1. Covered Services: All Covered Services must be furnished to a Member:

   (1) by a Primary Care Physician;

   (2) by another Participating Provider and authorized by a Primary Care Physician or Community First;

   (3) by a Non-Participating Provider if referred by a PCP and pre-authorized by Community First;

   (4) by a Participating Specialty Care Physician approved by Community First's Medical Director to perform the services of a Primary Care Physician pursuant to a request of a Member with a chronic, disabling or Life-Threatening illness; or

   (5) by a participating obstetrician or gynecologist as described in II.A.3. above or a participating behavioral health provider as described in II.B.1. above.

   It is Your responsibility to obtain a referral from Your
   PCP to see a Speciality Care Physician. Pre-authorization may be required to obtain specific services or supplies from a Specialty Care Physician or prior to undergoing hospitalization, outpatient surgery or diagnostic procedures.

   If Medically Necessary Covered Services are not available through a Participating Provider, Community First will, at the request of a Participating Provider, and within a reasonable time period allow referral to a Non-Participating Provider and shall fully reimburse the Non-Participating Provider at the usual and customary rate or at a negotiated rate. Before such a requested referral can be denied, Community First must have the request reviewed by a specialist of the same or similar specialty as the Physician or provider to whom the referral is requested.

2. After Hours Care: Illnesses and Injuries often do not happen during normal office hours. You may call Your PCPs office 24 hours a day, 7 days a week and You should contact him or her if You need after hours care. If the call is not placed during office hours, You will be assisted by an answering service that will notify the physician on call and advise You on how to proceed.
   
   
3. Urgent Care Services:
   (1) Urgent Care in the Service Area. In the event of an
   urgent situation (Illness or Injury) that is severe or painful
   enough to require assessment and/or treatment within 24
   hours, You should contact Your PCP who will direct You to a contracted facility.
   
   (2) Urgent Care Outside the Service Area. Community First
   will cover Urgent Care obtained from a Physician or licensed
   facility outside our Service Area if the services cannot safely
   be delayed until You come back to the service area to obtain care through your PCP.
   
   You must obtain the services immediately after the urgent
   condition occurs, or as soon as possible afterward.
   Communtiy First has the right to review the services and the
   circumstances in which You received them. If we decide
   that some or all of the services do not meet the coverage
   requirements of this section, You will have to pay for the
   non-coverd services.
   
   Exceptions to these requirements for Covered Services
   furnished in connection with Emergency Care for medical
   conditions occurring inside or outside the Service Area are
   set forth below.
   
   
4. Medical Emergency: Services for a Medical Emergency are covered anywhere in the world 24 hours a day. If a Medical Emergency occurs, Members should go to the nearest participating or non-participating medical facility.
   
   Necessary Emergency Care services will be provided to
   Members, including the treatment and stabilization of a
   Medical Emergency, and any medical screening examination
   or other evaluation required by state or federal law which is
   necessary to determine if a Medical Emergency exists.
   
   If it is determined that a Medical Emergency does exist,
   Community First will pay for Emergency Care services
   performed by non-Participating Providers at negotiated or
   usual and customary rates for the services performed.
   Community First will approve or deny coverage of poststabilization care, as requested by a treating provider, within the timeframe appropriate to the circumstances, but in no case to exceed one hour.
   
   Community First will have Pre-authorization staff on duty at
   phones during regular business hours. If You have received
   Emergency Care and the Provider who treated You indicates that You will need follow-up care to complete the treatment, the follow-up care must be rendered by Your PCP, not by the Provider who treated You for the Medical Emergency. The Member, or someone acting on the Member’s behalf, should contact the Member’s PCP within 24 hours, or as soon as reasonably possible, so that he or she may arrange for follow-up care. All Covered Services rendered by a Non- Participating Provider, except in the case of a Medical Emergency, require Pre-authorization.
   
   Members should not use the Emergency Room or Urgent
   Care facility for routine or non-emergent services. If you
   choose to use the Emergency Room or Urgent Care facilities
   for routine, or non-emergent services, then You will be
   responsible for all billed charges relating to the services. You
   can use Community First’s Complaint and Appeal Process to resolve a dispute regarding Emergency Care.

Member Financial Responsibility.  When accessing authorized Covered Services from a Participating Provider, You will only owe a Copayment to that Provider.  It is the Member’s responsibility to ensure that the Providers from whom You receive services are contracted with Community First. 

All services received from a Non-Participating Provider require pre-authorization except for emergency care.  You will be liable for all charges if services are not pre-authorized. If You receive pre-authorized services from a Non-participating Provider, and that Provider has not agreed to a negotiated rate from Community First, then Community First may pay the usual and customary charge for the services provided, and You may be responsible for the difference between the amount paid by Community First and the amount of the full charge billed by the Non-participating Provider. 

If You pay up front and seek reimbursement for the pre-authorized services you received from a Non-Participating Provider, You will be reimbursed the usual and customary charge less the copayment.

You should ask about the contract status of the Providers from whom you receive treatment, especially when You are referred by your PCP to a Specialty Care Physician and when You receive services at a Participating Hospital, as some facility based physicians or other heatlh care practitioners such as anesthesiologists, pathologists, neonatologist, emergency room physicians, and radiologists may not be included in Community First’s network and may balance bill You for amounts not paid by Communtiy First. If you receive a bill from any Participating Provider asking you to pay for something other than a Copayment, please notify Community First’s Member Services Department immediately.

1. Premiums: Members may pay a premium for Plan
   coverage. The premium amount and payment arrangements
   are made through Your Employer.
   
   
2. Copayments: In addition to any payroll deduction Your
   Employer may impose, You will be responsible for
   appropriate Copayments, up to out-of-pocket maximums.
   The Co-payments that apply to certain Covered Services, as
   well as out-of-pocket maximums, are described in the
   Schedule of Co-payments attached to and made a part of
   this Certificate. Community First’s Participating Providers will look only to Community First and not to You for payment ofCovered Services, except for payment of applicable Copayments.
   
   Community First may not impose Copayment charges that
   exceed fifty percent (50%) of the total cost of providing any
   single service to Community First’s enrollees, nor in the
   aggregate more than twenty percent (20%) of the total cost
   to Community First of providing all basic health care
   services. In any Contract Year, the aggregate amount of a
   person's Copayments will not exceed an amount equal to
   two times the total annual premium cost that the Contract
   Holder (and/or Member) is required to pay. This applies only if the Contract Holder or Member demonstrates that Copayments in that amount have been paid in that year.
   
   
   
3. Services or Supplies that are not Covered under this Certificate of Group Health Care Coverage. If You receive health care services or supplies that are not Covered Services and Supplies. You will be financially responsible for the entire cost of service.
   
   
4. Unauthorized Services. You will be financially responsible for the entire cost of service if you:
   
   
   • Obtain health care services, in circumstances other than
     a Medical Emergency, from a Non-participating Provider
     without preauthorization from Community First; or
   • Obtain services from a Participating Provider who is not
     Your PCP without a referral from Your PCP, except for
     the following services, which do not require a referral or
     Pre-authorization:
     
     
     • Emergency Care;
     • Accessing care from a Participating Provider who is an obstetrician or gynecologist;
     • Accessing no more than 25 visits in a Contract Year from a Participating Provider who is a behavioral health specialist.

1. Acquired Brain Injury. Acquired Brain Injury: Cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabiliatation, neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment, neurofeedback therapy, and remediation. Postacute transition services, community reintegration services, including outpatient day treatment services, or other postacute treatment services. These services can be obtained at a hospital including an acute or post-acute rehabilitation hospital or an assisted living facility regulated under Chapter 247, Health and Safety Code.
   
   Also covered is reasonable expenses related to periodic
   reevaluation of the care provided to a member who has
   incurred an acquired brain injury, has been unresponsive to
   treatment and becomes responsive to treatment at a later
   date. See Definitions.
   
   
2. Allergy and Treatment. Medically Necessary allergy testing to evaluate and determine the cause of allergy and
   appropriate allergy treatments including injections and
   serum. See Schedule of Copayments.
   
   
3. Ambulance Services. Emergency ground or air ambulance
   transportation when Medically Necessary.
   
   
4. Anesthetics and their administration.
   
   
5. Asthma. Treatment, care and supplies related to asthma,
   as provided or prescribed by a Participating Physician or
   other qualified Participating Provider.
   
   
6. Autism Spectrum Disorder. If an enrollee is older than two years of age and younger than six years of age and is
   diagnosed with Autism Spectrum Disorder, CFHP will cover
   medically necessary services that are generally recognized
   services when prescribed by the members PCP. Generally
   recognized services may include:
   

   1.	evaluation and assessment services;
   2.	applied behavior analysis;
   3.	behavior training and behavior management;
   4.	speech therapy;
   5.	occupational therapy;
   6.	physical therapy; or
   7.	medications or nutritional supplements used to address symptoms of autism spectrum disorder.
   An individual providing treatment prescribed (under such statute) must be a health care practitioner who is licensed, certified, or registered by an appropriate agency of this state; whose professional credential is recognized and accepted by an appropriate agency of the United States; or who is certified as a provider under the TRICARE military health system.. See Exclusions.

7. Biofeedback therapy is covered when it is reasonable and
   Medically Necessary for the individual for muscle reeducation of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and conventional treatments (heat, cold, massage, exercise, support) have not been successful. See Exclusions.
   
   
8. Blood and Blood Derivatives. Including administration,
   when prescribed by a Participating Provider and determined
   to be Medically Necessary by Community First.
   
   
9. Breast Cancer Treatment. Diagnosis and treatment
   including coverage for inpatient care for a Member for a
   minimum of:

   (1) 48 hours following a mastectomy; and
   (2) 24 hours following a lymph node dissection for the
         treatment of breast cancer;
   
   unless the Member and the attending physician determine
   that a shorter period of inpatient care is appropriate.
   

10. Chemotherapy, Radiation Therapy. Treatment by X-ray,
    radium or any other radioactive substance, or by
    chemotherapy.
    
    
11. Cochlear Implant. See Schedule of Copayments.
    
    
12. Chemical Dependency. Medically Necessary care and
    treatment of Chemical Dependency will be covered the same
    as any other physical illness. Treatment could also include
    treatment under the direction and continued medical
    supervision of a doctor of medicine or doctor of osteopathy
    in a Residential Treatment and/or Psychiatric Day Treatment
    Facility.
    
    
13. Dental Treatment: Services that Must Be Performed in a Hospital Setting. Community First will cover certain services provided to a Member who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the Member’s PCP and the dentist. These services include the hospital or facility, and/or anesthesia charges only. The Dentist, Oral Surgeon and any assisting Dentist or Oral Surgeon charges are not covered.
    
    Injury to Sound Natural Teeth. Restoration and correction of
    damage caused by external violent accidental injury to
    healthy, natural teeth occurring while covered under this
    Certificate for Group Health Care Coverage and provided
    within 24 months of the date of the accident.
    
    
14. Diabetes Care. Covered Services and Supplies include
    diabetes treatment, equipment, supplies, medications and
    self-management training prescribed or provided by a
    Participating Provider. Diabetes equipment includes, but is
    not limited to, blood glucose monitors, including monitors
    designed to be used by blind individuals; insulin pumps and
    associated appurtenances; insulin infusion devices; and
    podiatric appliances for the prevention of complications
    associated with diabetes.
    
    Diabetes supplies include, but are not limited to, test strips
    for blood glucose monitors; visual reading and urine test
    strips; lancets and lancet devices; injection aids; syringes;
    glucagon emergency kits and alcohol wipes. The supply of
    necessary disposable syringes for the insulin supply will be
    provided for one Copayment. Diabetic supplies will include
    up to a thirty (30) day supply for one Copayment at a retail
    store or up to a ninety (90) day supply through mail order.
    Diabetes medications include, but are not limited to, insulin
    and insulin analogs; prescriptive and non-prescriptive oral
    agents for controlling blood sugar levels. Up to a thirty (30)
    day supply of insulin will be provided for one Copayment at a retail store or up to a ninety (90) day supply through mail
    order.
    
    
15. Diagnostic Laboratory and Radiological Services
    including professional fees. Such diagnostic services include mammography services and therapeutic radiology services.
    
    
16. Durable Medical Equipment. Rental or purchase that is
    Medically Necessary and approved by Community First.
    Coverage is provided for the initial equipment only and for
    standard equipment. Special features that are not part of the
    basic equipment are not covered, such as electric beds and
    electric wheelchairs. Benefits for rental are limited to, and
    will not exceed, the purchase price of the equipment. For
    equipment purchased at Community First’s option, this item
    includes repair if not due to neglect or abuse, and necessary
    maintenance of purchased equipment not provided under a
    manufacturer's warranty or a purchase agreement.
    
    
17. Eye Exam. One annual eye exam per plan year, including
    dilation of the eye, by a Doctor of Ophthalmology or a Doctor of Optometry which, when within the scope of their license, includes such services as:
    
     (1) external examination of the eye and its structure;
     (2) determination of refractive status; and
     (3) Glaucoma screening test.
    
    The Member is responsible for any additional charges for
    services associated with contact lenses, including but not
    limited to, contact lens eye exams, contact lens fittings and
    follow up care.
    
    
18. Family Planning and Infertifily Services related to the
    diagnosis of infertility shall be provided as Medically
    Necessary and as prescribed and authorized by a
    participating provider and includes the following services:
    
    (1) counseling;
    (2) sex education instruction in accordance with medically
         acceptable standards;
    (3) contraceptive devices;
    (4) placement of contraceptive devices;
    (5) diagnostic procedures to determine the cause of
          infertility;
    (6) vasectomies;
    (7) tubal ligations and laparoscopies;
    (8) infertility drugs – see Schedule of Copayments for
          limitations.
    
    
19. Foot Care. Services and supplies for the care and
    treatment of diseases of, or injuries to, the feet, when
    prescribed by the PCP and determined to be Medically
    Necessary by Community First. Shoe orthotics, insoles, shoe inserts or other supportive devices of the feet are covered only when prescribed as part of a treatment plan for
    someone with a primary diagnosis of diabetes. Orthopedic
    shoes are covered only when the shoe is an integral part of
    a medically necessary leg brace. Covered foot orthotics are
    limited to two per plan year and shoes are limited to two pair
    per plan year.
    
    
20. Formulas. Dietary formulas, including over-the-counter
    products, if medically necessary for the treatment of
    Phenylketonuria and other Heritable Diseases for which a
    prescription is necessary for purchase. All other dietary
    over-the-counter formulas are excluded from coverage. See
    Exclusions.
    
    
21. Genetic Testing and Counseling.
    
    
22. Health Education. Services including, but not limited to the
    following:
    
    

    (1)	Information about Community First's Covered Services, including recommendations on generally accepted medical standards for the use and frequency of such services;
    (2)	Diabetes self-management training provided by a Participating Provider who is licensed in Texas to provide such services. Self-management training includes, but is not limited to:
    	(a) training provided to a Member after the initial diagnosis of diabetes in the care and management of that condition, including nutritional counseling and proper use of diabetes equipment and supplies; (b) additional training required as a result of a significant change in the Member’s symptoms or condition; (c) periodic continuing education training when prescribed by a Participating Physician as warranted by the development of new techniques and treatments for diabetes. (d) All diabetes self-management training is subject to Medical Director review.
    (3)	Other disease-specific health education programs provided by or approved by Community First.
    (4)	Prenatal education materials provided by Community First.
    (5)	Nutritional counseling and education provided by or approved by Community First.

    
    
23. Hearing Aids and Batteries: Benefit Limited to $500 per
    ear every three (3) years. Repairs not covered. Batteries
    are not subject to any dollar maximum. See Schedule of
    Copayments for limitations.
    
    
24. Home Health Care Services. Skilled nursing provided by or supervised by a registered nurse (R.N.). The services must be provided by a participating home health agency; your PCP refers You or arranges the services and is preauthorized by Community First. Services may include physical, occupational, speech or respiratory therapy; the service of home health aides under the supervision of an RN; medical social services under the supervision of an RN, and the provison of medical supplies.
    
    
25. Hospice Care Services and Supplies. Covered if
    authorized by a Participating Physician as part of a Hospice
    Care Program for a member who is Terminally-ill.
    

    (1)	Hospice care services including pain relief, symptom management and supportive services to terminally ill Members and their immediate families on both an outpatient and inpatient basis.
    (2)	Counseling Services provided by members of a Hospice Team.

    
    
26. Hospital Inpatient Services and Supplies. Semi-private
    room and board. This includes normal daily services and
    supplies furnished by the Hospital.
    
    For any day on which a PCP authorizes the person's stay in a private room in a Hospital that has no semi-private rooms, Hospital private room and board, including normal daily services and supplies will be included as Eligible Services and Supplies. Hospital private room and board, including normal daily services and supplies, will also be included as Eligible Services and Supplies for any day on which:
    

    (1)	The person is being isolated in a private room because of the person's communicable disease; or
    (2)	Use of a private room is Medically Necessary, as determined by Community First, for treatment of the person's Illness or Injury.

    
    
27. Hospital Outpatient Services and Supplies. Covered
    Services in connection with surgical treatment, including preadmission testing and/or treatment room, operating room
    and treatment, medical supplies such as splints and casts,
    and non-experimental drugs and medications furnished by
    and administered at the Hospital or facility.
    
    
28. Implant. A surgically implanted artificial device, determined
    by Community First to be Medically Necessary, that corrects a significant functional disorder (e.g. hip or knee joints, heart pacemakers, penile implants, and electrical stimulators).
    
    
29. Inhalation therapy.
    
    
30. Injectibles. Medically Necessary injectible drugs
    administered by a Participating Provider.
    
    
31. Maternity Inpatient Care. The maternity benefit offered
    includes coverage for inpatient care for a mother and her
    newborn child in a health care facility for a minimum of:
    

    (1)	48 hours following an uncomplicated vaginal delivery; and
    (2)	96 hours following an uncomplicated delivery by caesarean section; unless the Member and her attending physician determine that a shorter period of inpatient care is appropriate.
    Unless the Member and her attending physician determine that a shorter period of inpatient care is appropriate.

    
    
32. Outpatient Mental Health. Up to 25 fifty-minute outpatient Participating Physicians’ visits (or the equivalent) in a Contract Year, as may be necessary and appropriate for
    short-term evaluative or crisis intervention mental health
    services or both. For inpatient mental health coverage, see
    the Mental or Emotional Illness or Disorder and Alternative
    Mental Health Treatment Rider.
    
    
33. Ophthalmological Services. Covered Services and
    Supplies needed for the diagnosis and treatment of diseases
    of, or injury to the eye.
    
    
34. Organ Transplant Services. Covered medical services
    including evaluation and supplies for Medically Necessary and appropriate organ transplant services including:
    

    (1)	Heart transplant
    (2)	Lung transplant
    (3)	Heart/Lung transplant
    (4)	Kidney transplant
    (5)	Kidney/pancreas transplant
    (6)	Liver transplant
    (7)	Liver/small bowel transplant
    (8)	Pancreas transplant
    (9)	Small bowel transplant
    (10)	Corneal transplant
    (11)	Bone marrow transplant for aplastic anemia, leukemia, severe combined immuno-deficiency disease, and Wiskott Aldrich syndrome.

    The cost of artificial organs are excluded from coverage.
    Services or procedures considered experimental and/or
    investigational under current medical policy guidelines also
    are excluded. See Exclusions.
    
    Community First will not require that a Member travel out-ofstate to receive transplant services unless the informed
    consent of the Member has been obtained, which explains
    the benefits and detriments of in-state and out-of-state
    options.
    
    If the Member satisfies medical criteria developed by
    Community First for receiving transplant services.
    Community First will provide a written authorization for care
    to a transplant facility selected by Community First from a list of facilities it has approved. If, after referral, either Community First or the medical staff of the referral facility determines that the Member does not satisfy its respective criteria for the services involved, Community First’s obligation is limited to paying for Covered Services provided prior to such determination according to the Schedule of Copayments.
    
    
35. Orthotics (excluding foot orthotics/inserts, see foot
    care). Prescribed by a Participating Provider and
    determined to be Medically Necessary by Community First.
    
    
36. Oxygen and Rental of Equipment for use of Oxygen,
    when Medically Necessary and prescribed by a Participating
    Physician.
    
    
37. Pain Management Services. Medically Necessary pain
    management treatment and related services that are ordered
    by a participating provider and preauthorized by Communtiy
    First. Services can be expected to meet or exceed treatment
    goals and are scientifically proven and evidence-based to
    improve Your medical condition.
    
    
38. Physicians' Services for surgical procedures and for other
    medical care.
    
    
39. Preventive Health Services. The following preventive
    health services are covered.
    

    (1)	Well-baby and child care including childhood screening tests for hearing loss, as required by law, from birth through the date the child is 30 days old and any necessary diagnostic follow-up care related to the screening test from birth through the date the child is 24 months old.
    (2)	Annual eye and ear examination for members to determine the need for vision and hearing correction.
    (3)	Periodic adult health evaluations.
    (4)	Pediatric and adult immunizations in accordance with Community First clinical guidelines and/or as required by law.
    (5)	Annual well-woman exam including, but not limited to, periodic screening for breast and cervical cancer A conventional pap smear screening or a screening using liquid-based cytology methods alone or in combination with a test for the detection of the human papillomavirus.
    (6)	Annual diagnostic testing for the detection of prostate cancer. Coverage is provided for : (a) a physical examination for the detection of prostate cancer, and (b) a prostate-specific antigen test used for the detection of prostate cancer for each male who is: (1) at least 50 years of age and asymptomatic; or (2) at least 40 years of age with a family history of prostate cancer or another prostate cancer risk factor.
    (7)	For qualified individuals, medically accepted bone mass measurement for the detection of low bone mass and to determine the risk of osteoporosis and fractures associated with osteoporosis. Qualified individual means: (a) postmenopausal woman who is not receiving estrogen replacement therapy; (b) an individual with: (1) vertebral abnormalities; (2) primary hyperparathyroidism; or (3) a history of bone fractures; or (c) an individual who is (1) receiving long-term glucocorticoid therapy; or (2) being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy.
    (8)	Medically Necessary screenings for colorectal cancer for members 50 years of age or older and at normal risk for developing colon cancer. Members can choose from (1) a fecal occult blood test performed annually and a flexible sigmoidoscopy performed every five years or (2) a colonoscopy performed every ten years.

40. Prostheses. An external or removable artificial devices that
    replaces a body part (e.g. prosthetic arms, legs and eyes)
    and is determined by Community First to be Medically
    Necessary. The benefit includes repair and replacement
    when due to growth. See Schedule of Copayments.
    
    
41. Reconstructive Surgery after Mastectomy. Surgery to
    provide coverage for (1) reconstruction of the breast on
    which the mastectomy has been performed; (2) surgery and
    reconstruction of the other breast to achieve a symmetrical
    appearance; and (3) prostheses and treatment of physical
    complications, including lymphedemas, at all stages of
    mastectomy.
    
    
42. Reconstructive Surgery for Craniofacial Abnormalities
    in a Child younger than 18 years old. Surgery determined
    by Community First to be Medically Necessary to improve
    the function of, or to attempt to create a normal appearance
    of, an abnormal structure caused by congenital defects,
    developmental deformities, trauma, tumors, infections, or
    disease. See Exclusions.
    
    
43. Rehabilitative Services. Including physical, occupational,
    hearing and speech therapy, when ordered by a
    Participating Physician. Rehabilitative services and
    therapies that are Medically Necessary in the opinion of the
    physician may not be denied, limited, or terminated if they
    meet or exceed treatment goals for the person needing such
    services.
    
    For a physically-disabled person, treatment goals should
    include improvement or maintenance of functioning or
    prevention of or slowing of further deterioration. Covered
    Services for speech or hearing therapy are limited to therapy
    that is provided by a qualified speech therapist or audiologist
    for loss or impairment of speech or hearing.
    
    
44. Renal Dialysis. Services and supplies furnished in
    connection with dialysis for chronic renal disease.
    
    
45. Respiratory Therapy.
    
    
46. Serious Mental Illness. Acute inpatient and outpatient
    covered services/supplies for the treatment of serious mental
    illness. Covered as any other illness. See Schedule of
    copayments.
    
    
47. Sexually-transmitted Diseases (STD). Education,
    diagnosis and treatment for STDs, including HIV, AIDS, and AIDS-related illnesses.
    
    
    
48. Skilled Nursing Facility Services. Covered Services and
    Supplies for up to 60 days per plan year including:
    
    (1) If You were not admitted to a Skilled Nursing Facility,
    You would need acute care hospitalization;
    
    (2) The skilled nursing services are of a temporary nature
    and will lead to rehabilitation and increased ability to
    function;
    
    (3) Your PCP or attending specialist refers You and
    certifies that the Member needs 24-hour-a-day nursing care.
    
    
49. Speech and Rehabilitative Therapy. Services Medically Necessary to treat loss or impairment of speech and hearing are covered the same as any other physical Illness.  Hearing aids and batteries are a covered benefit.  See Schedule of copayments.
    
    
50. Supplies. Prescribed by a Participating Provider and determined to be Medically Necessary and appropriate by Community First.  Medical supplies are non-reusable, disposable, and are not useful in the absence of Illness or Injury. Common household items are not considered medical supplies.

    To be considered “Medically Necessary” or “appropriate” a medical supply must be determined by Community First to meet all of these conditions, and must not be listed under Exclusions. The supply(ies):

    1. must be part of a Participating Provider’s treatment plan;
    2. must be based on current treatment protocols;
    3. must be obtained from a Participating Provider; 
    4. must be required such that its omission would adversely affect the Member's health;

    (5) must be recognized as safe and effective for its intended use;
    (6) must be used in a manner that is consistent with generally accepted United States medical standards or guidelines.

    Examples of medical supplies may include, but not be limited to, diabetic supplies, ostomy supplies, Jobst stockings, sterile dressings and urinary catheters. See Exclusions.

    ay.Telemedicine.  Services provided through Telehealth Services and Telemedicine Medical Services, to the extent that coverage is required by Section 1455.004 of the Texas Insurance Code.

    az.Temporomandibular Joint (TMJ). Medically Necessary services for the diagnosis and/or medical/surgical treatment of conditions affecting the temporomandibular joint which includes the jaw or craniomandibular joint resulting from an accident, trauma, congential defect, developmental defect or a pahthology.

    ba.Wigs are covered when determined to be Medically Necessary.
    
    

1. Major Disaster or Epidemic. Community First will
   consistently make a good faith effort to provide or arrange
   for Covered Services, taking into account existing conditions
   and events. If there is a major disaster or an epidemic,
   Community First will provide or arrange for Covered
   Services to the extent possible or practical. Neither
   Community First nor any Participating Provider will have any
   liability or obligation on account of delay or failure to provide
   or arrange for Covered Services.
   
   
2. Circumstances Beyond the Control of Community First or
   Participating Providers. Due to circumstances not within the
   control of Community First or Participating Providers, there
   may be a delay in providing or arranging for Covered
   Services, or it may not be practical or possible to do so.
   Community First nor any Participating Provider will have any
   liability or obligation on account of delay or failure to provide
   or arrange for Covered Services if a good faith effort has
   been made to do so. Some examples of such
   circumstances are: complete or partial destruction of
   facilities because of war, riot, natural disasters or civil
   insurrection; the disability of a significant number of
   Participating Providers; and other similar causes.
   
   
3. Continuity of Treatment in the Event of the Termination of a PCP. Community First will notify You no less than thirty (30) days in advance if a Participating Physician or other provider treating You is going to be leaving the Community First network. If the Physician or other provider is treating You
   under a "special circumstance” and the treating Physician or
   provider makes the request, then Community First will
   continue to compensate the Physician or other provider, on
   Your behalf, for up to ninety (90) days. "Special
   circumstance" means a condition such that Your Physician
   or provider reasonably believes discontinuation of care could
   cause harm to You. Examples include:
   
   (1) A person who has a disability;
   (2) A person with an acute condition;
   (3) A person with a Life-threatening Illness;
   (4) A person who is past the twenty-fourth week of
   pregnancy, delivery of the child and immediate postpartum care and six-week checkup.
   (5) A person who has been diagnosed with a terminal
   illness at the time the provider terminated, Community
   First will reimburse the provider up to nine (9) months
   after the effective date of termination,
   
   
4. Non-participating Provider and Out-of-Area Services and
   Benefits. Only Emergency Care services are covered
   outside the Community First’s network and/or Service Area,
   unless Medically Necessary Covered Services are not
   available through Community First’s network of Participating
   Providers, or in the case of Court-Ordered Dependent
   Coverage. If Medically Necessary Covered Services are not
   available through Community First’s Participating Providers,
   Community First will allow, upon the request of a
   Participating Provider and within a reasonable time period,
   referral to a Non-Participating Provider.
   
   

1. Abortion services. Unless determined to be Medically Necessary to preserve the life of the mother.
   
   
2. Artificial Internal Organs and Animal Organs.
   
   
3. Acupuncture.
   
   
4. Allergy Testing, treatment and sera for food allergies.
   
   
5. Allowable Cost of Covered Services. Coverage normally
   provided for a Covered Service may not be applied toward
   the cost of a non-Covered Service or Supply.
   
   
6. Ambulance Services. Transport services for non-emergecy
   conditions unless preauthorized.
   
   
7. Autism Spectrum Disorder. Services considered to be
   investigational or experimental are not covered if they fall
   outside the scope of generally recognized services.
   
   
8. Biofeedback Therapy. Excluded for the treatment of
   ordinary tension and muscle-contraction headaches or
   psychosomatic conditions.
   
   
9. Charges for broken appointments.
   
   
10. Charges for completion of any forms.
    
    
11. Charges made by the Employer or a close relative.
    Services or supplies furnished by:
    
    (1) the Employer; or
    (2) You, Your spouse, or a child, brother, sister, or parent
    of You or Your spouse.
    
    
12. Chelation Therapy except when used in the treatment of
    heavy metal poisoning.
    
    
13. Clothing and Diapers.
    
    
14. Chemical Dependency aftercare services including but not
    limited to, AA/NA, support or education groups, and/or other
    services that primarily focus on relapse prevention to the
    Member who completed treatment and/or their family
    members.
    
    
15. Chiropractic Care. Services and supplies furnished in
    connection with correction, by manual or mechanical means,
    of subluxation of the spine.
    
    
16. Clothing, Shoes and Diapers unless specifically covered
    by this Certificate (e.g., correctional shoes or inserts
    associated with diabetes are covered).
    
    
17. Corrective Appliances and Artificial Aids. Including, but
    not limited to, communications devices, eyeglasses or
    contact lenses of any type except for treatment of
    keratoconus and initial replacements for loss of the natural
    lens.
    
    
18. Cosmetic Surgery. Services and supplies, including
    cosmetic surgery and any complications therefrom, furnished
    mainly to change a person's appearance are excluded. This
    includes surgery performed to treat a mental, psychoneurotic
    or personality disorder through change in appearance,
    subject to review for Medical Necessity and appropriateness.
    
    
19. Custodial Care. Services or supplies furnished in
    connection with Custodial Care.
    
    
20. Dental care, Oral Surgery or Treatment of Teeth or
    Periodontium. Services and supplies not covered unless
    the services (i) are for Medically Necessary diagnostic
    and/or surgical treatment of the temporomandibular (jaw or
    craniomandibular) joint (TMJ); or (ii) are received in
    connection with an Injury to sound natural teeth except for an
    Injury resulting from biting or chewing. See Section II.B,
    Covered Services and Supplies.
    
    Dental braces, dental implants or any treatment related to
    the preparation or fitting of dentures are not covered, unless
    covered by a Rider to the Group Contract. Oral appliances
    and devices to treat bruxism, or as part of an orthodontia
    care plan are not covered, unless covered by a Rider to the
    Group Contract.
    
    Community First will not exclude a member from coverage
    who is unable to undergo dental treatment in an office
    setting or under local anesthesia due to a documented
    physical, mental, or medical reason as determined by the
    Member’s PCP and the dentist.
    
    
21. Diagnostic Tests to establish paternity of a child and tests
    to determine sex of an unborn child.
    
    
22. Educational Testing and Therapy, motor or language skills
    or services that are educational in nature or are for
    vocational testing or training.
    
    
23. Environmental consultations and modifications.
    Consultations of an environmental engineer, air conditioners,
    humidifiers, dehumidifiers, purifiers, elevators and chair lifts.
    
    
24. Experimental or Investigational Services and Supplies.
    Including new and emerging health care technologies, that
    are determined by Community First to be Experimental or
    Investigational.
    
    Community First may, however, deem an Experimental or
    Investigational service or supply covered for treating a Life-
    Threatening Illness or condition if it is determined by
    Community First, through an Ombudsman Program, that the
    
    Experimental or Investigational service or supply at the time
    of the determination:
    
    (1) is proved to be safe with promising efficacy; and
    (2) is provided in a clinically controlled research setting;
    and
    (3) uses a specific research protocol that meets
    standards equivalent to those defined by the National
    Institutes of Health.
    
    
25. Eye Surgery. Services and supplies furnished in connection
    with eye surgery such as radial keratotomy, when the
    primary purpose is to correct myopia (nearsightedness),
    hyperopia (farsightedness) or astigmatism (blurring).
    
    
26. Foot Care. Routine foot care, treatment of flat feet and
    treatment of subluxations of the feet are excluded.
    Orthopedic shoes are not covered, except as part of an
    integral part of a medically necessary leg brace.
    
    
27. Home and Automobile Modifications or Improvements
    even when necessary to accommodate installation of
    Covered Services or to facilitate entrance or exit.
    
    
28. Hospital Private Room unless determined to be Medically Necessary by Community First. See Covered Services.
    
    
29. Infertility Diagnosis and Treatment. Services or supplies
    furnished in connection with any procedures which involve
    harvesting, storage and/or manipulation of eggs and sperm
    for in-vitro fertilization. Other procedures excluded, but are
    not limited to:
    
    

    (1)	In-vitro fertilization;
    (2)	Artificial insemination;
    (3)	Gamete or zygote intrafallopian transfer and similar procedures;
    (4)	Reversal of voluntarily induced sterility;
    (5)	Surrogate parent services and fertilizations;
    (6)	Donor egg or sperm;
    (7)	Embryo transfer;
    (8)	Embryo freezing. Infertility benefits also excluded from coverage include transsexual surgery, gender reassignment, and any services or supplies used in any procedures performed in preparation for or immediately after any of the above-referenced excluded procedures.

30. Infertility Drugs. Drug therapy for infertility which involves:
    (1) non-FDA approved indications;
    (2) non-standard dosages, length of treatment, or cycles
    of therapy;
    (3) in-vitro fertilization procedures.
    
    
31. Manipulative Therapy. Services and supplies furnished in
    connection with correction, by manual or mechanical means,
    of subluxation of the spine.
    
    
32. Medical record charges associated with copying or
    transferring medical records.
    
    
33. Military Service Connected Disabilities. Services and
    supplies furnished in connection with military service
    connected disabilities for which the Member is legally entitled
    to services and for which facilities are reasonably available
    to the Member.
    
    
34. Newborn Baby. Any charges incurred by a non-enrolled
    newborn baby beyond thirty-one (31) days of its birth, unless
    the parent Member notifies Community First and the
    Contract Holder during the initial thirty-one (31) days after
    the birth of the child.
    
    
35. Obesity. All treatment, services, surgical or invasive
    procedures intended for treatment of obesity.
    
    
36. Over-the-counter Medications and Supplies. Any care,
    treatment, service, supply or item that is available without a
    Physician’s recommendation or written prescription,
    including a dietary formula, is excluded unless expressly
    covered by this Certificate of Group Health Care Coverage
    (e.g., over-the-counter diabetic supplies are covered and
    Copayments will count toward Your out-of-pocket maximum,
    as are dietary formulas necessary for the treatment of
    Phenylketonuria and other Heritable Diseases).
    
    
37. Personal Comfort Items. Including but not limited to,
    personal care kits provided on Admission, telephone,newborn infant photographs, meals for guests of the patient, cots, maternity and paternity kits, and other articles which
    are not determined to be Medically Necessary or appropriate
    for the specific treatment of the Illness or Injury.
    
    
38. Physical Examinations provided solely for the purposes of
    travel, employment or school.
    
    
39. Public Facility. Services and supplies furnished in
    connection with conditions that state or local law requires be
    treated in a public facility.
    
    
40. Reconstructive Surgery for Craniofacial Abnormalities
    for anyone 18 years of age or older. See Covered
    Services.
    
    
41. Reduction Mammoplasty for cosmetic purposes, except for
    post-mastectomy reduction of the unaffected breast to
    achieve a symmetricial appearance.
    
    
42. School-based Therapy Services.
    
    
43. Services and Supplies that meet the following conditions:
    

    (1)	Unnecessary services and supplies that are not Medically Necessary or appropriate for the diagnosis and/or treatment of an Illness or Injury. Examples are rubber sheets, incontinent pads, diapers, nonsterile rubber gloves, emesis basins, powder, Band- Aids, tape, gauze bandages, ACE bandages, elastic joint supports, TED hose, paper towels, etc.
    (2)	Required by a court decree regarding a divorce action, a motor vehicle violation or other judgment not directly related to this Coverage, if they would not be covered in the absence of such a decree.
    (3)	Related to preservation and/or storage of body parts, fluids or tissues, except for autologous blood and related collection and storage costs in connection with covered non-eperimental services and supplies.
    (4)	Not furnished or authorized by a PCP.
    (5)	Furnished for Cosmetic Surgery except what is listed under Covered Services.
    (6)	Over-the-counter supplies.
    (7)	Received from a Nurse which do not require the skill and training of a Nurse.

    
    
44. Sex Changes. All services, medications and/or supplies
    furnished in conjunction with the sex change process. This
    includes hormonal medications required before and after
    surgery.
    
    
45. Smoking Cessation. Any service furnished in connection
    with a smoking cessation program.
    
    
46. Vocational Rehabilitation. Education or training for the
    purpose of gaining employment.
    
    
47. Voluntary Sterilization Reversal. Reversal of a previous
    Surgical Procedure intended to induce permanent infertility.
    
    
48. Work Related Injury or Illness. Services and supplies for
    any work-related injury if any other source of coverage or
    reimbursement which is in force and in effect for the
    services. Sources of coverage or reimbursement available to
    You may include Your employer, a work-related benefit plan
    maintained by Your employer, and any Workers’
    Compensation, occupational disease or similar program
    under local, state, or federal law.