75 The information considered or reviewed to decide whether a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is Experimental or Investigational under the above criteria may include one or more items from the following list which is not all inclusive: • published authoritative, peer-reviewed medical or scientific literature, or the absence thereof; or • evaluations of national medical associations, consensus panels, and other technology evaluation bodies; or • documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate, or investigate the use of the Drug, biologic, device, Diagnostic, product, equipment, procedure, treatment, service, or supply; or • documents of an IRB or other similar body performing substantially the same function; or • consent document(s) and/or the written protocol(s) used by the treating Physicians, other medical professionals, or facilities or by other treating Physicians, other medical professionals or facilities studying substantially the same Drug, biologic, device, Diagnostic, product, equipment, procedure, treatment, service, or supply; or • medical records; or • the opinions of consulting Providers and other experts in the field. The Plan has the sole authority and discretion to identify and weigh all information and decide all questions pertaining to whether a Drug, biologic, device, Diagnostic, product, equipment, procedure, treatment, service, or supply is Experimental or Investigational.

Benefit Booklet: Plan 2 - Page 76 Benefit Booklet: Plan 2 Page 75 Page 77