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Other Provisions (�ont'd)* <br /> Medical Services Advisory Program: O Yes ❑ No <br /> If yes, MSA Non-Compliance: $ ($amount benefits reduced) or % (%benefits reduced) <br /> OB-Precertification�tirst crimescer�: ❑Yes ❑ No Healthy Expectations: ❑Yes 0 No <br /> Healthy Expectations II: �Yes O No Outpatient Service Review: ❑ Yes ❑ No <br /> If no MSA, UR administered by an outside vendor: ❑ Yes ❑ No /fyes, name of vendor <br /> Mental Health/Chemical Dependency Utilization Management(MSA Reduction Amount Applies) <br /> Note: If MSA applies, either Enhanced Utilization Management(EUM)or Network must be selected below. <br /> EUM: ❑Yes ❑ No If yes: ❑ Inpatient Review Only(std) or ❑ Inpatient and Outpatient Review <br /> Network: ❑ Yes ❑ No If yes; Payment Levels: in-Network: % Out-of-Network: % <br /> Employee Assistance Program (EAP): ❑ Yes ❑ No <br /> Limiting Age: Dependent Age: Student Age: <br /> Pre-existing Condition Waiting Period: ❑Yes O No If yes: <br /> Initial Waiver: ❑Yes(std) ❑ No Pre-existing Definition: ❑ 6 months(std) ❑3 months <br /> Employee Days: ❑365(std) ❑270 ❑ 180; Dependent: �365(std) ❑ 270 ❑ 180 <br /> Late Enroliees Accepted: ❑Yes(std) ❑ No <br /> If yes, Employee Days: ❑ 546(std) ❑365 ❑270 ❑ 1 S0; Dependent: ❑546(std) ❑365 ❑270 ❑ 180 <br /> Medical Necessity: Hard Rider Reimbursement Provision: �Yes ❑No <br /> Medicare Coverage: ❑ Carve Out or ❑Other(please describe in Other Special Provisions on page 4) <br /> Prescription Drug Benefits* <br /> Covered under Other Covered Services: ❑ Yes ❑ No <br /> Prescription Drug Card Program: ❑ Yes ❑ No <br /> Copay: $ Generic/Brand with no Generic available $ Brand w�th Generic availabie <br /> Injectables: ❑Yes ❑ No <br /> Mail Order: �Yes O No <br /> If yes; $ Generic/Brand with no Generic available $ Brand with Generic available <br /> Orai Contraceptives: O Yes ❑ No <br /> Nicotine Patches: ❑Yes ❑ No <br /> Benefit Variables for ASO Groups Only* <br /> Infertility Coverage: ❑Yes ❑ No <br /> If yes; ❑State-mandated benefits or 0 Other(please describe below in Other Special Provisions o�page 4) <br /> Lifetime Maximum: ❑ Yes ❑ No /f yes;$ <br /> Special Human Organ Transplants(HOTs)Coverage—Subject to Program Maximum: o Yes o No <br /> Separate HOTs Lifetime Maximum: o Yes o No If yes, Separate Lifetime Maximum$ <br /> Licensed Clinical Social Workers Exc/uded: ❑ Yes ❑ No <br /> Coordination of Benefits(COB)Gender R��le: ❑ Yes ❑ No(Birthday Rule is std) COB Non-Duplication of Benefits: ❑ Yes o No <br /> Subscriber Share Methodology for Claims Processing Applies: ❑ Yes ❑No <br /> (If no; a letter declinin Subscriber Share participation required at each renewal attached to BPA.) <br /> An Independent Licensee of the Blue Cross and Blue Shield Association ' <br /> OB 3172 Rev.7/97 'Any variations other than those specified require Start-Up Committee approval. page 3 �I <br />