolled in Two MVP Plans. If you are covered under MVP as
an Enrollee and also a Dependent of a separate MVP plan, you are responsible for the
Cost Share under the primary plan only.

7. Payments to Others. We may repay to any other person, insurance company or

organization the amount which it paid for your Covered Services and which we decide we
should have paid. These payments are the same as benefits paid.

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 SECTION NINETEEN - THIRD PARTY LIABILITY AND RIGHTS OF REPAYMENT

1. Introduction. If MVP provides benefits to an Enrollee for an injury, illness, or condition for
which a third party is or may be responsible, then MVP retains the right to repayment of
the full cost of all benefits provided by MVP that are for or related to the injury, illness or
condition. MVP may recover the full cost of all benefits provided by MVP without regard
to any fault by the Enrollee.

2. Right to Subrogation. When MVP has provided benefits as described above and the
Enrollee has not yet recovered such costs from the third party, MVP is subrogated to the
Enrollee's rights of recovery against any third party for the full cost of benefits. MVP
proceed against any third party without the consent of the Enrollee.

3. Right to Reimbursement. When MVP has provided benefits as described above and the
Enrollee or Enrollee’s representative has recovered such costs from the third party, MVP is
entitled to reimbursement from the Enrollee for the full cost of benefits. As a condition of
coverage under this Contract, each Enrollee hereby grants to MVP: (1) an assignment of
the proceeds of any settlement, judgment, benefits under any automobile policy or other
coverage, or any other payment received by the Enrollee, to the extent of the full cost of
all benefits provided by MVP; and (2) a first priority lien against the proceeds of any
settlement, verdict, judgment, benefits under any automobile policy or other coverage,
insurance proceeds, or any other payment received by the Enrollee, to the extent of the
full cost of all benefits provided by MVP.

4. Sources of Payment. MVP’s rights apply to any payments made to or on behalf of an

Enrollee from third-party sources, including, but not limited to: (1) payments made by a
tortfeasor or any insurance company on behalf of such third-party tortfeasor, (2) any
payments or awards under an uninsured or undersinsured motorist automobile policy, (3)
any worker’s compensation or disability award or settlement, (4) medical payments
coverage under any automobile policy, (5) premises or homeowners medical payments
coverage or premises or homeowners insurance coverage, (6) any other payments from a
source intended to compensate an Enrollee for injuries resulting from alleged negligence
of a third party. No court costs or attorney’s fees may be deducted from MVP’s recovery
without MVP's prior written consent.

5. Cumulative Rights. MVP may choose to exercise either or both rights.

6. Enrollee’s Obligations.

A. Promptly notify MVP when notice is given to any third party to pursue a claim for
injuries, illnesses or conditions that may be the legal responsibility of a third party.

B. Cooperate with MVP to protect MVP’s rights to reimbursement and subrogation,

including:

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 (1) signing and delivering, within 30 days of a reasonable request to do so, any
documents needed to secure MVP’s subrogation claim, to protect MVP’s
right to reimbursement, or to effect the assignment or lien described in
paragraph 3 above;
(2) providing any relevant information;
(3) obtaining the consent of MVP before releasing any party from liability for
payment of medical expenses;
(4) taking such other actions as may be needed to assist MVP in making a full
recovery of the cost of all benefits provided; and
(5) not taking any action that prejudices MVP’s rights to reimbursement or
subrogation, including but not limited to making any settlement or
recovery which specifically attempts to reduce or exclude the full cost of
benefits provided by MVP.

7. Consequence of Failure to Comply. If the Enrollee fails to comply with the requirements
of paragraph 6, an Enrollee shall be responsible for all benefits provided by MVP in
addition to costs, attorneys’ fees, and interest incurred by MVP in obtaining repayment.

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 SECTION TWENTY – GRIEVANCES AND INDEPENDENT EXTERNAL REVIEW

1. Grievances. A grievance means a written or verbal complaint submitted to MVP by or on

behalf of an Enrollee expressing dissatisfaction regarding the availability, delivery or
quality of health care services, claims payment, handling or reimbursement for health care
services, or expressing dissatisfaction regarding matters governed by or related to this
Contract, including requests that MVP change decisions that services are not Medically
Necessary or are not Covered Services. You, your designated representative (such as a
family member, friend, or lawyer), or a Provider acting on your behalf, may submit a
grievance. You must call MVP at 1-800-348-8515 in order to designate a representative.
If English is not your primary language, you may call MVP’s Customer Care Center for help
1-888-687-6277 or to get information in your primary language about how to file a
grievance and how to participate in the grievance process. You may also call either the
Vermont Department of Financial Regulation’s Consumer Service at 1-800-964-1784 or
the Vermont Office of Health Care Advocate at 1-800-919-7787 for assistance. If you are
unable to file a written grievance, you may notify MVP of a grievance orally or through
another alternative mechanism. MVP shall be responsible for documenting such
grievances. At your request, MVP will provide reasonable access to copies of these
documents, records and other information relevant to your grievance within two (2)
business days. Copies may be provided to you or your appointed representative. If you
have a disability, you shall be provided with reasonable accommodations for filing
grievances and for participating in the grievance process. Your decision as to whether or
not to submit a grievance has no effect on your rights to any other benefits under this
Contract. This means that you must commence and complete a First Level Grievance
before you may seek any other internal or external remedy, including Independent External
Review or court action.

2. Grievance Reviewers.

(a) First Level Grievances. Medical grievances are reviewed by one of MVP’s medical
directors. Non-medical grievances are reviewed by a member of MVP’s
administrative staff who has the necessary education and experience to resolve the
matter. First level grievances are reviewed by persons who were not involved in
making the initial decision and who are not subordinate to such persons.

(b) Second Level Grievances. Not available to individual plan members. This applies
to group coverage only. Second level grievances are reviewed by a panel
comprised of MVP senior medical and administrative staff and/or board members
with the necessary education, training and experience to resolve the matter. The
medical staff participating in at least one level of grievance review will have
appropriate training and experience in the field of medicine involved in the
particular grievance, and will be actively practicing in the same or similar specialty
who typically treats the condition or provides the services that is the subject of the
grievance. Alternatively, MVP may engage independent organizations to provide

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 medical specialists practicing in the same or similar specialty as consultants for a
particular grievance. Second level grievances are reviewed by persons not involved
in making the initial decision or the first level grievance decision and who are not
subordinate to such persons. Further information about the panel reviewing your
grievance is included in MVP’s written response to the grievance.

3. First Level Grievances - General Information.

A. In deciding a first level grievance of an adverse benefit determination that is based

in whole or in part on a medical judgment, including determinations with regard to
whether a particular treatment, drug, or other item is experimental, investigational,
or not medically necessary or appropriate, or based in whole or in part on any other
adverse benefit determination that is an appealable decision pursuant to Vermont’s
independent external review laws, the reviewers shall include at least one (1) clinical
peer of the Enrollee's treating provider.

B. Information Reviewed. MVP will review all comments, documents, records and
other information you provide, without regard to whether such information was
submitted or considered when making the initial decision or any first level
grievance decision.

C. MVP’s medical director or the medical director’s designee shall offer to, and if the
offer is accepted, shall directly communicate with the Enrollee’s treating provider
or the treating provider’s designee before a resolution of the grievance is made;

D. For any grievances relating to an adverse determination, we shall promptly

authorize and/or otherwise arrange for coverage for any covered service that had
been denied or restricted and as to which a reversal has been made by its reviewers
under this section.

E. No fees or costs are imposed on you as part of the Mandatory First Level or
Voluntary Second Level Grievance.

F. Time Limit for Submitting a First Level Grievance. You must submit a grievance
within 180 days of receiving our decision regarding the matter that is the subject
of the grievance. You should describe the reasons why you disagree with the
decision and provide any further information you think is relevant. You may submit
an oral grievance by calling MVP at 1-800-348-8515. You may submit a written
grievance to MVP Health Plan, Inc., Attn: Member Appeals 625 State Street,
Schenectady, New York 12305.

4. First-Level Concurrent Review Grievance - Timeframe for Completion and Notification:

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 A. A grievance related to a request to continue or extend a course of treatment shall be
decided as soon as possible consistent with the medical exigencies of the case. MVP shall
notify you and your treating provider of our determination (whether adverse or not) as
soon as possible consistent with the medical exigencies of the case, but not later than
twenty-four (24) hours after receipt of the grievance.

B. In the case of a grievance related to an adverse concurrent review determination, neither

you nor the provider shall be liable for any services provided before notification to you of
the adverse determination and the final outcome of any grievance or independent external
review, unless the treating provider or designee has refused or repeatedly failed to engage
in communication with MVP when it has been offered at a time in a manner reasonably
convenient for the provider, in which case the provider, not you, shall be liable for any
services provided.

C. We shall notify the treating provider and you of the determination orally as soon as the
determination has been made. Written (either hard copy or, if elected by you or your
treating provider, appropriately secure electronic) confirmation of the determination shall
be sent to the treating provider and you within twenty-four (24) hours of the oral
notification.

5. First-Level Urgent, Pre-Service Grievance - Timeframe for Completion and Notification:

A. Grievances related to Emergency Services or Urgently-Needed Care and in cases

where:

i. application of the time periods described in subparagraph B below:

a. could, applying the judgment of a prudent layperson with an

average knowledge of health and medicine, seriously jeopardize
your life or health or your ability to regain maximum function; or

b. would, in the opinion of a physician with knowledge of your medical

condition, subject you to severe pain that cannot be adequately
treated without the requested services; or

ii. a physician with knowledge of your medical condition determines that a

concurrent review or Pre-Authorization request is urgent.

MVP shall notify you and your treating provider (if known) of our determination
(whether adverse or not) as expeditiously as your medical condition requires, but
not later than twenty-four (24) hours after receipt of the grievance.

B. MVP shall notify the treating provider (if known) and you of the determination
orally as soon as the determination has been made. Written (either hard copy, or if

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 elected by you or treating provider, appropriately secure electronic) confirmation
of the determination shall be sent to the treating provider (if known) and to you
within twenty-four (24) hours of the oral notification.

C. For purposes of this section, the following grievances shall be treated as urgent:

1. all pre-service grievances related to mental health and substance abuse

conditions that were handled as urgent at the review level, unless:

a. you have authorization for the treatment in dispute such that

treatment can continue uninterrupted for the duration of any non-
expedited grievance(s) and independent external review, if any;

b. the request is for a service scheduled sufficiently in the future such

that non-expedited grievance(s) and independent external review,
if any, can be completed prior to the date scheduled for the service;
or

c. the managed care organization otherwise has good cause to believe

that it is not medically necessary to expedite the timeframe for
grievance review, and you and your provider agree;

2. all pre-service requests related to whether use of a prescription drug for

the treatment of cancer is medically necessary or is an experimental or
investigational use; and

3. any grievance designated as urgent by your health care provider or by you.

6. First-Level Non-Urgent, Pre-Service Grievance - Timeframe for Completion and

Notification:

A. In the case of a grievance relating to a non-urgent, pre-service request, MVP shall

notify you and your treating provider (if known) of our determination (whether
adverse or not) not later than fifteen (15) calendar days after receipt of the
grievance.

B. Written (either hard copy or, if elected by you or your treating provider,
appropriately secure electronic) confirmation of the determination shall be sent to
the treating provider (if known) and to you.

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 7. First-Level Post-Service Grievance - Timeframe for Completion and Notification:

A. In the case of a post-service grievance, MVP shall decide and notify you and your
treating provider (if known) of our determination (whether adverse or not) within a
reasonable period of time but not later than fifteen (15) calendar days after receipt
of the grievance.

B. Written (either hard copy or, if elected by you or your treating provider,
appropriately secure electronic) confirmation of the determination shall be sent to
the treating provider (if known) and to you.

8. First-Level Grievance Unrelated to an Adverse Determination - Timeframe for Completion

and Notification:

A. For grievances not related to adverse benefit determinations, you shall be notified
within fifteen (15) calendar days after receipt of the grievance.

B. Written (either hard copy or, if elected by you, appropriately secure electronic)
confirmation of the determination shall be sent to you.

9. If you are not satisfied with MVP's decision in response to your First Level Grievance, you
may, in addition to any other legal remedy available to you:

A. Commence a Voluntary Second Level Grievance with MVP as described in

paragraphs 11-16 below. If you do so, your time to commence court action will
not start until you receive MVP’s response to the Voluntary Second Level Grievance.
Paragraphs 11-16 are not applicable to enrollees in individual health plans. If you
are in an individual health plan, please proceed directly to paragraph 17.

10. Additional Provisions.

A. MVP waives any right to assert that you failed to exhaust administrative remedies
because you did not elect to make a Voluntary Second Level Grievance.

B. MVP agrees that any statute of limitations or other defense based on timeliness is
tolled during the time that your Voluntary Second Level Grievance is pending.

C. No fees or costs are imposed on you as part of the Mandatory First Level or
Voluntary Second Level Grievance.

11. Voluntary Second Level Grievances - General Information. (Paragraphs 11-16 are not
applicable to enrollees in individual health plans. If you are in an individual health plan,
please proceed directly to paragraph 17.)

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 A. If you are not satisfied with MVP’s decision in response to the first level grievance,
you may submit a voluntary second level grievance. You are not required to make
a voluntary second level grievance in order to pursue any external remedy that may
be available to you.

B. MVP Shall:

(i) Provide you the right to meet with one (1) or more of the reviewers, at your
request, before a final determination is made on the voluntary second level
grievance.
(ii) Provide for either an in-person meeting or a telephone meeting; however,
if it is inconvenient for you to participate in the manner offered by MVP,
the other method of meeting must be made available to you.
(iii) Ensure that your treating provider(s) and any other person(s) requested by
you is (are) entitled but not required to participate in such a meeting or call.
(iv) Ensure that the meeting date shall be arranged in consultation with you.
(v) Not unreasonably deny a request for postponement of the review made by
you.
(vi) Ensure that the right to have a voluntary second level grievance considered
shall not be made conditional on your appearance either in person or by
telephone at such a meeting.
(vii) For any grievances relating to an adverse benefit determination, we shall
promptly authorize and/or otherwise arrange for coverage for any covered
service that had been denied or restricted and as to which a reversal has
been made by its reviewers under this section.

C. Submitting a Voluntary Second Level Grievance. You must submit this grievance
within 90 days of receiving our decision issued in response to the first level
grievance. You should describe the reasons why you disagree with the decision
and provide any further information you think is relevant. You may submit an oral
grievance by calling MVP at 1-800-348-8515. You may submit a written grievance
to MVP Health Plan, Inc., 625 State Street, Schenectady, New York 12305. Second
level grievances are reviewed by a panel. You also have the right to appear before
the panel to discuss your grievance. If you cannot appear before the panel in
person, you may communicate with the panel by conference call or other
appropriate technology.

12. Voluntary Second-Level Concurrent Review Grievance - Timeframe for Completion and
Notification:
A. A grievance related to a request to continue or extend a course of treatment shall
be decided as soon as possible consistent with the medical exigencies of the case.
MVP shall notify you and your treating provider (if known) of our determination

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 (whether adverse or not) as soon as possible consistent with the medical exigencies
of the case, but not later than twenty-four (24) hours after receipt of the grievance.
B. In the case of a grievance related to an adverse concurrent review determination,
neither you nor your provider shall be liable for any services provided before
notification to you of the adverse benefit determination and the final outcome of
any grievance or independent external review, unless the treating provider or
designee has refused or repeatedly failed to engage in communication with MVP
when it has been offered at a time in a manner reasonably convenient for the
provider, in which case your provider and not you shall be liable for any services
provided.
C. MVP shall notify the treating provider and you of the determination orally as soon
as the determination has been made. Written (either hard copy, or, if elected by
you or your treating provider, appropriately secure electronic) confirmation of the
determination shall be sent to the treating provider and to you within twenty-four
(24) hours of the oral notification.
13. Voluntary Second-Level Urgent, Pre-Service Grievance - Timeframe for Completion and
Notification:

A. In the case of a voluntary second-level grievance relating to an urgent, pre-service

request, and in cases where:

(i) application of the time periods described in subparagraph B below:

(A) could, applying the judgment of a prudent layperson with an

average knowledge of health and medicine, seriously jeopardize
your life or health or your ability to regain maximum function; or

(B) would, in the opinion of a physician with knowledge of your medical

condition, subject you to severe pain that cannot be adequately
treated without the requested services; or

(ii) a physician with knowledge of your medical condition determines that a

concurrent review or Pre-Authorization request is urgent. MVP shall notify
you and your treating provider (if known) of our determination (whether
adverse or not) as expeditiously as your medical condition requires, but not
later than twenty-four (24) hours after receipt of the voluntary second-level
grievance. You will be notified of our decision by telephone and in writing.
B. MVP shall notify the treating provider (if known) and you of the determination
orally as soon as the determination has been made. Written (either hard copy, or,
if elected by you or your treating provider, appropriately secure electronic)
confirmation of the determination shall be sent to the treating provider and you
within twenty-four (24) hours of the oral notification.

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 14. Voluntary Second-Level Non-Urgent, Pre-Service Grievance - Timeframe for Completion
and Notification:

A. In the case of a voluntary second-level grievance relating to a non-urgent, pre-

service request, MVP shall notify you and your treating provider (if known) of our
determination (whether adverse or not) as expeditiously as your medical condition
requires, but not later than fifteen (15) calendar days after receipt of the grievance.

B. Written (either hard copy or, if elected by you or your treating provider,
appropriately secure electronic) confirmation of the determination shall be sent to
the treating provider (if known) and to you.

15. Voluntary Second-Level Post-Service Grievance - Timeframe for Completion and

Notification:
A. In the case of a voluntary second-level post-service grievance, MVP shall notify you
and your treating provider (if known) of our determination (whether adverse or not)
within a reasonable period of time but not later than fifteen (15) calendar days after
receipt of the grievance.
B. Written (either hard copy or, if elected by you or treating provider, appropriately
secure electronic) confirmation of the determination shall be sent to the treating
provider (if known) and to you.

16. Voluntary Second-Level Grievance Unrelated to an Adverse Benefit Determination -

Timeframe for Completion and Notification:

A. For voluntary second-level grievances not related to adverse benefit

determinations, you shall be notified within fifteen (15) calendar days after receipt
of the grievance.

B. Written (either hard copy or, if elected by you, appropriately secure electronic)
confirmation of the determination shall be sent to you.

If you are not satisfied with MVP’s decision in response to your Second Level Grievance,
you may, in addition to any other legal remedy available to you, proceed directly to
Independent External Review as described in paragraph 17 below.

17. Independent External Review.

A. You have the right to an “independent external review” of an appealable decision

made by MVP. An independent external review is an independent review of our
decision by a third party known as an independent review organization.

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 Independent review organizations (“IRO”) are selected by the DFR and must not
have any conflict of interest associated with the review.

You have the right to request a review by a State approved IRO after the first level
of internal appeal has been exhausted or after the voluntary second level of appeal
where MVP has denied coverage based on medical necessity; experimental or
investigational nature of the services; off-label use of a drug; choice of provider;
and for mental health and substance abuse reviews. You do not have the right to
external review of any other decisions, even if those other decisions affect your
eligibility or benefits.

Exhaustion of the internal grievance process is not required when MVP has waived
the internal grievance process or has been deemed to have waived the internal
grievance process by failing to adhere to grievance process time requirements. (An
expedited External Appeal can be made simultaneously with an expedited first level
of internal appeal.) The right to independent external review is contingent on the
Enrollee’s exhaustion of MVP’s first level internal grievance process unless as noted
above.

You may have the right to an expedited external review if the subject of the review
concerns an emergency medical condition, emergency services, or urgently needed
care. The timeframes for expedited external reviews are shorter than the
timeframes for standard external reviews. You may request an expedited external
appeal even if your internal appeal was non-expedited.

B. You must request this review within 120 days or 4 months, whichever is longer,
from the date any of the following occur:

(i) You receive written documentation of MVP’s final grievance decision and
notice of appeal rights; or
(ii) MVP waives the required grievance process; or
(iii) MVP is deemed to have waived the grievance process by failing to adhere
to grievance process time requirements.

To request an independent, external review, you must call the DFR at 800-964-
1784.

C. You may request an independent external review only if the service that is the
subject of the review is a Covered Service.

D. Your Right to an Immediate External Appeal. If we fail to adhere to the appeals

review requirements described in your Contract, you will be deemed to have
exhausted the internal claims and appeals process and may initiate an external
appeal as described in your Contract.

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 18. Effect of Review Organization’s Decision; Coverage. The decision of the independent
review organization is binding on MVP, the member, the provider, and the group. If the
independent review organization decides in our favor, we will not change our decision or
provide benefits for the service that is the subject of the review. If the independent review
organization decides in your favor, we will provide benefits subject to all other terms and
conditions of this Contract. We will not provide benefits for any service that is not a
Covered Service. In addition, this section does not change any Cost Sharing
responsibilities.

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 SECTION TWENTY ONE - GENERAL PROVISIONS

1. Assignment. Only you are eligible for benefits under this Contract. You cannot assign
your right any benefits due under this Contract to any person, corporation or other
organization, your right to collect for those benefits, or your right to bring legal action
against us. Any such assignment shall be null and void and, at our option, may result in
termination of your coverage.

2. Notices. Any notice which we give you will be mailed to you at your address as it appears
in our records. You must immediately notify MVP of any change of address. All notices to
MVP must be mailed, postage prepaid, registered or certified mail, return receipt
requested, or personally delivered to us at 625 State Street, Schenectady, New York 12305.

3. Statement of ERISA Rights. If your group's plan is covered by the Federal Employee
Retirement Income Security Act of 1974 ("ERISA"), you are entitled to certain rights and
protections under ERISA, as described below:

ERISA provides that all plan participants shall be entitled to:

A. Receive Information About Your Plan and Benefits. Examine, without charge, at the
plan administrator’s office and at other specified locations, such as worksites and
union halls, all documents governing the plan, including insurance contracts and
collective bargaining agreements, and a copy of the latest annual report (Form
5500 Series) filed by the plan with the U.S. Department of Labor and available at
the Public Disclosure Room of the Pension and Welfare Benefit Administration.
Obtain, upon written request to the plan administrator, copies of documents
governing the operation of the plan, including insurance contracts and collective
bargaining agreements, and copies of the latest annual report (Form 5500 Series)
and updated summary plan description. The administrator may make a reasonable
charge for the copies. Receive a summary of the plan’s annual financial report. The
plan administrator is required by law to furnish each participant with a copy of this
summary annual report.

B. Prudent Actions by Plan Fiduciaries. In addition to creating rights for plan

participants ERISA imposes duties upon the people who are responsible for the
operation of the employee benefit plan. The people who operate your plan, called
‘‘fiduciaries’’ of the plan, have a duty to do so prudently and in the interest of you
and other plan participants and beneficiaries. No one, including your employer,
your union, or any other person, may fire you or otherwise discriminate against
you in any way to prevent you from obtaining a (pension, welfare) benefit or
exercising your rights under ERISA.

C. Enforce Your Rights. If your claim for a benefit is denied or ignored, in whole or in
part, you have a right to know why this was done, to obtain copies of documents

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 relating to the decision without charge, and to appeal any denial, all within certain
time schedules. Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request a copy of plan documents or the latest annual
report from the plan and do not receive them within 30 days, you may file suit in a
Federal court. In such a case, the court may require the plan administrator to
provide the materials and pay you up to $110 a day until you receive the materials,
unless the materials were not sent because of reasons beyond the control of the
administrator. If you have a claim for benefits which is denied or ignored, in whole
or in part, you may file suit in a state or Federal court. In addition, if you disagree
with the plan’s decision or lack thereof concerning the qualified status of a
domestic relations order or a medical child support order, you may file suit in
Federal court. If it should happen that plan fiduciaries misuse the plan’s money, or
if you are discriminated against for asserting your rights, you may seek assistance
from the U.S. Department of Labor, or you may file suit in a Federal court. The court
will decide who should pay court costs and legal fees. If you are successful, the
court may order the person you have sued to pay these costs and fees. If you lose,
the court may order you to pay these costs and fees, for example, if it finds your
claim is frivolous.

D. Assistance with Your Questions. If you have any questions about your plan, you
should contact the plan administrator. If you have any questions about this
statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the plan administrator, you should contact the nearest office of
the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed
in your telephone directory or the Division of Technical Assistance and Inquiries,
Pension and Welfare Benefits Administration, U.S. Department of Labor, 200
Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain
publications about your rights and responsibilities under ERISA by calling the
publications hotline of the Pension and Welfare Benefits Administration.

E. Newborns and Mothers Health Protection Act. Group health plans and health
insurance issuers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section. However, Federal law generally does not prohibit the
mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours following
a cesarean section). In any case, plans and issuers may not, under Federal law,
require that a provider obtain authorization from the plan or the insurance issuer
for prescribing a length of stay not in excess of 48 hours (or 96 hours following a
cesarean section).

F Health and Cancer Rights Act of 1998 (“WHCRA”) If you have had or are going to
have a mastectomy, you may be entitled to certain benefits under the WHCRA. For

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 individuals receiving mastectomy-related benefits, coverage will be provided in a
manner determined in consultation with the attending physician and the patient,
for:

(i) all stages of reconstruction of the breast on which the mastectomy was
performed;

(ii) surgery and reconstruction of the other breast to produce a symmetrical

appearance;

(iii) prostheses; and

(iv) treatment of physical complications of the mastectomy, including

lymphedema.

These benefits will be provided subject to the same Cost Share as applicable to
other similar medical and surgical benefits provided under this Contract as is set
forth on the Summary of Benefits and Coverage (SBC).

If you would like more information on WHCRA benefits, you may call the Customer
Care Center at 1-888-687-6277.

4. Your Medical Records. To provide benefits, it may be necessary to get your medical
records from providers who treated you. Providing benefits includes determining your
eligibility, processing your claims, reviewing grievances involving your care, and quality
assurance and quality improvement reviews of your care, whether based on a specific
complaint or a routine audit of randomly selected cases. When you become covered under
this Contract, you automatically authorize each and every provider to:

A. disclose to MVP all facts about your care, treatment, and condition to assist us in
reviewing a treatment or claim, or in connection with a complaint or quality of care
review;

B. give reports about your care, treatment and condition to assist us in reviewing a
treatment of claim; and

C. permit MVP to review and copy your records.

Further, at any time requested by us, you will provide us with a signed authorization to
obtain your records for these purposes. We have the right to deny benefits under this
Contract if you refuse to provide us with such authorization. We will maintain your medical
records in accordance with state and federal confidentiality laws. However, you
automatically authorize us to provide your medical records to DFR or other quality
oversight organizations.

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 5. Changes to this Contract.

A. We may change the terms of this Contract and modify or eliminate any of the
benefits if approved by DFR. Enrollees have no vested rights to any benefits or
other provisions of this Contract. We will provide you with at least 30 days prior
written notice.

B. This Contract may not be modified, amended or changed, except in writing, and
signed by our Chief Executive Officer.

6. Time to File Claims. Claims for services rendered by Participating Providers under this
Contract must be submitted to us for payment within 180 days after the date of service.
Claims for services rendered by Non-Participating Providers must be submitted to us for
payment within 24 months after the date of service. You will not be responsible for
payment of late submitted charges by providers.

7. Who Receives Payment Under this Contract. Payments for Covered Services provided by
a Participating Provider will be made by us directly to the provider. When services are
provided by a Non-Participating Provider, you or the provider must submit a claim to MVP.
Payments may be made to you or to the provider.

8. Legal Action. No legal action may be maintained against us prior to exhaustion of the
grievance process specified in Section Twenty. You must start any lawsuit against us within
3 years from the date we made a second level grievance decision. Service or process must
be made upon an officer of MVP at 625 State Street, Schenectady, New York 12305 or
otherwise in accordance with state or federal law.

9. Venue for Legal Action. You must start any lawsuit against us in a court in Vermont. You
agree not to start a lawsuit against us in a court located anywhere else. You also consent
to these courts having personal jurisdiction over you. That means that, when the proper
procedures for starting a lawsuit in those courts have been followed, the courts can order
you to defend any action we bring against you.

10. MVP’s Relationship with Providers. MVP and Participating Providers have an independent
contract relationship. Providers are not agents or employees of MVP and MVP is not an
agent or employee of any provider. This Contract does not require any particular provider
to accept you as a patient and we do not guarantee such acceptance by any particular
provider. Participating and Non-Participating Providers are solely responsible for all
services rendered or not rendered to Enrollees.

MVP does not control the treatment or other professional actions of providers. MVP’s
decisions relate only to whether we will provide benefits under this Contract and are not
a substitute for the professional judgment of your provider. Further, the persons making

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 these decisions for MVP do not receive incentives to limit or deny benefits and are not
paid based upon the quantity or type of such decisions. MVP pays most Participating
Providers on a fee for service basis, which means that providers bill MVP for services
rendered and MVP pays the providers according to an agreed upon fee structure. MVP
also has arrangements with some Participating Providers, which allows MVP to withhold a
certain percentage of the agreed upon fee during the course of a year and to keep all or
a part of this withheld amount if medical costs have exceeded a certain budgeted amount.
Some Participating Providers are paid through a capitation arrangement. This means that
MVP pays the provider a fixed amount on a regular basis, usually monthly, based upon the
number of MVP Enrollees the provider serves. This fixed amount is paid regardless of how
many or how few services are provided to MVP Enrollees during the month. If services are
rendered by a Non-Participating Provider, MVP may pay the provider’s charges or a
different rate negotiated with the provider or with an out of system provider network.

11. Termination of Participating Providers. A provider’s participation with MVP may be

terminated at any time by MVP or the provider. In such event, MVP shall provide notice
to affected Enrollees within fifteen (15) days of our receipt of a notice of termination
without cause or the date of a termination for cause. Covered Services rendered by the
provider to Enrollees between the date of notice of termination or the date of termination
and ten (10) business days after notice is mailed, shall continue to be Covered Services.
Please refer to Section Four – Access to Providers, to find out when and how you may
continue receiving services from a non-participating provider.

12. Identification Cards. Possession of a card confers no automatic right to benefits. To be

eligible for benefits, you must be listed on a completed enrollment form submitted to and
accepted by VHC and your premiums must be paid in full. We may terminate your
Coverage if you allow another person to wrongfully use an MVP identification card.

13. Furnishing Information. You must, within 30 days of our request, provide us with all
information and records that we may need to perform our obligations under this Contract.
In the event of a dispute concerning the provision or denial of benefits, MVP may require
that an Enrollee be examined, at MVP’s expense, by a provider designated by MVP.

14. Inability to Provide Service. In the event of circumstances not within our reasonable
control, including but not limited to major disaster, epidemic, complete or partial
destruction of facilities, riot, civil insurrection, disability of our offices, a significant part of
our network, or entities with whom MVP has arranged for services, and our ability to
provide benefits under this Contract is delayed or becomes impossible, we will not be
liable for such delay or failure, except to refund unearned premiums. We are required only
to make a good faith effort to provide or arrange for the provision of benefits.

15. Recovery of Overpayments. If we make a payment to you in error, we will explain the
problem to you and you must return the amount of the overpayment to us within 60 days.

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 If we owe you a payment for other claims received, we have the right to subtract any
amount you owe us from any payment we make to you.

16. Waiver. MVP’s waiver or failure to insist on strict performance of this Contract shall not
be considered a waiver or act as a bar to any decision or action for subsequent acts of
non-performance.

17. Time Limit on Certain Defenses. After 3 years from the effective date of this Contract, no
misstatements, except fraudulent misstatements, made by the Enrollee or his or her
Dependents in the enrollment application for this Contract, shall be used to void this
Contract or used as a basis to deny a claim after the expiration of such 3 year period.

18. Choice of Law. Unless federal law applies, this Contract shall be governed by the laws of
Vermont.

19. Severability. The unenforceability or invalidity of any provision of this Contract shall not
affect the validity and enforceability of the remainder of this Contract.

20. Travel Time - When You are in our Service Area, you should not usually have to travel
more than 30 minutes from home or work for:
x Routine office-based medical provider treatment
x Routine office-based mental health and substance abuse treatment

You should not usually have to travel more than 60 minutes for:
x Prescription drugs
x Labs
x X-rays
x MRIs
x Eye Exams
x Intensive outpatient, partial hospital, residential or inpatient mental health and
substance abuse services
x Inpatient medical rehab
x outpatient physician specialty care

You should not usually have to travel more than 90 minutes for:
x Kidney transplants
x Major trauma treatment
x Open-heart surgery
x Cardiac catheterization laboratory services
x Neonatal intensive care

You will have reasonable access to specialty care such as:

x Major burn care
x Organ transplants (other than kidney)

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 x Specialty pediatric care

Some Enrollees may get services at “centers of excellence” outside Vermont.

21. Waiting Times for Appointments

You shall have instant access to Emergency care.
Appointment: You should not usually have to wait longer than:
x 24 hours for Urgently Needed Care.
x Two weeks for routine initial treatment. Prompt follow-up visits and visits to specialists,
if needed.
x Thirty days for routine lab, x-ray, general optometry and all other routine services.
x Ninety days for preventive care. This includes routine physical exams.

22. Enrollees have the right to get information about MVP. You have the right to get the
information in this Contract. You will also get MVP’s Healthy News, which gives updates
about health news and changes to your coverage. You have the right to certain additional
information:

You have a right to this information. You can find this information here.

1. A list of providers, updated every 6 1. This is in your Provider Directory,

months. which is updated twice a year. The
Provider Directory is posted on
MVP’s Web site too, where it is
updated more frequently. You may
also get a hard copy or an electronic
copy from MVP’s Customer Care
Center. Call 1-888-687-6277.

2. Information about your coverage. 2. This is in your Contract and Riders.

3. Information on Pre-Authorization 3. This is in your Contract.

and UM.

4. A description of the financial 4. This is in your Contract.

arrangements between MVP and
Participating Providers.

5. Enrollee responsibility to pay 5. This is in your Contract, Riders, and

premiums, Coinsurance, your Summary of Benefits and
Copayments, and Deductibles. Coverage (SBC).

6. Enrollee payment for non-Covered 6. This is in your Contract.

Services.

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 You have a right to this information. You can find this information here.

7. MVP’s process for picking 7. This is in your Contract. Call the

Participating Providers Credentialing Department for more
information.

8. What to do when you have a 8. This is in your Contract.

grievance.

9. Enrollees as part of MVP’s quality 9. This is in your Contract. Call MVP’s

improvement program. Customer Care Center at 1-888-687-
6277 for more information.

10. How MVP decides whether services 10. This is in your Contract.
are Medically Necessary. UM staff
and procedures.

11. Getting Emergency care and 11. This is in your Contract.

Urgently Needed Care.
12. MVP addresses and telephone 12. These are in your Contract and
numbers. Riders.

13. Waiting and travel time standards. 13. This is in your Contract.

14. How providers are paid and that 14. This is in your Contract.
they can see non-MVP patients.

15. The services offered by the Vermont 15. This is in your Contract.
Department of Financial Regulation.

16. Access to Enrollee medical records 16. Call MVP’s Customer Care Center
and procedures to keep medical at 1-888-687-6277 for more
records private. information.

17. Access to Prescription Drug 17. This is in your Contract. You can
Formulary also Call MVP’s Customer Care
Center at 1-888-687-6277 or check
the MVP website.

23. Services for Hearing-Impaired Enrollees

Call a Verizon relay operator at 1-800-662-1220. The operator will call MVP.

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 24. Interpreter/Translation Services
MVP provides these services. Call MVP’s Customer Care Center at 1-888-687-6277 for
help.

25. Quality Improvement (QI)

The scope of the QI Program is comprehensive and addresses both the quality and safety
of clinical care and quality of services provided to MVP members including medical,
behavioral health, dental, and vision care as applicable to MVP’s benefit package. MVP
wants you to have access to and receive good health care. In addition, MVP wants you to
be happy with the services you receive. Many of MVP’s structured quality improvement
committees have both MVP member and external provider participation to help make
decisions about the QI program.

The main goals of the Program are:

x To measure and improve Enrollee satisfaction.
x To ensure Providers meet MVP and regulatory standards.
x To offer Enrollees both health and case management programs, like MVP’s Asthma and
Diabetes Management Programs. To learn more, please call the numbers at the end of
this book.
x To set and monitor goals for access and availability of medical care and services and,
the quality of service outcomes.

MVP involves Enrollees in policy development and development of QI activities.

At least twenty percent (20%) of the seats on MVP’s Board of Directors are for Enrollees.
The Board sets the policies for the plan. The Board approves new QI activities.

MVP welcomes your ideas about policies and QI activities. Call 1-518-991-3609, email
[email protected], or write to this address:

Quality Department
MVP Health Care
625 State St.
Schenectady, NY 12305

MVP reviews all ideas.

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 IMPORTANT TELEPHONE NUMBERS

MVP Customer Care Center 1-888-687-6277

TTY (for the hearing impaired) 711
MVP After Hours 1-888-687-6277

Little Footprints (8:30 a.m. to 5:00 p.m. Mon.-Fri.) 1-866-942-7966

(for Enrollees with pregnancy problems)
MVP Asthma Care Program (8:30 a.m. to 5:00 p.m. Mon.- Fri.) 1-866-942-7966
MVP Diabetes Care Program (8:30 a.m. to 5:00 p.m. Mon.- Fri.) 1-866-942-7966
MVP Cardiac Care Program (8:30 a.m. to 5:00 p.m. Mon. - Fri.) 1-866-942-7966
MVP Low Back Pain Program (8:30 a.m. to 5:00 p.m. Mon. - Fri.) 1-866-942-7966

Mail Order Pharmacy - Call toll free 1-800-716-3752

Vermont Office of HealthCare Advocate 1-800-919-7787
A free statewide program to help Vermonters resolve problems
and complaints with their health insurance.
Vermont Department of Financial Regulation 1-800-964-1784
Contact for assistance in submitting an appeal.
Vermont Health Connect 1-855-899-9600

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 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024 – 12/31/2024
MVP VT Bronze 2 Coverage for: Single/Family | Plan Type: HMO .
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for
covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.mvphealthcare.com/vermont. For general
definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the
Glossary at www.healthcare.gov/sbc-glossary/ or call 1-800-348-8515to request a copy.
Important Questions Answers Why This Matters:
In-Network -$6,450 individual /$12,900 Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If
What is the overall family you have other family members on the plan, each family member must meet their own individual deductible until the
deductible? total amount of deductible expenses paid by all family members meets the overall family deductible.
Yes, Preventive Care, Generic This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or
Prescription Drugs, Pediatric Vision, coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before
Are there services covered Dental Class 1 you meet your deductible. See a list of covered preventive services at
before you meet your
https://www.healthcare.gov/coverage/preventive-care-benefits/.
deductible?
Are there other Rx Brand -$1,100 individual /$2,200 You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay
deductibles for specific family for these services.
services?
In-Network -$9,450 individual /$18,900 The out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in
family.Includes Diabetic Supplies and this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
Equipment.
What is the out-of-pocket Pharm -$1,500 individual /$3,000 family
limit for this plan? Medical and Pharmacy Out of Pocket
Limits are combined
Copayments for certain services, Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
What is not included in
premiums, balance-billing charges, and
the out-of-pocket limit?
healthcare this plan doesn't cover.
Yes. See www.mvphealthcare.com or This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the
call 1-800-348-8515 for a list of network most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between
Will you pay less if you use
a network provider? providers. the provider’s charge and what your plan pays (balance billing).Be aware, your network provider might use an out-
of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to No. You can see the specialist you choose without a referral.
see a specialist?

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 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
$35 copay/office visit Deductible applies Not covered None
Primary care visit to treat an
injury or illness
$90 copay/visit Deductible applies Not covered None
Specialist visit
If you visit a health $45 copay/visit Deductible applies for Not covered No visit limit for Chiropractic Care. Applies to all
care provider’s office
Chiropractic Care and Physical Therapy outpatient settings
or clinic Other practitioner office visit
No charge Not covered You may have to pay for services that aren’t preventive.
Ask your provider if the services you need are
Preventive care/screening/ preventive. Then check what your plan will pay for.
immunization
Lab Office - $35/visit Deductible applies; Not covered Lab Office - None;
Lab Facility - 50% coinsurance Deductible Lab Facility - None;
applies; Radiology Office - None;
Radiology Office - PCP: $35/visit Deductible Radiology Facility - None
Diagnostic test applies & Spec: $90/visit Deductible applies;
(x-ray, blood work) Radiology Facility - 50% coinsurance
Deductible applies
If you have a test
Office - 50% coinsurance Deductible applies; Not covered Prior authorization is required for some services
Facility - 50% coinsurance Deductible applies
Imaging
(CT/PET scans, MRIs)

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 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
30 day supply $20/prescription Deductible Not covered None
does not apply;
Tier 1
90 day supply $50/prescription Deductible
(Generic drugs)
does not apply
30 day supply $85/prescription Deductible Not covered Prior authorization is required for some prescriptions
If you need drugs to
treat your illness or applies;
Tier 2
condition 90 day supply $212.50/prescription
(Preferred brand drugs)
More information about Deductible applies
prescription drug
coverage is available 60% coinsurance Deductible applies Not covered Prior authorization is required for some prescriptions.
at
Includes Diabetic Supplies and Equipment
Tier 3
www.mvphealthcare.com/vermont
(Non-preferred brand drugs)
60% coinsurance Deductible applies Not covered Prior authorization is required for some prescriptions.
Tier 4 30 day supply available through Specialty Pharmacy
Specialty drugs
50% coinsurance Deductible applies Not covered Prior authorization is required for some services
Facility fee (e.g., ambulatory
If you have outpatient surgery center)
surgery 50% coinsurance Deductible applies Not covered Prior authorization is required for some services
Physician/surgeon fees
50% coinsurance Deductible applies 50% coinsurance None
Emergency room care Deductible applies
If you need $100 copay/trip Deductible applies $100 copay/trip None
immediate medical Emergency medical Deductible applies
attention transportation
$100 copay/visit Deductible applies $100 copay/visit None
Urgent care Deductible applies

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 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
50% coinsurance Deductible applies Not covered Prior authorization is required for some services
Facility fee
(e.g., hospital room)
If you have a hospital
stay 50% coinsurance Deductible applies Not covered Prior authorization is required for some services
Physician/surgeon fees
$35 copay/visit Deductible applies Not covered None
Outpatient services
If you need mental
health, behavioral
health, or substance 50% coinsurance Deductible applies Not covered None
abuse services
Inpatient services
$35 copay/visit Deductible applies Not covered Cost sharing does not apply to certain preventive
services. Depending on the type of services, a copay,
Office visits
coinsurance, and/or deductible may apply. Maternity
care may include tests and services described
50% coinsurance Deductible applies Not covered elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery
If you are pregnant professional services
50% coinsurance Deductible applies Not covered
Childbirth/delivery facility
services

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 What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Services You May Need In-Network Provider Provider
Medical Event Information
(You will pay the least) (You will pay the
most)
50% coinsurance Deductible applies Not covered None
Home health care
OP ReHab: 50% coinsurance Deductible OP ReHab: Not covered OP ReHab: 30 combined PT/OT/ST visits per year. OP
applies IP ReHab: Not covered PT applies Other practitioner office visit cost share in all
IP ReHab: 50% coinsurance Deductible OP settings
Rehabilitation services/
applies IP ReHab: None
Habilitation services
If you need help
recovering or have
other special health
needs 50% coinsurance Deductible applies Not covered None
Skilled nursing care
50% coinsurance Deductible applies Not covered Prior authorization is required for some items
Durable medical equipment
50% coinsurance Deductible applies Not covered None
Hospice services
$20 copay/exam Deductible does not apply Not covered One eye exam per year to age 21
Children’s eye exam
$20 copay/pair Deductible does not apply $20 copay/pair One pair per year to age 21. Eyewear can be purchased
Children’s glasses Deductible does not from any provider
If your child needs apply
dental or eye care
Class 1: No charge Class 1: Not covered Two dental exams per year to age 21. Adult Dental not
Class 2: 30% coinsurance Deductible applies Class 2: Not covered covered
Children’s dental check-up Class 3 and Orthodontic: 50% coinsurance Class 3 and
Deductible applies Orthodontic: Not
covered

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Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture • Weight Loss Programs
• Cosmetic Surgery
• Dental Care (Adult)
• Long-Term Care
• Non-Emergency care when traveling outside the U.S
• Routine Eye Care (Adult)
• Routine Foot Care(Routine Foot Care for Diabetes is covered)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion
• Bariatric Surgery(Requires Prior Authorization)
• Chiropractic Care
• Hearing Aids
• Infertility Treatment
• Private-Duty Nursing

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Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
MVP Health Care
P.O. Box 2207
Schenectady, NY 12301
Toll Free: 1-888-687-6277
www.mvphealthcare.com/vermont
[email protected]
You can also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa, or the U.S. Department of Health and Human
Services at 1-877-267-2323 x61565 or cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals
should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too,
including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-
318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For
more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim,
appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
MVP Health Care
Attn: Member Appeals
P.O.Box 2207
Schenectady, NY 12301
Toll Free:1-800-348-8515
www.mvphealthcare.com
[email protected]
You can also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 or dol.gov/ebsa/healthreform, or the Vermont Department of
Financial Regulation at 1-800-631-7788 or dfr.vermont.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Vermont Legal Aid at 1-800-
889-2047 or vtlegalaid.org.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and
certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under
different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)
„ The plan’s overall deductible $6,450 „ The plan’s overall deductible $6,450 „ The plan’s overall deductible $6,450
„ Specialist Copay $90 „ Specialist Copay $90 „ Specialist Copay $90
„ Hospital (facility) Coinsurance 50% „ Hospital (facility) Coinsurance 50% „ Hospital (facility) Coinsurance 50%
„ Other Coinsurance 50% „ Other Copay $35 „ Other Coinsurance 50%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $6,450 Deductibles $5,000 Deductibles $2,800
Copayments $0 Copayments $20 Copayments $0
Coinsurance $2,400 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $70 Limits or exclusions $100 Limits or exclusions $10
The total Peg would pay is $8,920 The total Joe would pay is $5,120 The total Mia would pay is $2,810

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 Non-Discrimination Notice
For MVP Commercial Plans
MVP Health Care® complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex (including sexual orientation and gender identity). MVP Health Care does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex (including sexual orientation and gender identity).

What MVP Health Care Provides Multi-Language Interpreter Services

Free aids and services to people with disabilities Español (Spanish)
to communicate effectively with us, such as: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia
• Qualified sign language interpreters linguística. Llame al 1-844-946-8010 (TTY: 1-800-662-1220).
• Written information in other formats (large (Chinese)
print, audio, accessible electronic formats,
other formats) 1-844-946-8010 TTY 1-800-662-1220
Free language services to people whose
primary language is not English, such as: Русский (Russian)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
• Qualified interpreters услуги перевода. Звоните 1-844-946-8010 (телетайп: 1-800-662-1220).
• Information written in other languages
Kreyòl Ayisyen (French Creole)
If You Need These Services ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou.
Rele 1-844-946-8010 (TTY: 1-800-662-1220).
If you need these services, contact
Elona Charles-Wilson at 1-844-946-8009 (Korean)
(TTY: 1-800-662-1220).
1-844-946-8010 (TTY: 1-800-662-1220)
How to File a Grievance
or Complaint Italiano (Italian)
ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza
If you believe that MVP has not given you these
linguistica gratuiti. Chiamare il numero 1-844-946-8010 (TTY: 1-800-662-1220).
services or has treated you differently because
of race, color, national origin, age, disability, or (Yiddish)
sex, you can file a grievance with MVP by:
Mail: ATTN: ELONA CHARLES-WILSON .1-844-946-8010 (TTY: 1-800-662-1220)
CIVIL RIGHTS COORDINATOR (Bengali)
MVP HEALTH CARE
625 STATE ST
SCHENECTADY NY 12305-2111
Phone: 1-844-946-8009 Polski (Polish)
(TTY/TDD: 1-800-662-1220) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-844-946-8010 (TTY: 1-800-662-1220).
In person: 625 State Street, Schenectady, NY
(Arabic)
Email: civilrightscoordinator@
mvphealthcare.com
You can also file a civil rights complaint with the Français (French)
U.S. Department of Health and Human Services ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés
Office for Civil Rights by: gratuitement. Appelez le 1-844-946-8010 (ATS: 1-800-662-1220).
Online: ocrportal.hhs.gov
(Urdu)
Mail: US DEPT OF HEALTH & HUMAN SRVS
200 INDEPENDENCE AVE SW .(TTY: 1-800-662-1220) 1-844-946-8010
HHH BLDG ROOM 509F Tagalog (Tagalog-Filipino)
WASHINGTON DC 20201 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng
Phone: 1-800-368-1019 tulong sa wika nang walang bayad. Tumawag sa 1-844-946-8010 (TTY: 1-800-662-1220).
(TTY/TTD: 1-800-537-7697) Ελληνικά (Greek)
Complaint forms are available by visiting ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
hhs.gov/regulations and selecting υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-844-946-8010 (TTY: 1-800-662-1220).
Complaints & Appeals, then Civil Rights: How Shqip (Albanian)
to file a complaint.
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa
pagesë. Telefononi në 1-844-946-8010 (TTY: 1-800-662-1220).
MVPCORP0021 (07/2021) ©2021 MVP Health Care

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 Notice of Privacy Practices
MVP Health Plan, Inc.
MVP Health Services Corp.
MVP Health Insurance Company

Effective Date MVP’s Duties Regarding Your

This Notice of Privacy Practices is effective as of Health Information
April 1, 2014 and revised April 21, 2023. MVP is required by law to:
This notice describes how medical information • Maintain the privacy of information about
about you may be used and disclosed, and how your health in all forms including oral, written,
you can get access to this information. Please and electronic
review it carefully. • Train all MVP employees in the protection of
MVP Health Plan, Inc., MVP Health Services Corp., oral, written, and electronic protected health
and MVP Health Insurance Company (collectively information (PHI)
“MVP”, “we”, or “us”) respect the confidentiality • Limit access to MVP’s physical facility and
of your health information and will protect your information systems to the required minimum
information in a responsible and professional necessary to provide services
manner. We are required by law to maintain the • Maintain physical, electronic, and procedural
privacy of your health information, provide you safeguards that comply with federal and state
with this notice of our privacy practices and legal regulations to guard PHI
duties and to abide by the terms of this notice.
• Notify you following a breach of unsecured
In compliance with the Health Insurance Portability health information
and Accountability Act of 1996 (HIPAA), and state • Provide you with this notice of our legal duties
laws and regulations regarding the confidentiality and health information privacy rules
of health information, MVP provides this notice to
• Abide by the terms of this notice.
explain how we may use and disclose your health
information to carry out payment and health care We reserve the right to change the terms of this
operations and for other purposes permitted or notice at any time, consistent with applicable law,
required by law. Health information is defined as and to make those changes effective for health
enrollment, eligibility, benefit, claim, and any other information we already have about you. Once
information that relates to your past, present, or revised, we will advise you that the notice has
future physical or mental health. been updated, provide you with information on
The terms and conditions of this privacy notice how to obtain the updated notice, and will post it
supplement any other communications, on mvphealthcare.com.
policies, or notices that MVP may have provided
How We Use or Disclose Your
regarding your health information. In the event of
conflict between this notice and any other MVP Heath Information
communications, policies, or notices, the terms As a member, you agree to let MVP share
and conditions of this notice shall prevail. information about you for treatment, payment,
Y0051_8320_C MVPCORP0002 (04/2023) ©2023 MVP Health Care

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 MVP Health Care Notice of Privacy Practices Page 2

and health care operations. The following are ways Disclosures to a Business Associate
we may use or disclose your health information. We may disclose your health information to other
For Treatment companies that perform certain functions on
our behalf. These companies are called Business
We may share your health information with a
Associates. These Business Associates must agree
physician or other health care provider in order
in writing to protect your privacy and follow the
for them to provide you with treatment.
same rules we do.
For Payment
Disclosures to a Plan Sponsor
We may use and / or disclose your health
We may disclose limited information to the plan
information to collect premium payments,
sponsor of your group health plan (usually your
determine benefit coverage, or to provide
employer) so that the plan sponsor may obtain
payment to health care providers who render
premium bids, modify, amend, or terminate
treatment on your behalf.
your group health plan and perform enrollment
For Health Care Operations functions on your behalf.
We may use or disclose your health information Disclosures to a Third-Party Representative
for health care operations that are necessary to
We may disclose to a Third-Party Representative
enable us to arrange for the provision of health
(family member, relative, friend, etc.) health
benefits, the payment of health claims, and to
information that is directly relevant to that
ensure that our members receive quality service.
person’s involvement with your care or payment
For example, we may use and disclose your health
for care if we can reasonably infer that the person
information to conduct quality assessment and
is involved in your care or payment for care and
improvement activities (including, e.g., surveys),
that you would not object.
case management and care coordination,
licensing, credentialing, underwriting, premium Disclosures to a Third-Party Application
rating, fraud and abuse detection, medical review, You may direct MVP to provide specific
and legal services. We will not use or disclose your information it maintains about you, including
health information that is genetic information for health information, through a third-party
underwriting purposes. We also use and disclose application chosen by you. If so, MVP may
your health information to assist other health disclose your information to one or more
care providers in performing certain health care third-party applications as directed by you.
operations for those health care providers, such as
quality assessment and improvement, reviewing Email or Telephonic Communications to You
the competence and qualifications of health care You agree that we may communicate as allowed
providers, and conducting fraud detection or by applicable law via email or phone, including
investigation, provided that the information used by text message, with you regarding insurance
or disclosed pertains to the relationship you had premiums or for other purposes relating to
or have with the health care provider. your benefits, claims, or our products/services.
Your agreement includes consent to receive
Health-Related Benefits and Services
email, phone, or text message communications
We may use or disclose your health information to from us to the extent such consent is required
tell you about alternative medical treatments and or allowed by applicable law, including as may
programs, or about health-related products and be allowed or required under the Telephone
services that may be of interest to you. Consumer Protection Act. Further, you
understand that such communications (utilizing
encryption software for our email transmissions

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 MVP Health Care Notice of Privacy Practices Page 3

or other security controls for phone and text Authorization to Disclose Information form on
message) may contain confidential information, file from the minor to disclose most information
protected health information, or personally to a parent, guardian, or other third-party
identifiable information. representative. Please note that MVP can always
share benefit / eligibility / cost-share information
Disclosures Authorized by You
with a subscriber for their dependents.
Except for the scenarios described in this
notice, HIPAA prohibits the disclosure of your To download the Authorization to Disclose
health information without first obtaining your Information form, visit mvphealthcare.com/ADI.
authorization. MVP will not use or disclose your You can also call the MVP Member Services /
health information to engage in marketing, Customer Care Center at the phone number listed
other than face to face communications, the on the back of your MVP Member ID card (TTY 711).
offering of a promotional gift, or as set forth in
Special Use and Disclosure Situations
this notice, unless you have authorized such use
or disclosure. MVP will not use or disclose your Under certain circumstances, as required by law,
health information for any reason other than MVP would be required to share your information
those described above, unless you have provided without your permission. Some circumstances
authorization. We can accept an Authorization include the following:
to Disclose Information form if you would like us Uses and Disclosures Required by Law
to share your health information with someone
We may use and disclose health information about
for a reason we have not stated above. Using this
you when we are required to do so by federal, state,
form, you can designate whom you would like
or local law.
us to share information with, what information
you would like us to share, and how long you Public Health
want us to be able to share your information with We may disclose your health information for
that individual. A copy of this form is available by public health activities. These activities include
calling the MVP Member Services / Customer Care preventing or controlling disease, injury, or
Center. Or visit mvphealthcare.com/ADI. You disability; reporting births or deaths; or reporting
must complete this form and return it to MVP by reactions to medications or problems with medical
mail or fax. You can cancel this Authorization at products, or to notify people of recalls of products
any time in writing and per the requirements on they have been using.
the form.
Health Oversight
Disclosures to Parents (or Other We may disclose your health information to a health
Third-Party Representatives) of Minors oversight agency that monitors the health care
MVP has a policy in place to protect the privacy system and government programs for designated
of minors with sensitive diagnoses. MVP has oversight activities.
developed this position based upon legal Legal Proceedings
requirements together with MVP’s commitment
We may disclose your health information in the
to safeguarding the privacy of its members who
course of any judicial or administrative proceeding,
receive care for sensitive needs.
in response to an order of a court or administrative
If a minor 12–18 years old receives services or tribunal (to the extent such disclosure is expressly
treatment related to mental health, chemical authorized) and, in certain situations, in response
dependency or substance use, venereal disease, to a subpoena, discovery request, or other
HIV/AIDS, family planning, prenatal care, or lawful process.
abortion-related services, MVP must have an

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 MVP Health Care Notice of Privacy Practices Page 4

Law Enforcement Workers’ Compensation

We may disclose your health information, so We may disclose your health information as
long as applicable legal requirements are met, authorized to comply with workers’ compensation
for law enforcement purposes. laws and other similar legally-established programs.
Abuse or Neglect What are your rights?
We may disclose your health information to a
The following are your rights with respect to your
public health authority, or other government
health information. Requests for restrictions,
authority authorized by law to receive reports
confidential communications, accounting
of child abuse, neglect, or domestic violence
of disclosures, amendments to your health
consistent with the requirements of applicable
information, to inspect or copy your health
federal and state laws.
information, or questions about this notice can be
Coroners, Funeral Directors, and made by using the Contact Information below.
Organ Donation
Right to Request Restrictions
We may disclose your health information to
You have the right to request a restriction or
a coroner or medical examiner to identify a
limitation on your health information we disclose
deceased person, determine a cause of death, or as
for payment or health care operations. You also
authorized by law. We may also disclose your health
have the right to request a limit on the information
information to funeral directors as necessary to
we disclose about your health to someone who is
carry out their duties. If you are an organ donor,
involved in your care or the payment for your care,
we may release your health information for
like a family member, relative, or friend. While we
procurement, banking, or transplantation.
will try to honor your request, we are not legally
Research Purposes required to agree to restrictions or limitations. If
In certain circumstances, we may use and disclose we agree, we will comply with your request or
your health information for research purposes. limitations except in emergency situations.

Criminal Activity Right to Request Confidential Communications

We may disclose your health information when You have the right to request that we communicate
necessary to prevent or lessen serious and with you about your health information in a certain
imminent threat to the health and safety of a way or at a certain location if the disclosure of
person or the public. information could endanger you. We will require
the reason for the request and will accommodate
Military Activity all reasonable requests.
We may disclose your health information to
Right to an Accounting of Disclosures
authorized federal officials if you are a member
of the military (or a veteran of the military). You have the right to request an accounting of
disclosures of your health information made by us
National Security other than those necessary to carry out treatment,
We may disclose your health information to payment, and health care operations, disclosures
authorized federal officials for national security, made to you or authorized by you, or in certain
intelligence activities, and to enable them to other situations.
provide protective services for the President
Right to Inspect and Obtain Copies of Your
and others.
Health Information
You have the right to inspect and obtain a copy
of certain health information that we maintain.

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 MVP Health Care Notice of Privacy Practices Page 5

In limited circumstances, we may deny your Services. Complaints filed directly with the
request to inspect or obtain a copy of your health Secretary must: (1) be in writing; (2) contain the
information. If we deny your request, we will notify name of the entity against which the complaint is
you in writing of the reason for the denial and if lodged; (3) describe the relevant problems; and
applicable the right to have the denial reviewed. (4) be filed within 180 days of the time you became
or should have become aware of the problem. We
Right to Amend
will provide you with this address upon request.
If you feel that the health information we maintain
about you is incomplete or inaccurate, you may We Will Not Take Any Action Against
ask us to amend the information. In certain You for Filing a Complaint
circumstances we may deny your request. If we
We will not retaliate in any way if you choose to
deny the request, we will explain your right to file a
file a complaint in good faith with us or with the
written statement of disagreement. If we approve
U.S. Department of Health and Human Services.
your request, we will include the change in your
We support your rights to the privacy of your
health information and tell others that need to
medical information.
know about your changes.
Right to a Copy of the Notice of Privacy Practices Contact Information
You have the right to obtain a copy of this notice If you have questions, or would like to request
at any time. You can also view this notice at this notice in an alternate language or format, call
mvphealthcare.com/privacy-notices. the MVP Member Services / Customer Care Center
at the phone number listed below. The phone
Exercising Your Rights number is also on the back or your MVP Member
Unless you provide us with a written authorization, ID card for your convenience.
we will not use or disclose your health information MVP Medicare Customer Care Center
in any manner not covered by this notice. If
October 1–March 31, call seven days a week,
you authorize us in writing to use or disclose
8 am–8 pm Eastern Time. April 1–September 30,
your health information in a manner other than
call Monday–Friday, 8 am–8 pm Eastern Time.
described in this notice, you may revoke your
authorization, in writing, at any time. If you revoke 1-800-665-7824 (TTY 711)
your authorization, we will no longer use or disclose
MVP Member Services/Customer Care Center
your health information for the reasons covered by
Monday–Friday, 8 am–6 pm Eastern Time.
your authorization; however, we will not reverse
any uses or disclosures already made in reliance MVP Medicaid, Child Health Plus, and
on your authorization before it was revoked. MVP Harmonious Health Care Plan Members
®

1-800-852-7826 (TTY 711)

You have a right to receive a copy of this notice
at any time. You can also view this notice at MVP DualAccess (D-SNP) Members
mvphealthcare.com/privacy-notices. 1-866-954-1872 (TTY 711)
If you believe that your privacy rights have been All Other MVP Members
violated, you may file a complaint by contacting 1-888-687-6277 (TTY 711)
an MVP Member Services / Customer Care
Representative at the address or phone number Mail written communications to MVP at:
indicated in the Contact Information at the end MVP CUSTOMER CARE CENTER
of this notice. PO BOX 2207
You may also file a complaint with the Secretary SCHENECTADY NY 12301-2207
of the U.S. Department of Health and Human
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 Authorization to Disclose Information
Protecting your confidentiality is important to MVP Health Care, Inc. and its subsidiaries
(collectively, “MVP”). If you would like MVP to share your health information with another party,
you must first give your permission to do so.
By completing and signing this form, you give that permission. MVP may then share your
health information with the people you have authorized. Please read this form carefully.

Instructions for Completing this Form

There are six sections on this form to complete.
Section 1: Fill in your name, MVP member • The third option gives MVP permission to share
identification number, address, and date of birth information about HIV / AIDS, mental health and
identifying you as the MVP member. substance use, family planning and pregnancy, or
This section may also be used if you are giving MVP sexually transmitted diseases, and is explained
permission to share health information of a minor more fully below.
for whom you are the parent or legal guardian. Information for Parents of Minors with
Sensitive Diagnoses
Section 2: Fill in the name(s), address(es), and
phone number(s) of the person(s) with whom MVP has a policy in place to protect the privacy
you are authorizing MVP to share your health of minors with sensitive diagnoses. MVP has
information. developed this position based upon legal
requirements together with MVP’s commitment
Be sure to write the contact’s full name and address.
to safeguarding the privacy of its members who
MVP will only share information if the contact
receive care for sensitive needs. If a minor 12–18
correctly verifies the name, address, and phone
years old receives services or treatment related to
number you have written.
mental health, chemical dependency or substance
Section 3: Reason for the disclosure. use, venereal disease, HIV / AIDS, family planning,
This section tells MVP the reason for the disclosure. prenatal care, or abortion-related services, MVP
must have an Authorization to Disclose Information
Section 4: Select the health information you are form on file from the minor to disclose most
authorizing MVP to share. information to a parent or guardian.
There are three options: MVP will not share this information if you have
• The first option gives MVP permission to share all not authorized MVP to do so by initialing the
of your health information, except for information specific items. Please read the special notice from
involving HIV / AIDS, mental health and substance the New York State Department of Health on page 2
use, family planning and pregnancy, or sexually of these instructions.
transmitted diseases. You must specifically
Section 5: Read and make sure you understand
authorize MVP to share this information with
your rights under this authorization.
another party.
You may use this section to specify an expiration
• The second option gives MVP permission to
date on this form, otherwise it will remain in effect
share only the information you specify, such as
indefinitely or until you request it to be revoked.
eligibility information only, information specific
to a particular service, or claims information for a For members covered on plans written in the
specific provider. State of Vermont, this form shall be valid until the
expiration date you specify, which in no event shall
be more than 24 months.
Y0051_7158_C MVPform0022 (07/2023)

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 Authorization to Disclose Information Instructions for Completing this Form Page 2

Section 6: Sign and date the form and print your related test, or has HIV infection, HIV related illness
name underneath your signature. or AIDS, or any information which could indicate
If you are using this form to give MVP permission to that a person has been potentially exposed to HIV.
share health information of a minor for whom you Under New York State Law, confidential HIV related
are the parent or legal guardian, make sure to write information can only be given to people you allow
in your relationship to that member. to have it by signing a written release, or to people
If you are authorizing a person to act on your behalf, who need to know your HIV status in order to provide
that person must also sign and date the form. medical care and services, including: medical care
providers; persons involved with foster care or
By signing this form electronically, you acknowledge
adoption; parents and guardians who consent to
that your electronic signature has the same legal
care of minors; jail, prison, probation and parole
consequences as your written signature.
employees; emergency response workers and
When completed, please email, mail, or fax the other workers in hospitals, other regulated settings
completed Authorization to Disclose Information form or medical offices, who are exposed to blood/
to the email address, mailing address, or fax number body fluids in the course of their employment; and
on the top of the form. organizations that review the services you receive.
State law also allows your HIV information to be
Your Rights Related to the Authorization released under limited circumstances: by special
to Disclose Information court order; to public health officials as required
1. You may authorize someone to appeal an issue by law; and to insurers as necessary to pay for
on your behalf (with the exception of Medicare care and treatment. Under State law, anyone who
members, additional information is required). illegally discloses HIV related information may be
By doing so you are exercising your right to punished by a fine of up to $5,000 and a jail term
appeal and will not be permitted to appeal the of up to one year. However, some re-disclosures of
same issue yourself. such information are not protected under federal
law. For more information about HIV confidentiality,
2. MVP shall not condition treatment, payment,
call the New York State Department of Health HIV
enrollment, or eligibility for benefits under its
Confidentiality Hotline at 1-800-962-5065.
insured plans on receipt of this authorization.
By signing and initialing where indicated on the form,
3. Information disclosed pursuant to this
HIV related information can be given to the people
authorization may be disclosed by the recipient
listed on the form, and for the reason(s) you may list
and may no longer be protected by federal or
on the form. You do not have to sign the form, and
state law.
you can change your mind at any time by indicating
4. If information is disclosed from alcohol and drug your change in writing.
use records protected by Federal confidentiality
The law protects you from HIV-related discrimination
rules (42 CFR Part 2), these Federal rules prohibit
in housing, employment, health care, and other
the recipient from making any further disclosure
services. For more information, call the New
of this information unless further disclosure is
York State Division of Human Rights Office at
expressly permitted by written consent of the
1-888-392-3644 or the New York City Commission
person to whom it pertains or as otherwise
on Human Rights at 212-306-7450. These agencies
permitted by 42 CFR Part 2.
are responsible for protecting your rights.
Your Rights Relating to the Release of
Confidential HIV* Related Information
Confidential HIV related information is any
information indicating that a person had an HIV * Human Immunodeficiency Virus that causes AIDS.

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 Authorization to Disclose Information
By completing this form, you allow MVP Health Care to disclose health information to those identified below.
®

Return this completed form by email, mail, If This Form is Needed for An Appeal
or fax Return this completed form by email, mail, or fax.
Email: [email protected] Email: [email protected]
Mail: Mail:
MVP Health Care Attn: Appeals
PO Box 2207 MVP Health Care
Schenectady NY 12301-2207 PO Box 2207
Fax: 1-800-765-3808 Schenectady NY 12301-2207
Fax: 518-386-7600

Section 1: Information About the Member Whose Information is to be Released (please print)

Member Name Date of Birth MVP Member ID No.

Street Address City State Zip Code

Section 2: Information About the Person(s) with Whom Your Health Information is to be Shared

Name Phone No.

Street Address City State Zip Code

Name Phone No.

Street Address City State Zip Code

Section 3: Reason for the Disclosure

Request of Individual Other (explain):

Section 4: Health Information to be Released (check all that apply)

All health information (except the health information that requires your initials below)
Other (specify the health information you are authorizing MVP to disclose):

Y0051_7158_C MVPform0022 (07/2023) (Section 4 continued on page 2)

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 Authorization to Disclose Information Page 2
Member Name MVP Member ID No.

(Section 4 continued)
If you initial any items below, MVP can discuss the health information with the appointed person(s).
(Initials) HIV / AIDS related information and / or records (see page 2 of instructions)
(Initials) Mental health information and / or records
(Initials) Drug / alcohol diagnosis and treatment information
(Initials) Pregnancy, family planning, abortion information
(Initials) Sexually transmitted disease information

Information for Parents of Minors with Sensitive Diagnoses: MVP has a policy in place to protect
the privacy of minors with sensitive diagnoses. MVP has developed this position based upon legal
requirements together with MVP’s commitment to safeguarding the privacy of its members who receive
care for sensitive needs. If a minor 12–18 years old receives services or treatment related to mental health,
chemical dependency or substance use, venereal disease, HIV/AIDS, family planning, prenatal care, or
abortion-related services, MVP must have an Authorization to Disclose Information form on file from the
minor to disclose most information to a parent or guardian.

Section 5: Read and Understand Your Rights (see page 2 of instructions)

This authorization shall be in force and effect until such time as MVP Health Care no longer maintains the
health information, or until revoked by the undersigned in the manner described below or until (insert
applicable date or event) .
I understand that I have the right to revoke this authorization, at any time by sending written notification
to the address indicated below. The revocation should clearly state your intent to revoke this authorization
and the date such revocation is to take effect.
For members covered on plans written in the State of Vermont, this form shall be valid until the expiration
date you specify, which in no event shall be more than 24 months.

Section 6: Sign and Date this Form

By signing this form electronically, you acknowledge that your electronic signature has the same legal
consequences as your written signature.

Member Signature Name (print) Signature Date

Authorized Representative Signature Name (print) Signature Date

Authorized Representative Signature Name (print) Signature Date

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 Nonpublic Personal Financial
Information Policy
MVP Health Plan, Inc. (except for Medicare Advantage products), MVP Health Services Corp.,
and MVP Health Insurance Company (collectively “MVP”).

Your Privacy is Important to MVP Our security practices and information

accuracy. We also take steps to safeguard member
MVP is committed to safeguarding your
information. We restrict access to the nonpublic
information. We want you to understand what
personal financial information of our members
information we may gather and how we may share
to those MVP employees who need to know that
it. This Nonpublic Personal Financial Information
information in the course of their job responsibilities.
Policy (the “Policy”) explains MVP’s collection,
We maintain physical, electronic, and procedural
use, retention, and security of nonpublic personal
safeguards that comply with federal and state
information such as: your social security number,
standards to protect member information. We also
your payment history, your date of birth, and your
have internal controls to keep member information
status as an MVP member.
as accurate and complete as we can. If you believe
How MVP collects information. We collect that any information about you is not accurate,
nonpublic personal financial information about please let us know.
you from the following sources:
• Your applications and other forms;
Other Information
• Your transactions with us, our affiliates, This Policy applies to products or services that are
and others; and purchased or obtained from MVP. We reserve the
• Consumer reporting agencies, in some cases. right to change this policy and any of the policies
described above, at any time. The examples
Sharing your information. We do not disclose contained within this policy are illustrations; they
any nonpublic personal financial information about are not intended to be exclusive or exhaustive.
our members or former members to anyone, except
as permitted by law. We may disclose the following Contact Information
information to companies that perform marketing Members can obtain a copy of our Privacy Notice
services on our behalf or to other companies with by visiting mvphealthcare.com/notices and
which we have joint marketing agreements: selecting Privacy Notices, or by calling the MVP
• Information we receive from you on applications Customer Care Center at 1-888-687-6277 (TTY 711).
or other forms, such as your name, address, or
status as an MVP member;
• Information about your transactions with us,
our affiliates, or others, such as your health plan
coverage, premium and payment history.
Our former members. Even if you are no longer
an MVP member, our Policy will continue to apply
to you.

MVPCORP0003 (10/2022) ©2022 MVP Health Care

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 mvphealthcare.com

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