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Section XXVI Schedule of Benefits EmblemHealth Silver CSR 3 COST-SHARING Deductible � Individual � Family Participating Provider Non-Participating Provider Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $0 None $0 None Out-of-Pocket Limit � Individual � Family OFFICE VISITS Primary Care Office Visits (or Home Visits) $1,000 $2,000 Participating Provider Member Responsibility for Cost-Sharing $10 Copayment Non-Participating Provider services are not covered except as required for Emergency Care Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description Specialist Office Visits (or Home Visits) Referral Required $20 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description 1 155-23-IONHIXS100Schedule (04/20) PREVENTIVE CARE � Well Child Visits and Immunizations* Participating Provider Member Responsibility for Cost-Sharing Covered in full Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description � Adult Annual Physical Covered in full Examinations* Non-Participating Provider services are not covered and You pay the full cost � Adult Immunizations* Covered in full Non-Participating Provider services are not covered and You pay the full cost � Routine Gynecological Covered in full Services/Well Woman Exams* � Mammograms, Covered in full Screening and Diagnostic Imaging for the Detection of Breast Cancer* � Sterilization Procedures for Women* Covered in full Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost � Vasectomy See Surgical Services Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost � Bone Density Testing* Covered in full Non-Participating Provider services are not covered and You pay the full cost 2 155-23-IONHIXS100Schedule (04/20) PREVENTIVE CARE � Continued Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing � Screening for Prostate Covered in full Cancer Non-Participating Provider services are not covered and You pay the full cost See benefit for description � All other preventive services required by USPSTF and HRSA. Covered in full Non-Participating Provider services are not covered and You pay the full cost � *When preventive services are not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA. EMERGENCY CARE Pre-Hospital Emergency Medical Services (Ambulance Services) Non-Emergency Ambulance Services Use Cost-Sharing for appropriate Service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures and Diagnostic Testing) Participating Provider Member Responsibility for Cost-Sharing $50 Copayment $50 Copayment Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider Member Responsibility for Cost-Sharing $50 Copayment Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description See benefit for description Emergency Department Copayment waived if admitted to Hospital Urgent Care Center $50 Copayment $50 Copayment Health care forensic examinations performed under Public Health Law � 2805-i are not subject to Cost-Sharing $30 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description See benefit for description 3 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE Advanced Imaging Services � Performed in a Specialist Office Participating Provider Member Responsibility for Cost-Sharing $20 Copayment Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not Covered and You pay the full cost Limits See benefit for description � Performed in a Freestanding Radiology Facility � Performed as Outpatient Hospital Services $20 Copayment $20 Copayment Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Preauthorization Required Allergy Testing and Treatment See benefit for description � Performed in a PCP Office $10 Copayment Non-Participating Provider services are not covered and You pay the full cost � Performed in a Specialist Office $20 Copayment Referral Required Ambulatory Surgical Center Facility Fee $25 Copayment Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost See benefit for description Anesthesia Services (all settings) Autologous Blood Banking Covered in full 5% Coinsurance Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost See benefit for description See benefit for description 4 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Cardiac and Pulmonary Rehabilitation Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing See benefit for description � Performed in a Specialist Office $10 Copayment Non-Participating Provider services are not covered and You pay the full cost � Performed as Outpatient Hospital Services $10 Copayment Non-Participating Provider services are not covered and You pay the full cost � Performed as Inpatient Included as part of Non-Participating Provider Hospital Services inpatient Hospital service services are not Covered and Cost-Sharing You pay the full cost Preauthorization Required Chemotherapy and Immunotherapy � Performed in a PCP Office $10 Copayment � Performed in a Specialist Office $10 Copayment � Performed as Outpatient Hospital Services $10 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost See benefit for description Preauthorization Required Chiropractic Services $20 Copayment Clinical Trials Preauthorization Required Use Cost-Sharing for Appropriate Service Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost See benefit for description See benefit for description 5 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Diagnostic Testing � Performed in a PCP Office � Performed in a Specialist Office Referral Required � Performed as Outpatient Hospital Services Preauthorization Required Dialysis � Performed in a PCP Office � Performed in a Specialist Office Referral Required � Performed in a Freestanding Center Referral Required � Performed as Outpatient Hospital Services Referral Required Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $10 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description $20 Copayment Non-Participating Provider services are not covered and You pay the full cost $20 Copayment Non-Participating Provider services are not covered and You pay the full cost $10 Copayment $10 Copayment $10 Copayment $10 Copayment Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost See benefit for description Dialysis performed by NonParticipating Providers is limited to 10 visits per calendar year Preauthorization Required Non-Participating Provider services are not Covered and You pay the full cost 6 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) � Performed in a PCP Office Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $15 Copayment Non-Participating Provider services are not covered and You pay the full cost Sixty (60) visits per condition per Plan Year. Combined therapies � Performed in a Specialist $15 Copayment Office Non-Participating Provider services are not covered and You pay the full cost � Performed in an Outpatient Facility $15 Copayment Non-Participating Provider services are not covered and You pay the full cost Preauthorization Required Home Health Care $10 Copayment Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost Forty (40) visits per Plan Year 7 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Infertility Services Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing Use Cost-Sharing for appropriate Service (Office Visit; Diagnostic Radiology Services; Surgery; Laboratory and Diagnostic Procedures) Non-Participating Provider services are not covered and You pay the full cost See benefit for description Preauthorization Required Infusion Therapy � Performed in a PCP Office $10 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description � Performed in a Specialist Office Referral Required $10 Copayment Non-Participating Provider services are not covered and You pay the full cost � Performed as Outpatient Hospital Services Preauthorization Required � Home Infusion Therapy Preauthorization Required Inpatient Medical Visits $10 Copayment $10 Copayment $0 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Home infusion counts toward home health care visit limits Non-Participating Provider services are not covered and You pay the full cost See benefit for description 8 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Interruption of Pregnancy Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing � Medically Necessary Covered in full Abortions Non-Participating Provider services are not Covered and You pay the full cost Unlimited � Elective Abortions Preauthorization Required See Surgical Services Cost-Sharing Non-Participating Provider services are not Covered and You pay the full cost One (1) procedure per calendar Year Laboratory Procedures � Performed in a PCP Office $10 Copayment Non-Participating Provider services are not Covered and You pay the full cost See benefit for description � Performed in a Specialist Office $20 Copayment Non-Participating Provider services are not Covered and You pay the full cost � Performed in a Freestanding Laboratory Facility � Performed as Outpatient Hospital Services $20 Copayment $20 Copayment Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Preauthorization Required 9 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Maternity and Newborn Care Participating Provider Member Responsibility for Cost-Sharing � Prenatal Care � Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA � Prenatal Care that is not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Covered in full Use Cost-Sharing for appropriate service (Primary Care Office Visit; Specialist Office Visit; Diagnostic Radiology Services; Laboratory Procedures and Diagnostic Testing) Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description One (1) home care visit is covered at no Cost-Sharing if mother is discharged from Hospital early Covered for duration of breast feeding � Inpatient Hospital Services and Birthing Center $100 Copayment per admission Non-Participating Provider services are not covered and You pay the full cost � Physician and Midwife Services for Delivery $25 Copayment Non-Participating Provider services are not covered and You pay the full cost � Breastfeeding Support, Covered in full Counseling and Supplies, Including Breast Pumps Non-Participating Provider services are not covered and You pay the full cost � Postnatal Care Preauthorization Required for Inpatient Services Outpatient Hospital Surgery Facility Charge Preauthorization Required Included in Physician Non-Participating Provider and Midwife Services for services are not covered and Delivery Cost Sharing You pay the full cost $25 Copayment Non-Participating Provider services are not covered and You pay the full cost 155-23-IONHIXS100Schedule (04/20) See benefit for description 10 PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Preadmission Testing Preauthorization Required Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $0 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description Prescription Drugs Administered in Office See benefit for description � Performed in a PCP Office Included as part of the PCP office visit CostSharing � Performed in Specialist Office Included as part of the Specialist office visit Cost-Sharing Diagnostic Radiology Services � Performed in a PCP Office $10 Copayment � Performed in a Specialist Office Preauthorization Required � Performed in a Freestanding Radiology Facility Preauthorization Required � Performed as Outpatient Hospital Services Preauthorization Required $20 Copayment $20 Copayment $20 Copayment Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost See benefit for description Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost 11 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Therapeutic Radiology Services � Performed in a Specialist Office Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $10 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description � Performed in a Freestanding Radiology Facility � Performed as Outpatient Hospital Services $10 Copayment $10 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Preauthorization Required Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) � Performed in a PCP office $15 Copayment � Performed in a Specialist office $15 Copayment � Performed in an Outpatient Facility) $15 Copayment Preauthorization Required Second Opinions on the Diagnosis of Cancer, Surgery and Other $20 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Sixty (60) visits per condition, per Plan Year. Combined therapies. Speech and physical therapy are only Covered following a Hospital stay or surgery. Non-Participating Provider services are not covered and You pay the full cost See benefit for description Referral Required Second opinions on diagnosis of cancer are Covered at participating Cost-Sharing for non-participating Specialist when a Referral is obtained. 12 155-23-IONHIXS100Schedule (04/20) PROFESSIONAL SERVICES and OUTPATIENT CARE � Continued Surgical Services (including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive and Corrective Surgery; and Transplants) Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider Member Responsibility for Cost-Sharing Limits See benefit for description � Inpatient Hospital Surgery $25 Copayment � Outpatient Hospital Surgery $25 Copayment � Surgery Performed at an Ambulatory Surgical Center $25 Copayment � Office Surgery � Performed in a PCP Office $10 Copayment � Performed in a Specialist Office $20 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost All transplants must be performed at designated Center of Excellence Facilities Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Preauthorization Required Telemedicine Program $0 Copayment Non-Participating Provider not subject to Deductible services are not Covered and You pay the full cost See benefit for description 13 155-23-IONHIXS100Schedule (04/20) ADDITIONAL SERVICES, EQUIPMENT and DEVICES ABA Treatment for Autism Spectrum Disorder Participating Provider Member Responsibility for Cost-Sharing $10 Copayment Preauthorization Required Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description Assistive Communication $10 Copayment Devices for Autism Spectrum Disorder Non-Participating Provider services are not covered and You pay the full cost See benefit for description Preauthorization Required Diabetic Equipment, Supplies and Self-Management Education � Diabetic Equipment, Supplies and Insulin (30-day supply) $10 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description � Diabetic Education $10 Copayment Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost 14 155-23-IONHIXS100Schedule (04/20) ADDITIONAL SERVICES, EQUIPMENT and DEVICES (Continued) Durable Medical Equipment and Braces Participating Provider Member Responsibility for Cost-Sharing 5% Coinsurance Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits See benefit for description Preauthorization Required External Hearing Aids 5% Coinsurance Preauthorization Required Cochlear Implants 5% Coinsurance Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Single purchase once every three (3) years One (1) per ear per time covered Hospice Care � Inpatient � Outpatient $100 Copayment per admission $10 Copayment Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost 210 days per Plan Year Five (5) visits for family bereavement counseling Preauthorization Required Medical Supplies 5% Coinsurance Preauthorization Required Non-Participating Provider services are not covered and You pay the full cost See benefit for description 15 155-23-IONHIXS100Schedule (04/20) ADDITIONAL SERVICES, EQUIPMENT and DEVICES � Continued Prosthetic Devices Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider Member Responsibility for Cost-Sharing � External 5% Coinsurance Non-Participating Provider services are not covered and You pay the full cost � Internal Preauthorization Required INPATIENT SERVICES and FACILITIES Inpatient Hospital for a Continuous Confinement (including an Inpatient Stay for Mastectomy Care, Cardiac and Pulmonary Rehabilitation, and End of Life Care) Included as part of Non-Participating Provider inpatient Hospital service services are not covered and Cost-Sharing You pay the full cost Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits One (1) prosthetic device, per limb, per lifetime with coverage for repairs and replacements Unlimited; See benefit for description Limits See benefit for description Preauthorization required. However, Preauthorization is not required for emergency admissions or services provided in a neonatal intensive care unit of a Hospital certified pursuant to Article 28 of the Public Health Law. Observation Stay $50 Copayment Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) $100 Copayment per admission Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost See benefit for description 200 days per Plan Year Preauthorization Required Inpatient Habilitation Services (Physical, Speech and Occupational Therapy) $100 Copayment per admission Preauthorization Required 155-23-IONHIXS100Schedule (04/20) Non-Participating Provider services are not Covered and You pay the full cost Sixty (60) days per Plan Year. Combined therapies 16 INPATIENT SERVICES and FACILITIES � Continued Inpatient Rehabilitation Services (Physical, Speech and Occupational therapy) Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Limits Sixty (60) days per Plan Year. Combined therapies. Preauthorization Required MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care for a continuous confinement when in a Hospital (including Residential Treatment) Participating Provider Member Responsibility for Cost-Sharing $100 Copayment per admission Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Speech and physical therapy are only Covered following a Hospital stay or surgery Limits See benefit for description Preauthorization Required. However, Preauthorization is not required for emergency admissions or for admissions at Participating OHM-licensed Facilities for Members under 18. Outpatient Mental Health Care (including Partial Hospitalization and Intensive Outpatient Program Services) See benefit for description � Office Visits $10 Copayment � All Other Outpatient $10 Copayment Services Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost 17 155-23-IONHIXS100Schedule (04/20) MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES � Continued Inpatient Substance Use Services for a continuous confinement when in a Hospital (including Residential Treatment) Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $100 Copayment per admission Non-Participating Provider services are not covered and You pay the full cost See benefit for description Preauthorization Required. However, Preauthorization is not Required for Emergency Admissions or for Participating OASAS- certified Facilities. Outpatient Substance Use Services (including Partial Hospitalization, Intensive Outpatient Program Services, and Medication Assisted Treatment) Unlimited; Up to 20 visits per calendar year may be used for family counseling � Office Visits $10 Copayment Non-Participating Provider services are not covered and You pay the full cost � All Other Outpatient $10 Copayment Services Non-Participating Provider services are not covered and You pay the full cost 18 155-23-IONHIXS100Schedule (04/20) PRESCRIPTION DRUGS Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing *Certain Prescription Drugs are not subject to CostSharing when provided in accordance with the comprehensive guidelines supported by HRSA or if the item or service has an "A" or "B" rating from the USPSTF and obtained at a participating pharmacy. Retail Pharmacy 30-day supply Tier 1 $6.00Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description Tier 2 $15.00 Copayment Tier 3 $30.00 Copayment Preauthorization is not required for a Covered Prescription Drug used to treat a substance use disorder, including a Prescription Drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal. 19 155-23-IONHIXS100Schedule (04/20) PRESCRIPTION DRUGS (Continued) Mail Order Pharmacy Up to a 90-day supply Tier 1 Tier 2 Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $15.00 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description $37.50 Copayment Tier 3 Enteral Formulas Tier 1 Tier 2 $75.00 Copayment $6.00 Copayment $15.00 Copayment Non-Participating Provider services are not covered and You pay the full cost See benefit for description Tier 3 WELLNESS BENEFITS Gym Reimbursement $30.00 Copayment Participating Provider Member Responsibility for Cost-Sharing $200 per six (6)-month calendar year period; $100 per six (6)-month calendar year period for covered Dependent(s) Non-Participating Provider Member Responsibility for Cost-Sharing $200 per six (6)-month calendar year period; $100 per six (6)-month calendar year period for covered Dependent(s) Limits $200 per six (6)-month calendar year period; $100 per six (6)month calendar year period for covered Dependent(s) 20 155-23-IONHIXS100Schedule (04/20) PEDIATRIC VISION CARE Pediatric Vision Care � Exams � Lenses and Frames � Contact Lenses Participating Provider Member Responsibility for Cost-Sharing $10 Copayment 5% Coinsurance Non-Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider services are not covered and You pay the full cost Non-Participating Provider services are not covered and You pay the full cost Limits One (1) exam per 12-month period; One (1) prescribed lenses and frames per 12month period 5% Coinsurance Non-Participating Provider services are not covered and You pay the full cost 21 155-23-IONHIXS100Schedule (04/20) PEDIATRIC DENTAL CARE � Preventive Dental Care � Routine Dental Care � Major Dental Care (Endodontics, Periodontics, Prosthodontics and Oral Surgery) � Orthodontics Participating Provider Non-Participating Provider Limits Member Responsibility Member Responsibility for for Cost-Sharing Cost-Sharing $10 Copayment $10 Copayment $10 Copayment $10 Copayment Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost Non-Participating Provider services are not Covered and You pay the full cost One (1) Dental Exam & Cleaning Per six (6)-Month Period Full mouth Xrays or panoramic Xrays at thirtysix (36) month intervals and bitewing Xrays at six (6) month intervals. Major Dental Care and Orthodontics require Preauthorization All in-network Preauthorization requests are the responsibility of Your Participating Provider. You will not be penalized for a Participating Provider's failure to obtain a required Preauthorization. However, if services are not covered under the Certificate, You will be responsible for the full cost of the services. Eligible American Indians, as determined by the NYSOH, are exempt from Cost-Sharing requirements when Covered Services are rendered by an Indian Health Service, Indian Tribe, Tribal Organization or Urban Indian Organization, or through Referral under contract health services. 22 155-23-IONHIXS100Schedule (04/20)