LIFE HAS A PLAN Your Benefit Plan Details oss Blue Shield Association t independent licensee of the Blue Cr ofi A nonpr 2014 Unity Enhanced Health Plan

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1 LIFE HAS A PLAN Your Benefit Plan Details A nonprofit independent licensee of the Blue Cross Blue Shield Association 2014 Unity Enhanced Health Plan

2 2014 Unity Enhanced Health Plan Plan Features Primary Care Physician (PCP) Referrals Out of network benefits Student/Dependent Coverage Domestic Partner Coverage Period Not Required Not Required Covered Covered to age 26 Covered 01/01/14-12/31/14 Questions? Call member services at (877) , Call our TTYphone at 1 (877) or visit us at excellusbcbs.com/unity 883

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6 2014 Unity Enhanced Health Plan Out of Network Plan Features Primary Care Physician (PCP) Referrals Out of network benefits Student/Dependent Coverage Domestic Partner Coverage Period Not Required Not Required Covered Covered to age 26 Covered 01/01/14-12/31/14 Questions? Call member services at (877) , Call our TTYphone at 1 (877) or visit us at excellusbcbs.com/unity 883

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9 Find a Doctor or Specialist Excellus BlueCross BlueShield is part of a network of BlueCross BlueShield Plans that make up the largest group of Participation Doctors and Specialists in the world. With that you get cost effective quality health care whenever you need it. Our online provider directory makes it easy to search for providers by: Name Zip code Gender Languages spoken Accepting new patients Hospital affiliation Results include: Office hours Locations Phone numbers Map & Directions Handicap Accessibility Just look over our alphabetical listing online at ExcellusBCBS. com/findprovider ExcellusBCBS.com/FindProvider Find a Doctor 09/13

10 Welcome to Blue365 Where taking care of yourself is an everyday thing. Take advantage of healthy deals and discounts* on fitness, healthy eating, personal care and more that you can use all year long. Explore all the healthy choices at ExcellusBCBS.com/Blue365 Blue365 is here for you. We understand that helping you live a healthy life means more than regular doctor visits - it s helping you find time for the things that matter most. That s why we created Blue365, an online destination featuring healthy deals and discounts exclusively for our members. These Blue365 Deals which complement your health care coverage, can help you maintain a healthy lifestyle, while spending less at some of your favorite Blue365 vendors nationwide. Because of the Blues buying power, Blue365 can offer access to great savings on a wide range of exciting health and wellness products and experiences. Blue365 makes it easy for you to find out about weekly Featured Deals by sending the news right to your . Our service is free to members of participating local Blue Companies. All you have to do is register on the website, and you are all set to enjoy our great health and wellness deals. You ll see weekly Featured Deals and long term Ongoing Deals on health products, along with discounts on health and fitness clubs, weight-loss programs, healthy travel experiences and so much more. Blue365 Blue365 includes offers from selected companies based on feedback from Blue365 members and independent researchers on the Blue365 team in four main categories. Fitness: Save on membership, monthly fees and other services at Healthways, Snap Fitness, Reebok, and Polar. Healthy Eating: Save on programs, products and consultations at Jenny Craig, Dole and Nutrisystems. Living: Save on services from H&R Block. Personal Care: Save on products and services from TruHearing, Beltone, LasikPlus, Davis Vision and QualSight Lasik. * Discounts are available through independent companies that do not provide Blue Cross and/or Blue Shield products or services and are solely responsible for the services provided. See our website for more information at: The content, tools and discounted offers available through Blue365 are subject to change. Please visit excellusbcbs.com/blue365 for the most current program details EX Blue365-10/22_R

11 Coverage wherever you go with Excellus BlueCross BlueShield All you have to do is show your ID card to any BlueCross BlueShield participating hospital or doctor anywhere in the country and you re covered. At the special negotiated rate, with no paperwork. That s the BlueCard program. BlueCard brings you: Freedom to choose any provider (85% of the hospitals and physicians in the U.S.) BlueCross BlueShield provider network discounts Customer service online and toll-free No claim forms with network providers An ID card recognized worldwide while traveling Coverage for kids who are away from home It s so easy to use. Choose the physician, specialist, or hospital you want to use by calling 1 (800) 810-BLUE (2583) or visiting ExcellusBCBS.com. Then just show your BlueCross BlueShield ID card when you arrive. To make it even easier, network providers bill us directly. You can also see providers outside the network. Your share of costs will probably be higher, but you have the freedom to choose. Two ways your coverage travels with you. As a BlueCross BlueShield member, you have access to health benefits across the country whether you re taking a quick trip or staying long term. Here s how it works: If you re traveling, the BlueCard program gives you access to doctors and hospitals almost everywhere. In an emergency, you should go directly to the nearest emergency room. For all other types of needed care, just call your Primary Care Physician (PCP) back at home for instruction on what to do. If you are away from home for more than 90 days, you can use the Guest Membership benefit through Away From Home Care. Guest Membership is a temporary enrollment that enables members who are living away from home to receive benefits including individual, routine and preventive services. It provides you and your family with the peace of mind of accessible health care. Perfect for any covered family member attending school out of state, located in a different service area on a long-term work assignment or retirees with dual residence (excludes Medicare). For eligibility information and specific locations where the Guest Membership benefit is available, please contact our Customer Service Department. Learn more about the BlueCard program You can call toll-free, within the United States, at 1 (800) 810-BLUE or, for international calls, 1 (804) , day or night, and get information on doctors and hospitals around the world. Visit us online at ExcellusBCBS.com. BlueCard - 12/07

12 3-Tier prescription drug benefit Your three-tier prescription drug benefit makes it easy for you to make informed choices and encourages savings when choosing your medications. Your co-payment will vary based on the tier placement of your prescription drug. Tier One drugs are typically generic drugs. Tier Two drugs are brand name drugs that have unique, significant clinical advantages and offer greater value over other products in the same class. Tier Three drugs are all other brand name drugs, including new brand name drugs and drugs that have generic equivalents. Visit xcellus.com to view our current Tier Three Formulary Guide. Where Can I Purchase My Prescription Medications? You have access to more than 6,000 participating pharmacies in our nationwide harmacy Network, including all national chains and most independent chains. Just show your ID card at any participating pharmacy, it identifies you as having prescription drug coverage and eligible for online claims processing. The pharmacy will transmit your prescription claim online to us and we ll immediately send a message to the pharmacist with your co-payment amount. Generic Trial Program The Generic Trial program helps encourage the use of generic drugs by giving you a one time, free 30-day trial of selected generic medications. Experience has shown that 90% of those who start with a generic drug will continue using it. You can save hundreds of dollars per year in out-of-pocket costs when you stay with a generic medication. The first time you fill a prescription for a generic medication included in the program at a participating network pharmacy, your co-payment, for the first 30-day supply, will be waived. The cost of all refills and future prescriptions is your responsibility and will be at your usual generic co-payment amount. Mail Service Pharmacy Get your prescriptions delivered right to your door! When you use our mail service pharmacy, Prim , you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our e ite. Using mail service pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Prim mail service pharmacy, please visit our eb ite or contact the Pharmacy Help Desk. Specialty Pharmacy Benefit Specialty medications are designed for conditions that are difficult to treat with traditional medications like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others. These medications are self-administered, either taken orally or by injection. Specialty pharmacies work exclusively with specialty medications and are experts in handling and administering these complex medications. Your prescription drug benefit provides coverage for certain specialty medications only when purchased at pharmacies participating in the Specialty Pharmacy Network. If you don t use a participating specialty pharmacy for your new and refill prescriptions, you will be responsible for the full cost of the prescription. However, the first time you fill a new prescrip- EX-3-Tier 3 Copay 10/08

13 tion for a specialty medication, you may have it filled at any participating network retail pharmacy of choice. A complete listing of participating specialty pharmacies is available at xcellus.com. Initial Fill The first time you get a new prescription at a retail pharmacy, it will be filled with a 30-day supply, no matter if your benefit allows for a greater supply. This is so you can be sure that the medication works for you. Often times members fill a prescription only to find after the first few days that the medication causes side-effects or does not work. By limiting the first fill of a new prescription to 30-days, we can eliminate waste and unnecessary expense. If you determine that the medication is effective all future fills can be purchased up to the maximum amount allowed by your benefit. Prior Authorization Prior authorization helps assure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require prior authorization which means that your doctor will contact us to get approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based on FDA and manufacturer guidelines, medical literature, safety, appropriate use and benefit design. Step Therapy Step Therapy is a program where you must first try a certain drug to treat your condition before another drug will be covered. Your medication treatment moves along a series of steps. Generic drugs are usually the first step. This first step lets you begin treatment with a prescription drug that is proven safe and cost effective. If the first step drug does not work for you, you then move to the next step. Brand-name drugs are usually in the second step and have a higher co-payment. The goal of step therapy is to minimize risk and control costs. Generic Advantage Program (GAP) The Generic Advantage Program promotes the use of generic medications. Under this program, if a member chooses a brandname medication when a generic equivalent is available, the member will pay the generic co-payment or coinsurance amount plus the difference between the brand-name cost and the generic cost. For more information about the above programs or to get a specific list of drugs or pharmacies for any of the programs: Visit the prescription drug section of our website at xcellus.com Dial the prescription drug number located on the back of your member ID card. Dial the Excellus BCBS Pharmacy Help Desk toll free at or (TTY)

14 Preventive care helps reduce the risks and costs of illness. Just as your health insurance is there if you need it, this helpful information is here for you every day. Here are the recommended schedules for exams, screenings, and immunizations. You can keep track of your schedules and your family s at My Health Connection on our web site. Birth 1 mo. 2 mos. 4 mos. 6 mos. 12 mos. 15 mos. 18 mos mos. 2 3 yrs. 4 6 yrs. Hepatitis B HepB HepB HepB Rotavirus RV RV RV Diphtheria, Tetanus, Pertussis DTaP DTaP DTaP DTaP DTaP Haemophilus influenza Type b Hib Hib Hib Hib Pneumococcal PCV PCV PCV PCV PPSV Inactivated Polio IPV IPV IPV IPV Influenza Influenza (yearly) Measles, Mumps, Rubella MMR MMR Varicella Varicella Varicella Hepatitis A HepA (2 doses) HepA series Meningococcal MCV 7 10 yrs yrs yrs. Diphtheria, Tetanus, Pertussis TdaP TdaP Human Papillomavirus HPV (3 doses) HPV Series Meningococcal MCV MCV MCV Influenza Influenza (yearly) Pneumococcal PPSV Hepatitis A HepA series Hepatitis B HepB series Inactivated Poliovirus IPV series Measles, Mumps, Rubella MMR series Varicella Varicella series Range of recommended ages for all children except certain high-risk groups Range of recommended ages catch-up vaccination Range of recommended ages for certain high-risk groups This schedule indicates the recommended ages for administration of currently licensed childhood vaccines, as of December 15, If doses are skipped, they should be made up at subsequent visits when possible. Approved by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians. As you can see on the chart below, there are many preventive screens that should be performed to help detect disease early and help you stay healthy. How often you have the following screenings depends on your age, your health, and things that increase your risk for specific diseases. Screenings that may be done at your routine checkups include: Alcohol abuse (misuse) Blood pressure Breast cancer for women Cervical cancer for women Cholesterol Colorectal cancer Coronary artery disease Depression Diabetes type 2 Gestational diabetes for women Hearing HIV Prostate cancer for men Sexually transmitted disease Skin cancer Testicular cancer for men Thyroid disease Tuberculosis Vision and glaucoma Monitor your weight, and see your doctor if you suddenly or consistently gain or lose weight. to become comfortable with the people and the office to receive the immunizations shown above. to have their growth and development monitored. to address any questions or concerns you might have about your child. Preventive 09/11

15 Influenza years years >65 years 1 dose annually Tetanus, diphtheria, pertussis Subsititute 1-time dose of Tdap for td Td booster every 10 yrs (Td/Tdap) booster;then boost with Td every 10 yrs Varicella Zoster 2 doses 1 dose Measles, Mumps, Rubella (MMR) 1 or 2 dose 1 dose Pneumococcal (polysaccharide) 1 or more dose 1 dose Meningococcal Hepatitis A Hepatitis B 1 or more doses 2 doses 3 doses Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at or by telephone, Information on how to file a Vaccine Injury Compensation Program claim is available at or by telephone, Information about filing a claim for vaccine injury is avail- able through the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C ; telephone, Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination also is available at or from the CDC-INFO Contact Center at 800-CDC-INFO ( ) in English and Spanish, 24 hours a day, 7 days a week. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. The recommendations in this schedule were approved by the Centers for Disease Control and Prevention s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Physicians (ACP).

16 A nonprofit independent licensee of the BlueCross BlueShield Association AUTHORIZATION TO SHARE MY PROTECTED HEALTH INFORMATION To comply with Federal HIPAA regulations, health plans must obtain a member s permission to share that member s protected health information with any other person. There are limited exceptions to this rule. Until a child reaches age 18, parents may access most of their child s health information without first obtaining the child s permission. However, regardless of the child s age, parents do not have access to diagnosis or treatment information, including payment information, for venereal diseases, abortion, and drug and alcohol abuse, unless the child specifically authorizes the release of such information. As a member, you can use this form to authorize us to share your protected health information. Each person you identify will have the same access to your information. If you would like each person to access different information or to have access to your information for a different period of time, you ll need to complete separate forms for each individual or time period. This authorization will include the disclosure of information relating to genetic testing, alcohol and drug abuse, mental health (excluding psychotherapy notes), abortion, and venereal disease information only if you place your initials on the corresponding line in Step 2. Additionally, if you would like to authorize us to release information regarding HIV/AIDS, a different form must be completed. To obtain a copy of this form please contact our office at the telephone number listed on your identification card, or access the form at the following website: Your authorization is completely voluntary. We will not condition your enrollment in a health plan, eligibility for benefits, or payment of claims on giving this authorization. If you need additional forms, you may copy this form, visit our Web site at: or contact our office at the telephone number listed on your identification card. As permitted by law, we will continue to communicate to providers of care involved in your treatment: (1) our payment activities in connection with your claims, (2) your enrollment in our health plan and (3) your eligibility for benefits. Please check here if you would like to authorize access to psychotherapy notes. If this box is checked, then this authorization cannot be used for another reason. If checked, steps two and three below can be skipped. B-1565 (Rev. 10/07) 1

17 Please be sure to complete all of the following steps. Step 1: Member to whom this authorization applies. Please use one form per member. Name: Address: City: State: Zip: Member ID Number(s): Step 2: Reasons to share your information. So Excellus Health Plan, Inc. can: Birth Date: / / Respond to all requests for confidential information about me made by the individual(s) or organization(s) I list below. I choose to include information regarding the following conditions in this authorization (please initial next to all that apply): Genetic testing Abortion Alcohol or substance abuse Venereal diseases Mental health (Please note: You must complete a separate form to authorize release of information related to HIV/AIDS. The New York State-approved consent form can be found at: Respond to requests for only the following specific information (such as claims submitted by a specific provider or information related to one of the protected diagnosis listed above): Please specify Respond to inquiries related to a specific date of service: Please specify Step 3: Specific information you d like us to share: Please list the specific protected health information you wish us to disclose. Check all that apply: My claim information (e.g. status, type of service, diagnosis, provider, dates of service, etc.) My membership information (e.g. coverage information, enrollment dates, eligibility, address, dates of birth, etc.) My benefit information (e.g. benefits available, benefits used, contract limits, etc.) My medical records (e.g. physician or hospital records, case management, etc.) Other information (please specify): Please exclude the following information: Step 4: Indicate with whom you d like us to share your information: Please list the person(s) and/or organization with which you want us to share the information you described above. Please remember if you d like us to share information with more than one person, the information to be disclosed and the expiration date must be the same for each person. Name/Organization Address B-1565 (Rev. 10/07) 2

18 Step 5: Indicate when you would like us to share your information: Please share my protected health information during the time period(s) below: Until Excellus Health Plan, Inc., completes the activities outlined in Step 2. Until I send Excellus Health Plan, Inc. a form canceling my authorization. From / / through / / Step 6: Member signature: To give Excellus Health Plan, Inc. authorization to share the protected health information noted above, please print your name on the line below and then provide your signature and today s date. I, have had full opportunity to read and consider the contents of this (Print Name Above) form, I confirm my authorization for the use, request and release of my confidential member protected health information as described in this form. I understand that I may cancel this authorization at any time by completing an authorization cancellation form and sending it to the address below. I also understand that the revocation of this authorization will not take effect until Excellus Health Plan, Inc. receives my authorization cancellation form and will not affect any actions Excellus Health Plan Inc. took in reliance on this authorization before they received the authorization cancellation form. I understand that the information disclosed as a result of this authorization may be subject to re-disclosure by the recipient, in which case it may no longer be protected under the federal privacy laws. Signature: (Member or Personal Representative) Date: If this request is by a personal representative on behalf of our member, please give us the following information: Personal Representative s Name: (please print) Description of Personal Representative s Authority (a power of attorney, legal guardian or state executor): Please note: personal representatives must provide legal proof of representation, such as power of attorney documentation. This form can be completed real time by visiting our Web site at Select the option to Share Your Protected Health Information. OR Please complete and return this form to: Excellus Health Plan, Inc. P.O. Box Rochester, NY OR FAX: PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS B-1565 (Rev. 10/07) 3

19 An added benefit to fit your healthy lifestyle Unity Health System s Health Plans include a lifestyle allowance that can help pay for services and programs you may already be using. And to make it as easy as possible to get and stay healthy, you can use your benefit more places than ever before. Your 2014 benefit Unity Enhanced Health Plan $500 annual benefit What it covers Gym Membership/Exercise Classes Facility must be open to the public and, at a minimum, provide both cardiovascular and strength training equipment. Classes must be held in a facility led by a qualified instructor. Weight Management Programs/ Nutritional Classes Weight management programs must require regular check-in. Nutrition classes must be led by a certified dietician. Lasik eye surgery Services must be rendered by a licensed Ophthalmologist. Teeth whitening Services must be provided by a licensed dentist. Toddler gym and swim programs Ages 2-5 years old. Kids fitness activities are community based fitness classes, physical activities and organized sports for children ages 5-18 years old. Hearing Aids Detailed receipt or Explanation of Benefits required S Unity Basic Health Plan $250 annual benefit Foot Orthotics Must be prescribed and obtained by a physician. Smoking Cessation Classes Available for reimbursement effective 3/1/2013 You can use your lifestyle allowance at any provider you choose, and Blue365 providers also offer discounts so you can save even more. View a full listing at excellusbcbs.com. What does not qualify? On-line weight management programs with the exception of Weight Watchers on-line Merchandise such as attire, fitness equipment, videos, publications, golf clubs, bicycles, and entry fees Diet foods and supplements Teeth whitening strips or over the counter whitening products Motorcycle classes or courses Drivers Education Foot orthotics purchased over-the-counter How to use it You choose your provider, pay for services, and submit the reimbursement form on the back of this sheet along with a receipt. Excellus BlueCross BlueShield will reimburse you directly. Expenses that qualify for reimbursement must be incurred by you or an eligible dependent enrolled in a Unity Health System health plan. How to submit your reimbursement form 1.Copies of all bills and/or receipts for reimbursement must be enclosed with this completed lifestyle allowance reimbursement form with the following information included: Full name and address of individual, business or organization providing services Dates of service Description of service Amount charged Full name and date of birth of member receiving services Explanation of Benefits or detailed receipt Balance bills, canceled checks, etc., are not acceptable. 1. All claims for the Lifestyle Allowance reimbursement must be submitted within 12 months of the date of service. Services must be rendered before they will be reimbursed. 2.Reimbursement forms must be signed by the member. 3.Mail completed forms with bills and/or receipts to: Excellus BlueCross BlueShield PO Box Rochester, NY If you have any questions, please call our Customer Service Department at the number on the back of your identification card. Reimbursement form on back

20 A nonprofit independent licensee of the BlueCross BlueShield Association PLEASE REVIEW AND LEGIBLY COMPLETE ALL SECTIONS (1-4) OF THIS FORM Please Note-If you do not have all of the required information please contact the provider of service for assistance prior to submitting your claim. Failure to supply all of the required information may result in delayed processing and/or subsequent return or denial of your claim submission. If your address has changed or is incorrect, please call our Customer Service Department at the telephone numbers listed on your identification card. SECTION 1 INFORMATION REQUIRED FOR REIMBURSEMENT SECTION 2 SUBSCRIBER INFORMATION Please enter all information exactly as shown on your ID card SUBSCRIBER'S LAST NAME SUBSCRIBER'S FIRST NAME INITIAL SUBSCRIBER IDENTIFICATION NUMBER Mail completed form and all required information to : Excellus BlueCross BlueShield P.O. Box Rochester, NY COPIES OF ALL BILLS/RECEIPTS/EXPLANATION OF BENEFITS FOR QUALIFIED EXPENSES MUST BE SUBMITTED WITH THIS FORM IN ORDER FOR REIMBURSEMENT TO BE CONSIDERED. BALANCE BILL, CANCELLED CHECKS ETC. ARE NOT ACCEPTABLE. BILLS MUST CLEARLY INDICATE ALL OF THE FOLLOWING: 1-FULL NAME AND DATE OF BIRTH OF MEMBER RECEIVING SERVICES 2-NAME AND ADDRESS OF THE INDIVIDUAL OR BUSINESS/ORGANIZATION PROVIDING THE SERVICE(S) 3-DATE FOR EACH SERVICE RENDERED 4-DESCRIPTION AND/OR VALID PROCEDURE CODE FOR EACH SERVICE RENDERED 5-CHARGE FOR EACH SERVICE RENDERED Unity Health System Lifestyle Allowance Reimbursement Form 6-ALL CLAIMS FOR THE LIFESTYLE ALLOWANCE REIMBURSEMENT MUST BE SUBMITTED WITHIN 12 MONTHS OF THE DATE OF SERVICE. SERVICES MUST BE RENDERED BEFORE THEY WILL BE REIMBURSED. ADDRESS-NUMBER AND STREET CITY STATE ZIP CODE SECTION 3 SERVICE INFORMATION Please complete all sections below for each individual service rendered MEMBER'S FULL NAME LAST NAME: FIRST NAME: LAST NAME: FIRST NAME: SECTION 4 SIGNATURE AND DATE MEMBER'S DATE OF BIRTH / / mm dd yyyy / / mm dd yyyy RELATIONSHIP TO SUBSCRIBER SELF SPOUSE CHILD SELF SPOUSE CHILD Unsigned forms will be returned DATE(S) OF SERVICE FROM: / / TO: / / FROM: / / TO: / / SERVICE INFORMATION LAST NAME: Teeth Whitening Gym/Health Club SELF FROM: / / D9972/Dx. V509 Exercise Classes / / SPOUSE Lasik Eye Surgery mm dd yyyy TO: / / S9446/Dx. V6541 FIRST NAME: 65771/Dx. V410 CHILD Kids Fitness $ Toddler/Preschool Exercise S9451/Dx. V6541 Program Hearing Aids S9445/Dx. V6541 V5299/Dx. V721 Weight Mgmt Program/ Foot Orthotics Nutrition Classes L3595/Dx. V729 S9449/Dx Smoking cessation classes S9453/Dx. V15.82 PROVIDED BY: Teeth Whitening D9972/Dx. V509 Lasik Eye Surgery 65771/Dx. V410 Toddler/Preschool Exercise Program S9445/Dx. V6541 Weight Mgmt Program/ Nutrition Classes S9449/Dx PROVIDED BY: Teeth Whitening D9972/Dx. V509 Lasik Eye Surgery 65771/Dx. V410 Toddler/Preschool Exercise Program S9445/Dx. V6541 Weight Mgmt Program/ Nutrition Classes S9449/Dx PROVIDED BY: Gym/Health Club Exercise Classes S9446/Dx. V6541 Kids Fitness S9451/Dx. V6541 Hearing Aids V5299/Dx. V721 Foot Orthotics L3595/Dx. V729 Smoking cessation classes S9453/Dx. V15.82 Gym/Health Club Exercise Classes S9446/Dx. V6541 Kids Fitness S9451/Dx. V6541 Hearing Aids V5299/Dx. V721 Foot Orthotics L3595/Dx. V729 Smoking cessation classes S9453/Dx. V15.82 I CERTIFY THAT THE INFORMATION SUBMITTED IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE EXPENSES INCURRED WERE FOR MYSELF, SPOUSE, OR QUALIFIED DEPENDENT(S) ENROLLED IN A UNITY HEALTH SYSTEM MEDICAL BENEFIT PLAN, AND THAT THESE EXPENSES ARE NOT REIMBURSABLE UNDER ANY OTHER HEALTH PLAN COVERAGE. SUBSCRIBER SIGNATURE: DATE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of each violation. AMOUNT $ $ MSA-99U Rev 10/13

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