IT IS UNDERSTOOD AND AGREED THAT THE FOLLOWING MODIFICATION SHALL BE MADE:

In the UTILIZATION REVIEW PROGRAM section of the Plan document, the MANDATORY SELECT SURGICAL PROCEDURE AND OUTPATIENT SERVICE
CERTIFICATION subsection will be deleted in its entirety and replaced with the following: MANDATORY SELECT SURGICAL PROCEDURE AND OUTPATIENT SERVICE CERTIFICATION

If a Covered Person’s treatment includes any of the services listed below, the treatment should be reviewed before its inception regardless of whether or not the treatment is in lieu of hospitalization. However, the Plan does not require certification for emergency services.

A. Select surgical procedures
B. Durable Medical Equipment if the purchase price or forecasted total rental cost will be $2,500 or more
C. Home Health Care
D. Custom-made Orthotic or Prosthetic Appliance if the purchase price will be $2,500 or more
E. Outpatient oncology treatment (chemotherapy or radiation therapy)
F. Outpatient infusion or injection of select products

NOTES:

1. The list of select surgical procedures that require certification can be accessed by logging on to the Claim Administrator’s Website address printed on the health plan identification card or by calling the Claim Administrator at the telephone number printed on the health plan identification card.
2. The infusion or injection of medications that are self-administered or that are administered in most Outpatient settings generally requires certification if the per-dosage cost is $2,000 or more per 30-day supply. For purposes of this provision, the cost will be calculated using either the actual per-dosage cost of the medication or the cost of a 30-day supply of the medication, whichever cost calculation is higher. However, when otherwise eligible for Plan coverage, antibiotics, post-transplant medication regimens, spinal injections, steroid injections, therapeutic injections for osteoarthritis of the knee, or total parenteral nutrition (TPN) will not subject to the Plan’s certification requirement.
   Medications related to an oncology diagnosis will also not be subject to the Outpatient infusion or injection certification requirement; however, such drugs will be reviewed as part of a Covered Person’s eligible treatment under the Outpatient oncology treatment
   certification requirement included in the service list above. A Covered Person can call the Certification telephone number on the health plan identification card to determine if a prescribed medication is subject to the Plan’s Certification Requirement.

A Covered Person must call the Certification telephone number on the health plan identification card as soon as possible before receiving the above-listed services, but in no event later than two business days after the services were rendered.

All other provisions of the Plan shall remain in effect and unchanged.