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HomeMy WebLinkAboutEmployee Healthcare ContractADOPTION The City of Jeffersonville has caused this City of Jeffersonville Employee Health Plan (Plnrr) to take effect as of the first day of January, 2010, at Jeffersonville, Indiana. I have read the document herein and certify the document reflects the terms and conditions of the employee welfare benefit plan as established by the City of Jeffersonville. `~ `~ Y: ~ DATE: t~ `~ City of Jeffersonville,~Changes from 2009 Humana Plan Document to 2010 PHP Plan Document Cover Page Changed Plan Number to 4097 and removed Package ID Number Page 3 #6 changed effective date from 2009 to 2010 #9 changed Plan Manager from Humana to Preferred Health Plan Page 7 Under Dependent #2 -changed limiting age for each dependent child to be end of calendar year of his/her 25th birthday, regardless of full time student status (changed per Indiana laws) Page 11 Removed Personal Nurse® and changed Plan Manager to Preferred Health Plan Page 17 Pre-Existing changed #4 to read Offer to request a certificate of prior creditable coverage from you. Page 18 Paragraph under #3 -removed pay stubs showing a payroll deduction of premium for health plan coverage and information obtained by telephone. Page 21 Removed reference to Personal Nurse® Page 23 Removed reference to Personal Nurse® Page 25 Changed Humana's sole discretion to Preferred Health Plan's sole discretion Changed phone number from Humana to MedWatch Page 27 Par Provider Directory -removed Humana website and added PHP website and removed or to request a directory to or your Human Resource Manager. Page 29 Paragraph #2 under Individual Out of Pocket Limit -removed chemical dependence and alcoholism expenses (changed per Mental Health Parity Act) Paragraph #2 under Family Out of Pocket Limit -removed chemical dependence and alcoholism expenses (changed per Mental Health Parity Act) Page 31 Benefit Box for Non-PAR Provider -Emergency Room -Removed 80%, added 100% of billed charges, and added after any national network discount Page 39 Removed reference to HumanaBeginnings® Page 45 Organ Transplant Benefit -changed phone number from Humana to PHP Page 47/48 Covered Services -Removed all references to Humana National Transplant Network Page 48 Behavioral Health Benefit (changed per Mental Health Parity Act) Page 49 Benefit Box above Outpatient Benefits -changed benefits from Par Provider @ 80% to 100% and Non-Par Provider from Not Covered to 80% after $500 copay per admission. Removed * comment under box Limitations on Mental Disorder, Chemical Dependence or Alcoholism Benefits - Removed marriage counseling Benefit Box for Outpatient Benefits -Non-Par Provider changed from Not Covered to 80% and removed * comment under box. Page 51 #1 in the middle of the page to now read: Elective Sterilizations; reversal of sterilization limited to one per lifetime regardless of network participation; and Benefit Box for PAR Providers -Added Reversal of Sterilizations (limited to 1 per lifetime) 80% after deductible Page 52 Benefit Box for Non-PAR Providers -Added Reversal of Sterilizations (limited to 1 per lifetime) 60% after deductible Page 54 Removed #11, #17 and #18 Page 66 Plan Contract Information -Changed to PHP Page 78 Claim Procedures -removed Humana information and added PHP Page 82 Appeals of Adverse Determinations -removed Humana information and added PHP Page 87 Schedule of Prescription Benefits -Changed the following: NOTE: Additional drug information can be obtained by contacting Partners Rx at 800-711-4550 Page 89 Prescription Drug Benefits -removed Humana information and added PHP Under Prior Authorization and Dispensing Limits changed Humana Partners Rx; removed the back of and or visit the Plan Manger's website at www.humana.com Page 90 Mail Order Pharmacy -changed last paragraph to read: Additional mail order pharmacy information can be obtained through your Human Resources Department or by calling the toll free customer service phone number for Partners Rx on your ID card. Page 91 Prescription Drug Coverage -removed the Humana information Page 92 Prescription Drug Limitation -- #1 removed Humana information and the back of; or visit the Plan Manger's website at www.humana.com PLAN DESCRIPTION INFORMATION SUMMARY PLAN DESCRIPTION For the PPO PLAN A Sponsored by CITY OF JEFFERSONVILLE The Plan Sponsor has established and continues to maintain this Group Health Plan (the "Plan.") for the benefit of its employees and their eligible dependents as provided in this document. Benefits under this Plan are provided on aself-insured basis, which means that payment for benefits is ultimately the sole financial responsibility of the Plan Sponsor. Certain administrative services with respect to the Plan, such as claims processing, are provided under a services agreement. The Plan Manager is not responsible, nor will it assume responsibility, for benefits payable under the Plan. Any changes in the Plan, as presented in this Summary Plan Description, must be properly adopted by the Plan Sponsor, and material modifications must be timely disclosed in writing and included in or attached to this document. A verbal modification of the Plan, or promise having the same effect, made by any person will not be binding with respect to the Plan. Services are subject to all provisions of the Plan, including the limitations and exclusions. Italicized terms within the text are defined in the Definitions section of this booklet. Plan Number: 4097 PLAN DESCRIPTION INFORMATION PLAN DESCRIPTION INFORMATION 3 DEFINITIONS 5 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE 15 PRECERTIFICATION 21 UTILIZATION MANAGEMENT 23 SCHEDULE OF BENEFITS 26 OTHER COVERED EXPENSES 50 LIMITATIONS AND EXCLUSIONS 53 TERMINATION OF COVERAGE 59 IMPORTANT NOTICE FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER 60 THE CONSOLH)ATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986 61 THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) 67 COORDINATION OF BENEFITS 68 REIMBURSEMENT/SUBROGATION 71 GENERAL PROVISIONS 73 CLAIM PROCEDURES 77 PRESCRIPTION DRUG BENEFIT 86 '~ PLAN DESCRIPTION INFORMATION I' 1. Proper Name of Plan: City of Jeffersonville Employee Health Plan 2. Plan Sponsor and Employer: City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 This Plan is maintained under a collective bargaining agreement. A copy of the agreement may be obtained on written request and is available for examination. 3. Plan Administrator and Named Plan Fiduciary: City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 4. Employer Identification Number: 35-6001067 5. The Plan provides medical and prescription drug benefits for participating employees and their enrolled dependents. 6. Plan benefits described in this booklet are effective January 1, 2010. 7. The Plan year and fiscal year are January 1 through December 31 of each year. 8. Service of legal process may be served upon the Plan Administrator as shown above or the following agent for service of legal process: City Attorney City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 9. The Plan Manager is responsible for performing certain delegated administrative duties, including the processing of claims. The Plan Manager and Claim Fiduciary is: Preferred Health Plan, Inc. P. O. Box 437017 Louisville KY 40253-7017 502-339-7500 3 PLAN DESCRIPTION INFORMATION (continued) 10. This is aself-insured and self-administered health benefit plan. The cost of the Plan is paid with contributions shared by the employer and employee. Benefits under the Plan are provided from the general assets of the employer and are used to fund payment of covered claims under the Plan plus administrative expenses. Please see your employer for the method of calculating contributions and the funding mechanism used for the accumulation of assets through which benefits are provided under this Plan. 11. Each employee of the employer who participates in the Plan receives a Summary Plan Description, which is this booklet. This booklet will be provided to employees by the employer. It contains information regarding eligibility requirements, termination provisions, a description of the benefits provided and other Plan information. 12. The Plan benefits and/or contributions may be modified or amended from time to time, or may be terminated at any time by the Plan Sponsor. Significant changes to the Plan, including termination, will be communicated to participants as required by applicable law. 13. Upon termination of the Plan, the rights of the participants to benefits are limited to claims incurred and payable by the Plan up to the date of termination. Plan assets, if any, will be allocated and disposed of for the exclusive benefit of the participating employees and their dependents covered by the Plan, except that any taxes and administration expenses may be made from the Plan assets. 14. The Plan does not constitute a contract between the employer and any covered person and will not be considered as an inducement or condition of the employment of any employee. Nothing in the Plan will give any employee the right to be retained in the service of the employer, or for the employer to discharge any employee at any time. It is provided, however, that the foregoing will not modify the provisions of any collective bargaining agreement which may be made by the employer with the bargaining representative of any employees. A copy of the collective bargaining agreement will be made available by the employer for review, upon written request. 15. This Plan is not in lieu of and does not affect any requirement for coverage by Workers' Compensation insurance. DEFINITIONS A Active states means performing on a regular, full-time basis all customary occupational duties, for 30 hours per week, at the employer's business locations or when required to travel for the employer's business purposes. Each day of a regular paid vacation and any regular non-working holiday will be deemed active status if you were in an active status on your last regular working day prior to the vacation or holiday. Alternative medicine means an approach to medical diagnosis, treatment or therapy that has been developed or practiced NOT using the generally accepted scientific methods in the United States of America. For purposes of this definition, alternative medicine shall include, but is not limited to: acupressure, acupuncture, aroma therapy, ayurveda, biofeedback, faith healing, guided mental imagery, herbal medicine, holistic medicine, homeopathy, hypnosis, macrobiotics, naturopathy, ozone therapy, reflexotherapy, relaxation response, rolfing, shiatsu and yoga. B Beneficiary means you and your covered dependent(s), or legal representative of either, and anyone to whom the rights of you or your covered dependent(s) may pass. Bodily injury means injury due directly to an accident and independent of all other causes. Muscle strain due to athletic or physical activity is considered a sickness. C Calendar year means a period of time beginning on January 1 and ending on December 31. Claimant means a covered person (or authorized representative) who files a claim. COBRA Service Provider means a provider of COBRA administrative services retained by the Plan Manager to provide specific COBRA administrative services. Complications of pregnancy means: 1. Conditions whose diagnoses are distinct from pregnancy but adversely affected by pregnancy or caused by pregnancy. Such conditions include: acute nephritis, nephrosis, cardiac decompensation, hyperemesis gravidarum, puerperal infection, toxemia, eclampsia and missed abortion; 2. A nonelective cesarean section surgical procedure; 3. Terminated ectopic pregnancy; or 4. Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible. DEFINITIONS (continued) Complications of pregnancy does not mean: 1. False labor; 2. Occasional spotting; 3. Prescribed rest during the period of pregnancy; 4. Conditions associated with the management of a difficult pregnancy but which do not constitute distinct complications of pregnancy; or An elective cesarean section. Concurrent care decision means a decision by the Plan to reduce or terminate benefits otherwise payable for a course of treatment that has been approved by the Plan (other than by Plan amendment or termination) or a decision with respect to a request by a claimant to extend a course of treatment beyond the period of time or number of treatments that has been approved by the Plan. Concurrent review means the process of assessing the continuing medical necessity, appropriateness, or utility of additional days of hospital confinement, outpatient care, and other health care services. Confinement means being a resident patient in a hospital or a qualified treatment facility for at least 15 consecutive hours per day. Successive confinements are considered one confinement i£ Due to the same bodily injury or sickness; and Separated by fewer than 30 consecutive days when you are not confined. Copayment, if applicable, means the amount to be paid by you for each applicable medical service Cosmetic surgery means surgery performed to reshape structures of the body in order to change your appearance or improve self-esteem. Covered expense means services incurred by you or your covered dependents due to bodily injury or sickness for which benefits may be available under the Plan. Covered expenses are subject to all provisions of the Plan, including the limitations and exclusions. Covered person means the employee or any of the employee's covered dependents. Creditable coverage means the total time of prior continuous health plan coverage periods used to reduce the length of any pre-existing condition limitation period applicable to you or your dependents under this Plan where these prior continuous health coverages) existed with no more than a 63-consecutive day lapse in coverage. Custodial care means services provided to assist in the activities of daily living which are not likely to improve your condition. Examples include, but are not limited to, assistance with dressing, bathing, toileting, transferring, eating, walking and taking medication. These services are considered custodial care regardless if a qualified practitioner or provider has prescribed, recommended or performed the services. DEFINITIONS (continued) D Dental injccry is an injury caused by a sudden, violent, and external force that could not be predicted in advance and could not be avoided. Dental injury does not include chewing injuries. Dependent means a covered employee's: 1. Legally recognized spouse; 2. Unmarried natural blood related child, step-child, legally adopted child or child placed with the employee for adoption, or child for which the employee has legal guardianship whose age is less than the limiting age. Each child must legally qualify as a dependent as defined by the United States Internal Revenue Service and be declared on and legally qualify as a dependent on the employee's federal personal income tax return filed for each year of coverage. The limiting age for each dependent child is: a. to the end of the calendar year of his/her 25~' birthday; or b. to the end of the calendar year of his/her 25~' birthday, if such child is in regular full-time attendance at an accredited secondary school, college or university. The dependent child must be enrolled for sufficient course credits to maintain full-time status as defined by that school. A dependent child continues to be eligible for coverage for up to four months following the close of a school term only if enrolled as a full-time student for the following school term. Adopted children and children placed for adoption are subject to all terms and provisions of the Plan, with the exception of the pre-existing condition limitation. A covered employee's child whose age is less than the limiting age and is entitled to coverage under the provisions of this Plan because of a medical child support order; You must furnish satisfactory proof, upon request, to the Plan Manager that the above conditions continuously exist. If satisfactory proof is not submitted to the Plan Manager, the child's coverage will not continue beyond the last date of eligibility. A covered dependent child who attains the limiting age while covered under the Plan will remain eligible for benefits if all of the following exist at the same time: 1. Mentally retarded or permanently physically handicapped; 2. Incapable of self-sustaining employment; 3. The child meets all of the qualifications of a dependent as determined by the United States Internal Revenue Service; 4. Declared on and legally qualify as a dependent on the employee's federal personal income tax return filed for each year of coverage; and 5. Unmarried. DEFINITIONS (continued) You must furnish satisfactory proof to the Plan Manager that the above conditions continuously exist on and after the date the limiting age is reached. The Plan Manager may not request such proof more often than annually after two years from the date the first proof was furnished. If satisfactory proof is not submitted to the Plan Manager, the child's coverage will not continue beyond the last date of eligibility. Durable medical equipment (DME) means equipment that is medically necessary and able to withstand repeated use. It must also be primarily and customarily used to serve a medical purpose and not be generally useful to a person except for the treatment of a bodily injury or sickness. E Emergency means an acute, sudden onset of a sickness or bodily injury which is life threatening or will significantly worsen without immediate medical or surgical treatment. Employee means you, as an employee, when you are permanently employed and paid a salary or earnings and are in an active status at your employer's place of business. Employer means the sponsor of the Group Plan or any subsidiary(s). Expense incurred means the fee charged for services provided to you. The date a service is provided is the expense incurred date. Experimental, investigational or for research purposes: A service is experimental, investigational or for research purposes if the Plan Manager determines; The service cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the service is furnished; or 2. The service or your informed consent document utilized with the service was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review and approval; or Reliable evidence shows that the service is the subject of on-going phase I or phase II clinical trials; is the research, experimental, study or investigational arm of ongoing phase III clinical trials; or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis; or Reliable evidence shows that the prevailing opinion among experts regarding the service is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or Reliable evidence will mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same service; or the written informed consent used by the treating facility or by another facility studying substantially the same service. rr,. DEFINITIONS (continued) >.. F Family member means you or your spouse, or you or your spouse's child, brother, sister, parent, grandchild or grandparent. Free-standing surgical facility means a public or private establishment licensed to perform surgery and which has permanent facilities that are equipped and operated primarily for the purpose of performing surgery. It does not provide services or accommodations for patients to stay overnight. Functional impairment means a direct and measurable reduction in physical performance of an organ or body part. H Hospital means an institution which: Maintains permanent full-time facilities for bed care of resident patients; 2. Has a physician and surgeon in regular attendance; Provides continuous 24 hour a day nursing services; Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care of sick or injured persons; Is legally operated in the jurisdiction where located; and 6. Has surgical facilities on its premises or has a contractual agreement for surgical services with an institution having a valid license to provide such surgical services; or Is a lawfully operated qualified treatment facility certified by the First Church of Christ Scientist, Boston., Massachusetts. Hospital does not include an institution which is principally a rest home, skilled nursing facility, convalescent home or home for the aged. Hospital does not include a place principally for the treatment of alcoholism, chemical dependence or mental disorders. L Late applicant means an employee and/or an employee's eligible dependent who applies for medical coverage more than 31 days after the eligibility date. DEFINITIONS (continued) ~. M Maintenance care means any service or activity which seeks to prevent bodily injury or sickness, prolong life, promote health or prevent deterioration of a covered person who has reached the maximum level of improvement or whose condition is resolved or stable. Maximum allowable fee for a service means the lesser o£ 1. The fee most often charged in the geographical area where the service was performed; 2. The fee most often charged by the provider; 3. The fee which is recognized as reasonable by a prudent person; 4. The fee determined by comparing charges for similar services to a national data base adjusted to the geographical area where the services or procedures were performed; or 5. The fee determined by using a national relative value scale. Relative value scale means a methodology that values medical procedures and services relative to each other that includes, but is not limited to, a scale in terms of difficulty, work, risk, as well as the material and outside costs of providing the service, as adjusted to the geographic area where the services or procedures were performed. Maximllm benefit means the maximum amount that may be payable for each covered person, for expense incurred. The applicable maximum benefit is shown on the Schedule of Benefits. No further benefits are payable once the maximum benefit is reached. Medically necessary or medical necessity means the extent of services required to diagnose or treat a bodily injury or sickness which is known to be safe and effective by the majority of qualified practitioners who are licensed to diagnose or treat that bodily injury or sickness. Such services must be: 1. Performed in the least costly setting required by your condition; 2. Not provided primarily for the convenience of the patient or the qualified practitioner; 3. Appropriate for and consistent with your symptoms or diagnosis of the sickness or bodily injury under treatment; 4. Furnished for an appropriate duration and frequency in accordance with accepted medical practices, and which are appropriate for your symptoms, diagnosis, sickness or bodily injury; and 5. Substantiated by the records and documentation maintained by the provider of service. Medicare means Title XVIII, Parts A and B of the Social Security Act, as enacted or amended. Mental disorder means a mental, nervous, or emotional disease or disorder of any type as classified in the Diagnostic and Statistical Manual of Mental Disorders, regardless of the cause or causes of the disease or disorder. 10 DEFINITIONS (continued) Morbid obesity means a body mass index (BMI) of 40 kilograms per mass squared or 100 pounds or more over your ideal weight as determined by the Metropolitan Life Height and Weight Tables for Men and Women, as of the date of service. Orthotic means acustom-fitted or custom-made braces, splints, casts, supports and other devices used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body when prescribed by a qualified practitioner. P Partial hospitalization means those services offered by a program: 1. Must be medically necessary; and 2. Not custodial care; and 3. Not day-care; and 4. Accredited by the Joint Commission on the Accreditation of Hospitals or in compliance with equivalent standards. Licensed drug abuse rehabilitation programs and alcohol rehabilitation programs accredited by the Joint Commission on the Accreditation of Health Care Organizations or approved by the appropriate state agency are also considered to be partial hospitalization services. Plan Manager means Preferred Health Plan Inc. The Plan Manager provides services to the Plan Administrator, as defined under the Plan Management Agreement. The Plan Manager is not the Plan Administrator or the Plan Sponsor. Plan year means a period of time beginning on the Plan anniversary date of any year and ending on the day before the same date of the succeeding year. Post-service claim means any claim for a benefit under a group health plan that is not apre-service claim. Preadmission testing means only those outpatient x-ray and laboratory tests made within seven days before admission as a registered bed patient in a hospital. The tests must be for the same bodily injury or sickness causing the patient to be hospital confined. The tests must be accepted by the hospital in lieu of like tests made during confinement. Preadmission testing does not mean tests for a routine physical check-up. 11 DEFINITIONS (continued) Precertification means the process of assessing the medical necessity, appropriateness, or utility of proposed non-emergency hospital admissions, surgical procedures, outpatient care, and other health care services. Predetermination of benefits means a review by the Plan Manager of a gz~alified practitioner's treatment plan, specific diagnostic and procedure codes and expected charges prior to the rendering of services. Pre-existing condition means a physical or mental condition for which you have received medical attention (medical attention includes, but is not limited to: services or care) during the six month period immediately prior to the enrollment date of your medical coverage under this Plan. Pre-existing conditions are covered after the end of a period of twelve months after the enrollment date (first day of coverage or, if there is a waiting period, the first day of the waiting period). Pre-existing condition limitations will be waived or reduced for pre-existing conditions that were satisfied under previous creditable coverage. Pre-service claim means a claim with respect to which the terms of the Plan condition receipt of a Plan benefit, in whole or in part, on approval of the benefit by the Plan Manager in advance of obtaining medical care. Protected health information means individually identifiable health information about a covered person, including: (a) patient records, which includes but is not limited to all health records, physician and provider notes and bills and claims with respect to a covered person; (b) patient information, which includes patient records and all written and oral information received about a covered person; and (c) any other individually identifiable health information about covered persons. Q Qualified practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or sickness, and who provides services within the scope of that license. Qualified treatment facility means only a facility, institution or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license. s Services means procedures, surgeries, examinations, consultations, advice, diagnosis, referrals, treatment, tests, supplies, drugs, devices or technologies. Sickness means a disturbance in function or structure of your body which causes physical signs or symptoms and which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of your body. 12 DEFINITIONS (continued) Sound naticral tooth means a tooth that: Is organic and formed by the natural development of the body (not manufactured); Has not been extensively restored; Has not become extensively decayed or involved in periodontal disease; and 4. Is not more susceptible to injury than a whole natural tooth. Sr~rgery means excision or incision of the skin or mucosal tissues, or insertion for exploratory purposes into a natural body opening. This includes insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other therapeutic purposes. T Timely applicant means an employee and/or an employee's eligible dependent who applies for medical coverage within 31 days of the eligibility date. Total disability or totally disabled means: During the first twelve months of disability you or your employed covered spouse are at all times prevented by bodily injury or sickness from performing each and every material duty of your respective job or occupation; 2. After the first twelve months, total disability or totally disabled means that you or your employed covered spouse are at all times prevented by bodily injury or sickness from engaging in any job or occupation for wage or profit for which you or your employed covered spouse are reasonably qualified by education, training or experience; For anon-employed spouse or a child, total disability or totally disabled means the inability to perform the normal activities of a person of similar age and gender. A totally disabled person also may not engage in any job or occupation for wage or profit. V Urgent care claim means a claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations: Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or 2. In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim; or 13 DEFINITIONS (continued) 3. Generally, whether a claim is a claim involving urgent care will be determined by the Plan Manager. However, any claim that a physician with knowledge of a claimant's medical condition determines is a "claim involving urgent care" will be treated as a "claim involving urgent care." Utilization review means the process of assessing the medical necessity, appropriateness, or utility of hospital admissions, surgical procedures, outpatient care, and other health care services. Utilization review includes precertification and concurrent review. Y YOlI and your means you as the employee and any of your covered dependents, unless otherwise indicated. 14 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE OPEN ENROLLMENT Once annually yozc will have a choice of enrolling yourself and your eligible dependents in this Plan. You will be notified in advance when the open enrollment period is to begin and how long it will last. If you decline coverage for yourself or your dependents at the time you are initially eligible for coverage, you will be able to enroll yourself and/or eligible dependents during the Open Enrollment Period. Your coverage will be subject to the pre-existing condition limitation. EMPLOYEE ELIGIBILITY You are eligible for coverage if the following conditions are met: Yoac are an eligible employee as defined in the Personnel Policy Manual or City Ordinance. Temporary, seasonal, or part-time employees are not eligible for health benefits; or 2. You are an elected or appointed official; and 3. You are in active status. Your eligibility date is your date of hire. EMPLOYEE EFFECTIVE DATE OF COVERAGE You must enroll in a manner acceptable to the Plan Manager. 1. If your completed enrollment is received by the Plan Manager before your eligibility date or within 31 days after your eligibility date, your coverage is effective on your eligibility date; 2. If your completed enrollment is received by the Plan Manager more than 31 days after your eligibility date, you are a late applicant and your coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Coverage will be effective immediately following receipt of your completed enrollment. EMPLOYEE DELAYED EFFECTIVE DATE If the employee is not in active status on the effective date of coverage, coverage will be effective the day the employee returns to active status. The employer must notify the Plan Manager in writing of the employee's return to active status. DEPENDENT ELIGIBILITY Each dependent is eligible for coverage on: The date the employee is eligible for coverage, if he or she has dependents who may be covered on that date; or The date of the employee's marriage for any dependent acquired on that date; or The date of birth of the employee's natural-born child; or 15 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) 4. The date a child is placed for adoption under the employee's legal guardianship, or the date which the employee incurs a legal obligation for total or partial support in anticipation of adoption; or 5. The date a covered employee's child is determined to be eligible as an alternate recipient under the terms of a medical child support order. The covered employee may cover dependents only if the .employee is also covered. Check with your employer immediately on how to enroll for dependent coverage. Late enrollment will result in your dependents' coverage being subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. No person may be simultaneously covered as both an employee and a dependent. If both parents are eligible for coverage, only one may enroll for dependent coverage. DEPENDENT EFFECTIVE DATE OF COVERAGE If the employee wishes to add a newborn dependent to the Plan and a change in the employee's level of coverage is not required, enrollment must be completed and submitted to the Plan Manager. The newborn dependent will be covered on the date he or she is eligible. If the employee wishes to add a dependent (other than a newborn) to the Plan and a change in the employee's level of coverage is not required, the dependent's effective date of coverage is determined as follows: If the completed enrollment is received by the Plan Manager before the dependent's eligibility date or within 31 days after the dependent's eligibility date, that dependent is covered on the date he or she is eligible; 2. If the completed enrollment is received by the Plan Manager more than 31 days after the dependent's eligibility date, the dependent is a late applicant. The dependent's coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Coverage will be effective the first of the month following receipt of the dependent's completed enrollment. No dependent's effective date will be prior to the covered employee's effective date of coverage. A dependent child who becomes eligible for other group coverage through any employment is no longer eligible for coverage under this Plan. If your dependent child becomes an eligible employee of the employer, he or she is no longer eligible as your dependent and must make application as an eligible employee. MEDICAL CHILD SUPPORT ORDERS An individual who is a child of a covered employee shall be enrolled for coverage under the Plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN). 16 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) A QMCSO is a state court order or judgment, including approval of a settlement agreement that: (a) provides for support of a covered employee's child; (b) provides for health care coverage for that child; (c) is made under state domestic relations law (including a community property law}; (d) relates to benefits under the Plan; and (e) is "qualified" in that it meets the technical requirements of applicable state law. QMCSO also means a state court order or judgment that enforces a state Medicaid law regarding medical child support required by Social Security Act §1908 (as added by Omnibus Budget Reconciliation Act of 1993). An NMSN is a notice issued by an appropriate agency of a state or local government that is similar to a QMCSO that requires coverage under the Plan for the dependent child of anon-custodial parent who is (or will become) a covered person by a domestic relations order that provides for health care coverage. Procedures for determining the qualified status of medical child support orders are available at no cost upon request from the Plan Administrator. PRE-EXISTING CONDITION LIMITATION Benefits for pre-existing conditions are limited under the Plan. Pre-existing condition is defined in the Definitions section of this booklet. Once you or your dependents obtain health plan coverage, you are entitled to use evidence of that coverage to reduce or eliminate any pre-existing condition limitation period that might otherwise be imposed when you become covered under a subsequent health plan. Evidence may include a certificate of prior creditable coverage. The length of any pre-existing condition limitation period under the subsequent health plan must be reduced by the number of days of creditable coverage. Prior to imposing apre-existing condition limitation, the Plan Manager will: 1. Notify you in writing of the existence and terms of any pre-existing condition limitation; 2. Notify you of your right to request a certificate of creditable coverage from any applicable prior plans; 3. Notify you of your right to submit evidence of creditable coverage to the Plan Manager to reduce the length of any pre-existing condition limitation; and 4. Offer to request a certificate of prior creditable coverage from you. If, after receiving evidence of creditable coverage, the Plan Manager determines the creditable coverage is not sufficient to completely offset the Plan's pre-existing condition limitation period, the Plan Manager will: L Notify you in writing of its determination; 2. Notify you of the source and substance of any information on which it relied; and 3. Provide an explanation of appeal procedures and allow a reasonable opportunity to submit additional evidence of creditable coverage. 17 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) The Plan Manager may modify an initial determination of creditable coverage if it determines the individual did not have the claimed creditable coverage, provided the Plan Manager: Notifies you of such reconsideration in writing disclosing its determination; 2. Notifies you with the source and substance of any information on which it relied; and Provides an explanation of appeal procedures and allows a reasonable opportunity to submit additional evidence of creditable coverage. Alternate means of providing evidence of creditable coverage may include an explanation of benefits, correspondence from a plan, third party statements verifying period(s) of coverage, and any other relevant document providing evidence of period(s) of health coverage. SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS If your employer continues to pay required contributions and does not terminate the Plan, your coverage will remain in force for: No longer than the end of the calendar month during part-time status; 2. No longer than the end of the calendar month during an approved leave of absence; No longer than the end of 18 months or the duration of an approved military leave of absence, whichever is shorter; 4. No longer than the end of the calendar month of a layoff; 5. No longer than the end of the calendar month during a period of total disability. REINSTATEMENT OF COVERAGE FOLLOWING INACTIVE STATUS If your coverage under the Plan was terminated after a period of layoff, total disability, approved leave of absence, approved military leave of absence (other than USERRA) or during part-time status, and you are now returning to work, your coverage is effective immediately on the day you return to work, subject to any pre-existing condition limitation. The eligibility period requirement will be waived with respect to the reinstatement of your coverage. If your coverage under the Plan was terminated due to a period of service in the uniformed services covered under the Uniformed Services Employment and Reemployment Rights Act of 1994, your coverage is effective immediately on the day you return to work. Eligibility waiting periods and pre- existing condition limitations will be imposed only to the extent they were applicable prior to the period of service in the uniformed services. 18 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) FAMILY AND MEDICAL LEAVE ACT (FMLA) If you are granted a leave of absence (Leave) by the employer as required by the Federal Family and Medical Leave Act, yoi~ may continue to be covered under the Plan for the duration of the Leave under the same conditions as other employees who are in active status and covered by the Plan. If you choose to terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required contribution, coverage may be reinstated on the date you return to active statics immediately following the end of the Leave. Charges incurred after the date of reinstatement will be paid as if you had been continuously covered. RETIREE COVERAGE If yoi~ are an early retiree under age 65 with at least 20 years of continuous service, you may continue coverage under the Plan with retiree benefits for you and any of your eligible dependents until you turn age 65, provided such coverage was effective at the time of your retirement. Please see your employer for more details. SURVIVORSHIP COVERAGE If the employee dies while covered under the Plan, the surviving spouse and any eligible dependents may continue coverage under the Plan as per federal, state stature, or city ordinance. Any dependents acquired through the remarriage of the employee's surviving spouse will not be eligible for coverage under the Plan. SPECIAL ENROLLMENT If you previously declined coverage under this Plan for yourself or any eligible dependents, due to the existence of other health coverage (including COBRA), and that coverage is now lost, this Plan permits you, your dependent spouse, and any eligible dependents to be enrolled for medical benefits under this Plan due to any of the following qualifying events: Loss of eligibility for the coverage due to any of the following: a. Legal separation; b. Divorce; c. Cessation of dependent status (such as attaining the limiting age); d. Death; e. Termination of employment; £ Reduction in the number of hours of employment; g. Meeting or exceeding a lifetime limit on all benefits; h. Plan no longer offering benefits to a class of similarly situated individuals, which includes the employee; i. Any loss of eligibility after a period that is measured by reference to any of the foregoing. However, loss of eligibility does not include a loss due to failure of the individual or the participant to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). 19 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) 2. Employer contributions towards the other coverage have been terminated. Employer contributions include contributions by any current or former employer (of the individual or another person) that was contributing to coverage for the individual. 3. COBRA coverage under the other plan has since been exhausted The previously listed qualifying events apply only if you stated in writing at the previous enrollment the other health coverage was the reason for declining enrollment, but only if your employer requires a written waiver of coverage which includes a warning of the penalties imposed on late enrollees. If you are a covered employee or an otherwise eligible employee, who either did not enroll or did not enroll dependents when eligible, you now have the opportunity to enroll yourself and/or any previously eligible dependents or any newly acquired dependents when due to any of the following changes: 1. Marriage; 2. Birth; 3. Adoption or placement for adoption; 4. Effective April 1, 2009: Loss of eligibility due to termination of Medicaid or State Children's Health Insurance Program (SCRIP) coverage; or 5. Effective April 1, 2009: Eligibility for premium assistance subsidy under Medicaid or SCRIP. You may elect coverage under this Plan provided enrollment is within 31 days from the qualifying event or 60 days from such event as identified in #4 and #5 above. You MUST provide proof that the qualifying event has occurred due to one of the reasons listed before coverage under this Plan will be effective. Coverage under this Plan will be effective the date immediately following the date of the qualifying event, unless otherwise specified in this section. In the case of a dependent's birth, enrollment is effective on the date of such birth In the case of a dependent's adoption or placement for adoption, enrollment is effective on the date of such adoption or placement for adoption. If yoz~ become eligible for coverage under this Plan through the special enrollment provision, benefits under the Plan will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. If you apply more than 31 days after a qualifying event or 60 days from such event as identified in #4 and #5 above, you are considered a late applicant and coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Please see your employer for more details 20 PRECERTIFICATION PRECERTIFICATION REQUIREMENTS Medical Management is a Utilization Revietiv service provided by the Plan Manager. The Medical Management unit will provide precertification as required by your Plan. Medical Management recommends calling as soon as possible to receive proper precertification. For precertification please call the toll-free number on the back of your ID card. The following benefits require precertification: INPATIENT HOSPITAL (INCLUDING INPATIENT BEHAVIORAL HEALTH) The Plan Manager must be notified at least 7 days in advance. If the admission is on an emergency basis, the Plan Manager must be notified within 48 hours or the first business day following admission. If the admission is not precertified, benefits for the hospital or qualified treatment facility will be subject to a $500 penalty per confinement. The penalty does not apply to the deductible or out-of-pocket maximums. OUTPATIENT SPEECH PHYSICAL AND OCCUPATIONAL THERAPY (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If therapy services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. OUTPATIENT SLEEP APENA (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. 21 PRECERTIFICATION (continued) OUTPATIENT PAIN MANAGEMENT (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. DURABLE MEDICAL EQUIPMENT The Plan Manager must be notified if the purchase or rental of durable medical equipment is expected to be $750 or more. If the purchase or rental of durable medical equipment does not have the Plan Manager's prior approval, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. HOME HEALTH CARE The Plan Manager must be notified prior to services being rendered. If home health care services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. SHILLED NURSING FACILITY The Plan Manager must be notified prior to services being rendered. If a skilled nursing facility is not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. HOSPICE CARE The Plan Manager must be notified prior to services being rendered. If hospice care services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. ORGAN TRANSPLANTS The Plan Manager must be notified prior to organ transplant services being rendered. If organ transplant services are not precertified, they are not covered. 22 UTILIZATION MANAGEMENT Utilization management services are designed to assist covered persons in making informed medical care decisions resulting in the delivery of appropriate levels of Plan benefits for each proposed course of treatment. These decisions are based on the medical information provided by the patient and the patient's physician. The patient and his or her physician determine the course of treatment. The assistance provided through these services does not constitute the practice of medicine. Payment of Plan benefits is not determined through these processes. PRECERTIFICATION Utilization review may include precertification and concurrent review. This provision will not provide benefits to cover a confinement or service which is not medically necessary or otherwise would not be covered under the Plan. Precertification is not a guarantee of coverage. If you or your covered dependent are to receive a service which requires precertification, you or your qualified practitioner must contact the Plan Manager, by telephone or in writing. Refer to the Precertification Requirements for time requirements. After you or your qualified practitioner have provided the Plan Manager, with your diagnosis and treatment plan, the Plan Manager will: Advise you by telephone, electronically, or in writing if the proposed treatment plan is medically necessary; and 2. Conduct concurrent review as necessary. If your admission is precertified by the Plan Manager, benefits are subject to all Plan provisions and are payable as shown on the Schedule of Benefits. If it is determined at any time your proposed treatment plan, either partially or totally, is not a covered expense under the terms and provisions of the Plan, benefits for services may be reduced or services may not be covered. PENALTY FOR NOT OBTAINING PRECERTIFICATION If you do not obtain precertification for services being rendered, your benefits for the qualified practitioner and hospital or qualified treatment facility may be reduced. Refer to the Precertification Requirements for the applicable penalty. 23 UTILIZATION MANAGEMENT (continued) SECOND SURGICAL OPINION A second surgical opinion may be required, as provided in the Plan, before the confinement will be precertified. Benefits for the second surgical opinion, including any medically necessary x-ray and laboratory tests performed by the second qualified practitioner, are payable as shown below. PAR Provider 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. If the two opinions disagree, you may obtain a third opinion. Benefits for the third opinion are payable the same as for the second opinion. The qualified practitioners providing the surgical opinions MUST NOT be in the same group practice or clinic. The qualified practitioner providing the second or third surgical opinion may confirm the need for surgery or present other treatment options. The decision whether or not to have the surgery is always yours. DISEASE MANAGEMENT The Disease Management Programs listed in this section are available to you and any eligible dependents covered by this Plan. These Disease Management Programs are provided at no cost to you. • Congestive Heart Failure: This program combines intervention, monitoring and education, which will enable you to take a more active role in managing your health. • Coronary Artery Disease: This program's objective is to promote good health through education, counseling and support. This program offers educational materials on diet, medication management, exercise and, if appropriate, smoking cessation. • End Stage Renal Disease: This program is designed to educate you and coordinate the multiple facets of your care. • Neonatal Intensive Care: This program combines care coordination and parent education to help improve the patient's outcome and reduce stress on the family. • Cancer: This program provides education, support and assistance regarding diagnosis and treatment of the patient's disease. • Chronic Kidney Disease: This program combines care coordination and education as the patient is guided through a 5-step process during the course of their treatment. 24 UTILIZATION MANAGEMENT (continued) Asthma: This program was developed to provide education. and environmental assessment of the patient's disease. This program also provides collaboration with the patient's physician to develop an appropriate treatment plan for controlling asthma. Diabetes: This program is designed to educate you and coordinate the multiple facets of your care. Rare Diseases (Amyotrophic Lateral Sclerosis, or Lou Gehrig's Disease; Chronic Inflammatory Demyelinating Disease (CIDP); Cystic Fibrosis; Dermatomyositis; Hemophilia; Multiple Sclerosis; Myasthenia Gravis; Parkinson's Disease; Polymyositis; Rheumatoid Arthritis; Scleroderma; Sickle Cell Disease; and Systemic Lupus): You will be educated on the specifics of your disease, the possible complications and the treatment options available. Certain programs may not be available in all areas. Specific programs and vendors may change at Preferred Health Plan's sole discretion. If you have any questions regarding the Disease Management Programs listed in this section, contact the Medical Management team at 1-800-432-8421 and one of the nurses will assist you. PREDETERMINATION OF MEDICAL BENEFITS You or your qualified practitioner may submit a written request for a predetermination of benefits. The written request should contain the treatment plan, specific diagnostic and procedure codes, as well as the expected charges. The Plan Manager will provide a written response advising if the services are a covered or non-covered expense under the Plan, what the applicable Plan benefits are and if the expected charges are within the maximum allotivable fee. The predetermination of benefits is not a guarantee of benefits. Services will be subject to all terms and provisions of the Plan applicable at the time treatment is provided. If treatment is to commence more than 90 days after the date treatment is authorized, the Plan Manager will require you to submit another treatment plan. 25 SCHEDULE OF BENEFITS COVERED AND NON-COVERED EXPENSES Benefits are payable only if services are considered to be a covered expense and are subject to the specific conditions, limitations and applicable maximums of the Plan. The benefit payable for covered expenses will not exceed the maximum allowable fee(s). A covered expense is deemed to be incurred on the date a covered service is received. The bill submitted by the provider, if any, will determine which benefit provision is applicable for payment of covered expenses. One copayment will be taken per visit per qualified practitioner. If you incur non-covered expenses, whether from a PAR provider or a Non-PAR provider, you are responsible for making the full payment to the health care provider. The fact that a qualified practitioner has performed or prescribed a medically appropriate procedure, treatment, or supply, or the fact that it may be the only available treatment for a bodily injury or sickness, does not mean that the procedure, treatment or supply is covered under the Plan. Please refer to the "Schedule of Benefits" and the "Limitations and Exclusions" sections of this Summary Plan Description for more information about covered expenses and non-covered expenses. PARTICIPATING AND NON-PARTICIPATING PROVIDERS The covered person has two (2) levels of benefits available -Participating Provider (PAR provider) benefits and Non-Participating Provider (Non-PAR provider) benefits. You may select any provider to provide your medical care. In most cases, if you receive services from a PAR provider, the Plan will pay a higher percentage of benefits and you will incur lower out-of-pocket costs. You are responsible for any applicable deductible, coinsurance and/or copayment. If you receive services from aNon-PAR provider, the Plan will pay benefits at a lower percentage and yozc will pay a larger share of the costs. Since Non-PAR providers do not have contractual arrangements with the Plan Manager to accept discounted or negotiated fees, they may bill you for charges in excess of the maximum allowable fee. You are responsible for charges in excess of the maximum allotivable fee in addition to any applicable deductible, coinsurance and/or copayment. Any amount you pay to the provider in excess of your coinsurance or copayment will not apply to your out-of-pocket limit or deductible. Not all qualified practitioners including, but not limited to, pathologists, anesthesiologists, radiologists, assistant surgeons and emergency room physicians, who provide services at PAR hospitals are PAR qualified practitioners. If services are provided to yozc by such Non-PAR qualified practitioners at a PAR hospital, the Plan will pay for those services at the PAR provider benefit percentage subject to the maximum allotivable fee. Non-PAR qualified practitioners may require payment from you for any amount not paid by the Plan. If possible, you may want to verify whether services are available from a PAR qualified practitioner. 26 SCHEDULE OF BENEFITS (continued) PAR PROVIDER DIRECTORY The Plan Administrator will automatically provide, without charge, information to you about how you can access a directory of PAR providers appropriate to your service area. An online directory of PAR providers is available to you and accessible via the Plan Manager's website at www.phpinc.com. This directory is subject to change. Due to the possibility of PAR providers changing status, please check the online directory of PAR providers prior to obtaining services. If you do not have access to the online directory, contact the Plan Manager at the customer service number on the back of your identification (ID) card prior to services being rendered or your Human Resource Manager. LIFETIME MAXIMUM BENEFIT Lifetime Maximum Benefit $2,000,000 per covered person. Lifetime maximum means the maximum amount of benefits available while you are covered under the Plan. Under no circumstances does lifetime mean during the lifetime of the covered person. INDIVIDUAL DEDUCTIBLE PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services No deductible. Other Medical Services $100 per covered person per calendar year. Non-PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Szzrgery No deductible. Hospital Physician Services $200 per covered person per calendar year. Other Medical Services $200 per covered person per calendar year. 27 SCHEDULE OF BENEFITS (continued) The deductible applies to each covered person each calendar year. Only charges which qualify as a covered expense may be used to satisfy the deductible. The amount of the deductible is stated above. You must satisfy the separate PAR or Non-PAR deductible before the Plan will pay any benefits. Copayments are not applied to the Individual Deductible limit. FAMILY DEDUCTIBLE PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services No deductible. Other Medical Services $200 per covered person per calendar year. Non-PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services $400 per covered person per calendar year. Other Medical Services $400 per covered person per calendar year. The total deductible applied to all covered persons in one family in a calendar year is subject to the maximum shown above. Only charges which qualify as a covered expense may be used to satisfy the deductible. You and yozzr covered dependents must satisfy the separate PAR or Non-PAR deductible before the Plan will pay any benefits. Copayments are not applied to the Family Deductible limit. 28 SCHEDULE OF BENEFITS (continued) INDIVIDUAL OUT-OF-POCKET LIMIT PAR Provider Non-PAR Provider $500 per calendar year. $500 per calendar year. When the amount of combined covered expenses paid by you satisfies the separate deductible and separate out-of-pocket limits as shown above, the Plan will pay 100% of covered expenses for the remainder of the calendar year, unless specifically indicated, subject to any calendar year maximums and the lifetime maximum of the Plan. If you use a combination of PAR and Non-PAR providers, the out-of-pocket amounts will track separately. Copayments and penalties are not applied to the Individual Out-of-Pocket Limit. FAMILY OUT-OF-POCKET LIMIT PAR Provider ~ $1,000 per calendar year. Non-PAR Provider ~ $1,000 per calendar year. When the amount of combined covered expenses paid by you and/or all your covered dependents satisfy the separate deductible and separate out-of-pocket limits as shown above, the Plan will pay 100% of covered expenses for the remainder of the calendar year, unless specifically indicated, subject to any calendar year maximums and the lifetime maximum of the Plan. If you and your covered dependents use a combination of PAR and Non-PAR providers, the out-of-pocket amounts will track separately. Copayments and penalties are not applied to the Family Out-of-Pocket Limit. INPATIENT HOSPITAL Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Covered expenses are payable as shown below and include charges made by a: Hospital for daily semi-private, ward, intensive care or coronary care room and board charges for each day of confinement. Benefits for a private or single-bed room are limited to the maximum allowable fee charged for asemi-private room in the hospital while a registered bed patient; Hospital for services furnished for your treatment during conj~nement. 29 SCHEDULE OF BENEFITS (continued) PAR Provider 100%. Non-PAR Provider (All services indicated above, 80% after $500 copayment per admission, unless except for the following.) otherwise specified. • Ancillary Services 80%. OUTPATIENT HOSPITAL Precertification is required for outpatient non-emergency surgery. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Covered expenses are payable as shown below. Covered expenses include charges made by a hospital for: 1. Treatment of a bodily injury, including the emergency room charge if rendered within 48 hours of an accident; 2. Treatment of a sickness following an emergency, including the emergency room charge; 3. Preadmission testing; 4. A surgical procedure; 5. Outpatient tests, laboratory tests and x-rays; 6. MRI, MRA, PET, CAT, SPECT Scans; 7. Outpatient physical, speech, occupational, cognitive and hearing therapy; 8. Regularly scheduled treatment such as chemotherapy, inhalation therapy, radiation therapy as ordered by your attending physician. 30 SCHEDULE OF BENEFITS (continued) PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Emergency Room (Facility) 100% after $40 copayment per visit. If you are admitted to the hospital, the copayment will be waived. • Outpatient Surgery 100%. • Physical, Speech, Occupational and Cognitive 80% after deductible. Therapy • Outpatient Surgical/Non-surgical Ancillary 100%. Services • MRI, MRA, PET, CAT, SPECT Scans 80% after deductible. • Chemotherapy and Radiation Therapy 80% after deductible. Non-PAR Provider 80% after deductible, unless otherwise specified. (All services indicated above, except for the following.) • Emergency Room 100% of billed charges after $40 copayment per visit and after any national network discount. If you are admitted to the hospital, the copayment will be waived. • Outpatient Surgery 80% after $250 copayment per visit. • Physical, Speech, Occupational and Cognitive 60% after deductible. • Outpatient Surgical/Non-surgical Ancillary 80%. Services • MRI, MRA, PET, CAT, SPECT Scans 60% after deductible. • Chemotherapy and Radiation Therapy 60% after deductible. 31 SCHEDULE OF BENEFITS (continued) URGENT CARE CENTER Facility charges made by an urgent care center are payable as shown below. Outpatient sairgery, diagnostic x-ray, laboratory tests and any additional services other than the facility charge are not payable under this benefit. Please refer to the other provisions of this Plan for available coverage. PAR Provider 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. FREE-STANDING SURGICAL FACILITY Precertification is required for outpatient non-emergency surgery. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Charges made by afree-standing surgical facility for surgical procedures performed and for services rendered in the facility are payable as shown below. PAR Provider 100%. Non-PAR Provider 80% after $250 copayment per visit. QUALIFIED PRACTITIONER Covered expenses are payable as shown below and include charges made by a qualified practitioner when incurred for: Office, home, emergency room physician or inpatient hospital visits; 2. Diagnostic x-ray or laboratory tests; Professional services of a radiologist or pathologist for diagnostic x-ray examination or laboratory tests, including x-ray, radon, radium and radioactive isotope therapy; Other covered medical services received from or at the direction of a qualified practitioner; Administration of anesthesia; 32 SCHEDULE OF BENEFITS (continued) 6. A surgical procedure, including pre-operative and. post-operative care; If multiple or bilateral surgical procedures are performed at one operative session, the amount payable for these procedures will be limited to the maximum allotivable fee for the primary surgical procedure and: a. 50% of the maximum allowable fee for the secondary procedure; and b. 25% of the maximum allowable fee for the third and subsequent procedures. No benefits will be payable for incidental procedures. 7. Assistant surgeon, payable at 20% of the maximum allowable fee allowed for the primary surgeon; 8. Physician assistant, payable at 20% of the maximum allowable fee allowed for the primary surgeon; 9. Allergy testing and vials; 10. Injections, other than routine, contraceptive and allergy injections; 11. MRI, MRA, PET, CAT, SPECT Scans; 12. Charges made by a qualified practitioner for services in performing certain oral surgical operations due to bodily injury or sickness are covered as follows: a. Excision of partially or completely unerupted impacted teeth; b. Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth when such conditions require pathological examination; c. Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth; d. Mandibular staple implant when not done to prepare the mouth for dentures; e. Removal of full bony impactions; f. Frenectomy (the cutting of the tissue in the midline of the tongue); g. Alveolectomyand alveoplasty related to tooth extraction; h. Orthognathic surgery if severe handicapping malocclusion is present and proved. 33 ~CH1;llUL)N: OF BENEFITS (continued) PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 100% after $20 copayment per visit. General & Family Practice), including Surgery Performed in an Office Setting and Injections • Office Visit (Obstetrician and Gynecology, 100% after $20 copayment per visit. Chiropractic, Surgeon and all others), including Surgery Performed in an Office Setting and Injections • Dental/Oral Surgeries Payable the same as any other sickness. Non-PAR Provider 80%after deductible, unless otherwise specified. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 80% after deductible. General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others), including Surgery performed in an office setting • Diagnostic X-ray and Laboratory Tests 80% after deductible. performed in an office setting • Diagnostic X-ray and Laboratory Tests 80%. performed in an outpatient setting • Dental/Oral Surgeries Payable the same as any other sickness. c~auiu-u~y, ratnoiogy, Hnestnesia ana r.mergency zoom Physician services rendered by a Non-PAR Physician but performed at a PAR facility are automatically paid at the PAR level of benefits. 34 SCHEDULE OF BENEFITS (continued) ALLERGY INJECTIONS Allergy injections and supplies are payable as shown below. PAR Provider 100% after $3 copayment per visit. Non-PAR Provider 80% after deductible. ROUTINE CARE - UP TO AGE 17 The following expenses are payable for your covered dependent, as shown below, subject to all terms and provisions of the Plan, except the exclusion for services which are not medically necessary, if your covered dependent is not confined in a hospital or qualified treatment facility and if such expenses are not incurred for diagnosis of a specific bodily injury or sickness. Benefits include: 1. Routine examinations; 2. Immunizations and Flu/Pneumonia; 3. Routine hearing exams and testing, limited to one per calendar year; 4. Routine x-ray and laboratory tests; 5. HPV Vaccine (i.e. Gardasil), covered beginning at age 9. No benefits are payable under this benefit for: 1. Any dental examinations; 2. Medical examination for bodily injury or sickness; 3. Routine vision screening. 35 SCHEDULE OF BENEFITS (continued) PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 100% after $20 copayment per visit. General & Family Practice) • Office Visit (Obstetrician and Gynecology, 100% after $20 copayment per visit. Chiropractic, Surgeon and all others) • Immunizations, Flu/Pneumonia and HPV 100% after $3 copayment per injection. Vaccine (i.e. Gardasil) • Routine Hearing Exam and Testing 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 80% after deductible. General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others) • Immunizations and Flu/Pneumonia Not covered. • Routine Hearing Exam and Testing 80% after deductible. ROUTINE CARE -AGE 18 AND OVER The following expenses are payable for you or your covered dependent, as shown below, subject to all terms and provisions of the Plan, except the exclusion for services which are not medically necessary, if you are not confined in a hospital or qualified treatment facility and if such expenses are not incurred for diagnosis of a specific bodily injury or sickness. Benefits include: Routine physical examinations, limited to one per calendar year, 2. Well woman examinations, not limited; Routine x-ray and laboratory tests; 4. Mammograms; 36 SCHEDULE OF BENEFITS (continued) 5. Pap smears; 6. Flu/pneumonia immunizations; 7. Prostate antigen testing; 8. Routine immunizations; 9. Routine hearing exams and testing, limited to one per calendar year; 10. Routine cancer screenings (colonoscopy, sigmoidoscopy and proctosigmoidoscopy); 11. HPV Vaccine (i.e. Gardasil), covered through age 26; 12. Shingles Vaccine (i.e. Zostavax), covered persons age 60 and over; 13. Meningitis Vaccine, covered persons through age 21. No benefits are payable under this benefit for: 1. Any dental examinations; 2. Medical examination for bodily injury or sickness; 3. Medical examination caused by or resulting from pregnancy; 4. Routine vision screening. PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 100%after $20 copayment per visit. General & Family Practice) • Office Visit (Obstetrician and Gynecology, 100% after $20 copayment per visit. Chiropractic, Surgeon and all others) • Immunizations, Flu/Pneumonia, HPV 100% after $3 copayment per injection. Vaccine, Shingles Vaccine and Meningitis Vaccine • Routine Hearing Exam and Testing 100% after $20 copayment per visit. 37 SCHEDULE OF BENEFITS (continued) Non-PAR Provider 80% after deductible. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 80% after deductible. General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others) • Immunizations and Flu/Pneumonia ~ Not covered. • Routine Hearing Exam and Testing ~ 80% after deductible. CHIROPRACTIC CARE Chiropractic care for the treatment of a bodily injury or sickness is payable as shown below. Maintenance care is not covered. PAR Provider (All services indicated above, 100% after $20 copayment per visit, unless except for the following.) otherwise specified. • Diagnostic X-ray and Laboratory Tests 100%. Non-PAR Provider 80% after deductible. Trvx ana Non-YAK provider covered expenses aggregate to a maximum of 20 visits per covered person, per calendar year. Only 1 copayment applies regardless of the number of services rendered. SUPPLEMENTAL ACCIDENT BENEFIT This provision provides benefits for you or your covered dependents in the event of a bodily injury. The expense must be incurred within 3 days of the date of the accident. Eligible expenses are payable as shown below and are not subject to the deductible and coinsurance. Dental x-rays and dental surgical procedures are included as eligible expenses under this provision. No benefits are payable under this provision for expenses incurred to treat a sickness. Supplemental Accident Benefit Payable at 100%, up to a maximum benefit of $500. Charges exceeding the $500 maximum benefit are payable the same as any other sickness. 38 SCHEDULE OF BENEFITS (continued) AMBULANCE SERVICE Local professional ambulance service to the nearest hospital equipped to provide the necessary treatment is covered as shown below. Ambulance service must not be provided primarily for the convenience of the patient or the qualified practitioner. If you receive treatment from aNon-PAR provider, and your condition is an emergency as defined in the Definitions section of this Plan, benefits will be paid at the PAR Provider level. PAR Provider Non-PAR Provider 80% after deductible. 80% of billed charges after PAR deductible. PREGNANCY BENEFITS Pregnancy is a covered expense for any covered person payable as shown below. Complications of pregnancy are payable as any other covered sickness at the point the complication sets in for any covered person. 39 SCFIEDULE OF BENEFITS (continued) Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans may not, under Federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Pregnancy benefits are subject to all terms and provisions of the Plan, with the exception of the pre- existing condition limitation as defined within the Definitions section of this booklet. PAR Provider 100%. Non-PAR Provider 80% after $500 copayment per admission. NEWBORN BENEFITS Covered expenses incurred during a newborn child's initial inpatient hospital confinement include hospital expenses for nursery room and board and miscellaneous services; qualified practitioner's expenses for circumcision; and qualified practitioner's expenses for routine examination before release from the hospital. PAR Provider 100%. Non-PAR Provider (All services indicated above, 80% after deductible, unless otherwise specified. except the following.) • Facility Charge 80% after $500 copayment per admission. BIRTHING CENTERS A birthing center is a free standing facility, licensed by the state, which provides prenatal care, delivery and immediate postpartum care, and care of the newborn child. Expense incurred within 48 hours after confinement in a birthing center for services and supplies furnished for prenatal care and delivery of child(ren) are payable as shown below. 40 SCHEDULE OF BENEFITS (continued) PAR Provider 100%. Non-PAR Provider (All services indicated above, 80% after deductible, unless otherwise specified. except the following.) • Facility Charge 80% after $500 copayment per admission. • Ancillary Charge 80%. PHYSICAL, SPEECH, OCCUPATIONAL, AND COGNITIVE THERAPY BENEFIT Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Covered expenses received for physical, speech, occupational, cognitive and hearing therapy are payable as shown below. PAR Provider Non-PAR Provider 80% after deductible. 60% after deductible. SHILLED NURSING FACILITY Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Expenses incurred for daily room and board and general nursing services for each day of confinement in a skilled nursing facility are payable as shown below. The daily rate will not exceed the maximum daily rate established for licensed skilled nursing care facilities by the Department of Health and Social Services. Covered expenses for a skilled nursing facility confinement are payable when the confinement: Begins while you or an eligible dependent are covered under this Plan; Begins after discharge from a hospital confinement or a prior covered skilled nursing facility confinement; Is necessary for care or treatment of the same bodily injury or sickness which caused the prior confinement; and Occurs while you or an eligible dependent are under the regular care of a physician. 41 SCHEDULE OF BENEFITS (continued) Skilled nursing facility means only an institution licensed as a skilled nursing facility and lawfully operated in the jurisdiction where located. It must maintain and provide: Permanent and full-time bed care facilities for resident patients; 2. A physician's services available at all times; 3. 24-hour-a-day skilled nursing services under the full-time supervision of a physician or registered nurse (R.N.); 4. A daily record for each patient; 5. Continuous skilled nursing care for sick or injured persons during their convalescence from sickness or bodily injury; and 6. A utilization review plan. A skilled nursing facility is not except by incident, a rest home, a home for care of the aged, or engaged in the care and treatment of mental disorders, chemical dependence or alcoholism. PAR Provider Non-PAR Provider 80% after deductible. 60% after deductible. *PAR and Non-PAR provider covered expenses aggregate to a maximum of 60 days per calendar year. HOME HEALTH CARE Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Expenses incurred for home health care as described below are payable as shown below. The maximum weekly benefit for such coverage may not exceed the maximum allowable weekly cost for care in a skilled nursing facility. Each visit by a home health care provider for evaluating the need for, developing a plan, or providing services under a home health care plan will be considered one home health care visit. Up to 4 consecutive hours of service in a 24-hour period is considered one home health care visit. A visit by a home health care provider of 4 hours or more is considered one visit for every 4 hours or part thereof. Home health care provider means an agency licensed by the proper authority as a home health agency or Medicare approved as a home health agency. Home health care will not be reimbursed unless the Plan determines: 1. Hospitalization or confinement in a skilled nursing facility would otherwise be required if home care were not provided; 42 SCHEDULE OF BENEFITS (continued) 2. Necessary care and treatment are not available from a family member or other persons residing with you; and 3. The home health care services will be provided or coordinated by astate-licensed or Medicare- certified home health agency or certified rehabilitation agency. The home health care plan must be reviewed and approved by the qualified practitioner under whose care you are currently receiving treatment for the bodily injury or sickness which requires the home health care. The home health care plan consists o£ Care by or under the supervision of a registered nurse (R.N.); 2. Physical, speech, occupational, cognitive, hearing and respiratory therapy and home health aide services; and 3. Medical supplies and durable medical equipment, laboratory services and nutritional counseling, if such services and supplies would have been covered ifyou were hospital confined. LIMITATIONS ON HOME HEALTH CARE BENEFITS Home health care benefits do not include: Charges for mileage or travel time to and from the covered person's home; 2. Wage or shift differentials for home health care providers; or 3. Charges for supervision of home health care providers. PAR Provider 80% after deductible. Non-PAR Provider 60% after deductible. • _r nn ..1,, ,. ,I,. *PAR and Non-YAK provider covered expenses aggre~a~c w a ~~~a~llllulll ~. ~~ ~ ~~_~, ,,,,..,~..,...,.w• ~-_-. HOSPICE CARE Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Hospice services must be furnished in a hospice facility or in your home. A qualified practitioner must certify you are terminally ill with a life expectancy of six months or less. For hospice services only, your immediate family is considered to be your parent, spouse, and your children or step-children. 43 SCHEDULE OF BENEFITS (continued) Covered expenses are payable as shown below for the following hospice services: 1. Room and board and other services and supplies; 2. Part-time nursing care by or supervised by a R.N. for up to 8 hours per day; Counseling services by a gz~alified practitioner for the hospice patient and the immediate family; 4. Medical social services provided to you or your immediate family under the direction of a qualified practitioner, which include the following: a. Assessment of social, emotional and medical needs, and the home and family situation; b. Identification of the community resources available; and c. Assistance in obtaining those resources. 5. Nutritional counseling; Physical or occupational therapy; Part-time home health aide service for up to 8 hours in any one day; and 8. Medical supplies, drugs and medicines prescribed by a qualified practitioner. LIMITATIONS ON HOSPICE CARE BENEFITS Hospice care benefits do NOT include: (1) private duty nursing services when confined in a hospice facility; (2) a confinement not required for pain control or other acute chronic symptom management; (3) funeral arrangements; (4) financial or legal counseling, including estate planning or drafting of a will; (5) homemaker or caretaker services, including a sitter or companion services; (6) housecleaning and household maintenance; (7) services of a social worker other than a licensed clinical social worker; (8) services by volunteers or persons who do not regularly charge for their services; or (9) services by a licensed pastoral counselor to a member of his or her congregation when services are in the course of the duties to which he or she is called as a pastor or minister. Hospice care program means a written plan of hospice care, established and reviewed by the qualified practitioner attending the patient and the hospice care agency, for providing palliative and supportive care to hospice patients. It offers supportive care to the families of hospice patients, an assessment of the hospice patient's medical and social needs, and a description of the care to meet those needs. Hospice facility means a licensed facility or part of a facility which principally provides hospice care, keeps medical records of each patient, has an ongoing quality assurance program and has a physician on call at all times. A hospice facility provides 24-hour-a-day nursing services under the direction of a R.N. and has afull- time administrator. 44 SCHEDULE OF BENEFITS (continued) Hospice care agency means an agency which has the primary purpose of providing hospice services to hospice patients. It must be licensed and operated according to the laws of the state in which it is located and meets all of these requirements: (1) has obtained any required certificate of need; (2) provides 24- hours aday, 7 day-a-week service supervised by a qualified practitioner; (3) has afull-time coordinator; (4) keeps written records of services provided to each patient; (5) has a nurse coordinator who is a R.N., who has four years of full-time clinical experience, of which at least two involved caring for terminally ill patients; and, (6) has a licensed social service coordinator. A hospice care agency will establish policies for the provision of hospice care, assess the patient's medical and social needs and develop a program to meet those needs. It will provide an ongoing quality assurance program, permit area medical personnel to use its services for their patients, and use volunteers trained in care of and services for non-medical needs. PAR Provider Non-PAR Provider 80% after deductible. 60% after deductible. ORGAN TRANSPLANT BENEFIT Precertification is required. If precertification is not received, organ transplant services will not be covered. The Plan will pay benefits for the expense of a transplant as defined below for a covered person when approved in advance by the Plan Manager, subject to those terms, conditions and limitations described below and contained in the Plan. Please contact the Plan Manager at our toll free number (800) 832-8212 when in need of these services. COVERED ORGAN TRANSPLANT Only the services, care and treatment received for, or in connection with, the pre-approved transplant of the organs identified hereafter, which are determined by the Plan Manager to be medically necessary services and which are not experimental, investigational or for research purposes will be covered by the Plan. The transplant includes: pre-transplant services, transplant inclusive of any chemotherapy and associated services, post-discharge services and treatment of complications after transplantation of the following organs or procedures only: 1. Heart; 2. Lung(s); 3. Liver; 4. Kidney; 5. Bone Marrow*; 45 SCHEDULE OF BENEFITS (continued) 6. Intestine; 7. Pancreas; Auto islet cell; 9. Multivisceral; 10. Any combination of the above listed organs; 11. Any organ not listed above required by federal law *The term bone marrow refers to the transplant of human blood precursor cells which are administered to a patient following high-dose, ablative or myelosuppresive chemotherapy. Such cells may be derived from bone marrow, circulating blood, or a combination of bone marrow and circulating blood obtained from the patient in an autologous transplant or from a matched related or unrelated donor or cord blood. If chemotherapy is an integral part of the treatment involving a transplant of bone marrow, the term bone marrow includes the harvesting, the transplantation and the chemotherapy components. Storage of cord blood and stem cells will not be covered unless as an integral part of a transplant of bone marrow approved by the Plan Manager. Corneal transplants and porcine heart valve implants, which are tissues rather than organs, are considered part of regular plan benefits and are subject to other applicable provisions of the Plan. For a transplant to be considered fully approved, prior written approval from the Plan Manager is required in advance of the transplant. You or your qualified practitioner must notify the Plan Manager in advance of your need for an initial transplant evaluation in order for the Plan Manager to determine if the transplant will be covered. For approval of the transplant itself, the Plan Manager must be given a reasonable opportunity to review the clinical results of the evaluation before rendering a determination. Once the transplant is approved, the Plan Manager will advise the covered person's qualified practitioner. Benefits are payable only if the pre-transplant services, the transplant and post-discharge services are approved by the Plan Manager. EXCLUSIONS No benefit is payable for, or in connection with, a transplant i£ It is experimental, investigational or for research purposes as defined in the Definitions section of this booklet; 2. The Plan Manager is not contacted for authorization prior to referral for evaluation of the transplant, unless such authorization is waived by the Plan Manager; The Plan Manager does not approve coverage for the transplant, based on its established criteria; Expenses are eligible to be paid under any private or public research fund, government program, except Medicaid, or another funding program, whether or not such funding was applied for or received; 46 SCHEDULE OF BENEFITS (continued) 5. The expense relates to the transplantation of any non-human organ. or tissue, unless otherwise stated in the Plan; 6. The expense relates to the donation or acquisition of an organ for a recipient who is not covered by the Plan; 7. A denied transplant is performed; this includes the pre-transplant evaluation, pre-transplant services, the transplant procedure, post-discharge services, immunosuppressive drugs and complications of such transplant; 8. The covered person for whom a transplant is requested has not met pre-transplant criteria as established by the Plan Manager. COVERED SERVICES For approved transplants, and all related complications, the Plan will cover only the following expenses: Hospital and qualified practitioner benefits, payable as shown below. 2. Organ acquisition and donor costs. Except for bone marrow transplants, donor costs are not payable under the Plan if they are payable in whole or in part by any other group plan, insurance company, organization or person other than the donor's family or estate. Coverage for bone marrow transplants procedures will include costs associated with the donor-patient to the same extent and limitations associated with the covered person; Direct, non-medical costs for the covered person: (a) transportation to and from the hospital where the transplant is performed; and (b) temporary lodging at a prearranged location up to $75 per day when requested by the hospital and approved by the Plan Manager. Transportation costs for the covered person to and from the hospital where the transplant is performed will be payable as shown below. These direct, non-medical costs are only available if the covered person lives more than 100 miles from the transplant facility;** 4. Direct, non-medical costs for one member of the covered person's immediate family (two members if the patient is under age 18 years), will be paid for: (a) transportation to and from the approved facility where the transplant is performed; and (b) temporary lodging at a prearranged location up to $75 per day during the covered person's confinement in the hospital. Transportation costs for the covered person's immediate family member(s) to and from the hospital where the transplant is performed will be payable as shown below. These direct, non- medical costs are only available if the covered person's immediate family member(s) live more than 100 miles from the transplant facility.** **All direct, non-medical expenses for the covered person receiving the transplant and his/her family member(s) are limited to a combined maximum benefit of $10,000 per transplant. 47 ~CHL+'llULE OF BENEFITS (continued) Par Provider Payable the same as any other sickness. Lodging and Transportation Services 80% after deductible. Non-Par Provider Payable the same as any other sickness. Lodging and Transportation Services 60% after deductible. Covered expenses are limited to a maximum benefit of $35,000 per transplant. MENTAL AND NERVOUS DISORDERS/CHEMICAL DEPENDENCY Inpatient or Partial Confinement Inpatient confinement is subject to precertification. Failure to obtain precertification shall result in a reduction in benefits. The Plan will pay the applicable coinsurance for confinement or parital confinement in a hospital or treatment center for services, supplies and treatment related to the treatment of mental and nervous disorders or chemical dependency. Covered expenses shall include: Inpatient hospital confinement; Individual psychotherapy; Group psychotherapy; Psychological testing and Electro-Convulsive therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider. Outpatient The Plan will pay the applicable coinsurance for outpatient services, supplies and treatment related to the treatment of mental and nervous disorders or chemical dependency. Covered expenses shall include charges for treatment of Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (AD/HD) 48 SCHEDULE OF BENEFITS (continued) PAR Provider 100% Non-PAR Provider 80% after $500 copay per admission OUTPATIENT BENEFITS Covered expenses for outpatient treatment received while not confined in a hospital or qualified treatment facility are payable as shown below, subject to the lifetime maximum of the Plan. Covered expenses for outpatient treatment do not aggregate toward the out-of-pocket limits described on the Schedule of Benefits. PAR Provider 100% after$20 copayment per visit. Non-PAR Provider 80% LIMITATIONS ON MENTAL DISORDER, CHEMICAL DEPENDENCE OR ALCOHOLISM BENEFITS No benefits are payable under this provision for treatment of nicotine habit or addiction, or for treatment of being obese or overweight. No benefits are payable under this provision for services performed at a Residential Treatment Facility. Treatment must be provided for the cause for which benefits are payable under this provision of the Plan. 49 OTHER COVERED EXPENSES The following are other covered expenses payable as shown below: Blood and blood plasma are payable as long as it is NOT replaced by donation, and administration of blood and blood products including blood extracts or derivatives; 2. Oxygen and rental of equipment for its administration; Drugs and medicines that are provided to, or administered to you, while you are confined in a hospital or skilled nursing facility, by a qualified practitioner during an office visit or from a home health care provider; Drugs and medicines required by law to be obtained on the written prescription of a qualified practitioner when not rendered by a pharmacy; 5. Initial prosthetic devices or supplies, including but not limited to, limbs and eyes. Coverage will be provided for prosthetic devices necessary to restore minimal basic function. Replacement is a covered expense if due to pathological changes. Covered expense includes repair of the prosthetic device if not covered by the manufacturer; Supplies, up to a 30-day supply, when prescribed by your attending physician; 7. Casts, trusses, crutches, orthotics, splints and braces. Orthotics must be custom made or custom fitted, made of rigid or semi-rigid material. Oral or dental splints and appliances must be custom made and for the treatment of documented obstructive sleep apnea. Unless specifically stated otherwise, fabric supports, replacement orthotics and braces, oral splints and appliances, dental splints and appliances, and dental braces are not a covered expense; 8. Initial contact lenses or eyeglasses following cataract surgery; 9. The rental, up to but not to exceed the purchase price, of a wheelchair, hospital bed, ventilator, hospital type equipment or other durable medical equipment (DME). The Plan, at its option, may authorize the purchase of DME in lieu of its rental, if the rental price is projected to exceed the purchase price. Repair, maintenance or duplicate DME rental is not considered a covered expense. Refer to the precertification requirements of this Plan if the rental or purchase price is expected to be $750 or more; 10. Wigs for cancer patients due to hair loss resulting from chemotherapy or radiation therapy; 11. Services for the treatment of a dental injury to a sound natural tooth, including but not limited to extraction and initial replacement. Services must begin within 90 days and be completed within 24 months after the date of the dental injury. Benefits will be paid only for expense incurred for the least expensive service that will, in the Plan Manager's opinion, produce a professionally adequate result; 12. Installation and use of an insulin infusion pump, diabetic self-management education programs and other equipment or supplies in the treatment of diabetes, except as specifically described within the Prescription Drug Benefit section; 50 OTHER COVERED EXPENSES (continued) 13. Reconstructive surgery due to bodily injury, infection or other disease of the involved part or congenital disease or anomaly of a covered dependent child which resulted in a fimctional impairment, 14. Reconstructive services following a covered mastectomy, including but not limited to: a. Reconstruction of the breast on which the mastectomy was performed; b. Reconstruction of the other breast to achieve symmetry; c. Prosthesis; and d. Treatment of physical complications of all stages of the mastectomy, including lymphedemas. 15. Respiratory therapy; 16. Chemotherapy and radiation therapy; 17. Cardiac rehabilitation, limited to phases I and II; 18. Surgical and non-surgical services for morbid obesity; 19. Private duty nursing (inpatient hospital only). The following services are considered other covered expenses and are payable as shown below, subject to all terms and provisions of the Plan, except the exclusion for services which are not medically necessary: 1. Elective Sterilizations; reversal of sterilization limited to one per lifetime regardless of network participation; and 2. Birth control devices, injections, implant systems and the removal of implant systems. PAR Provider (All services indicated above, except the following.) • Birth control devices, injections, implant systems and the removal of implant systems • Elective Sterilizations • Reversal of Sterilizations (limited to 1 per lifetime) ~ • Services for Morbid Obesity 80% after deductible, unless otherwise specified. Payable the same as any other sickness. Payable the same as any other sickness. 80% after deductible Payable the same as any other sickness. • Private Duty Nursing (inpatient hospital only) 1100%. ~ • Dentallnjury Payable the same as any other sickness. ~ • Diabetic/Nutritional Counseling Payable the same as any other sickness. 51 OTHER COVERED EXPENSES (continued) Non-PAR Provider (All services indicated above, except the following.) • Birth control devices, injections, implant systems and the removal of implant systems • Elective Sterilizations • Reversal of Sterilizations (limited to 1 per lifetime) 60% after deductible, unless otherwise specified. Payable the same as any other sickness. Payable the same as any other sickness. 60% after deductible • Services for Morbid Obesity Payable the same as any other sickness. • Private Duty Nursing (Inpatient hospital only) 80% after deductible. • Dentallnjury • Diabetic/Nutritional Counseling Payable the same as any other sickness. Payable the same as any other sickness. 52 LIMITATIONS AND EXCLUSIONS The Plan does not provide benefits for: Services: a. Not furnished by a qualified practitioner or qualified treatment facility; b. Not authorized or prescribed by a qualified practitioner; c. Not covered by this Plan whether or not prescribed by a qualified practitioner, d. Which are not provided; e. For which no charge is made, or for which you would not be required to pay if you were not covered under this Plan unless charges are received from and reimbursable to the United States Government or any of its agencies as required by law; or f. Furnished by or payable under any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); g. Furnished for a military service connected sickness or bodily injury by or under an agreement with a department or agency of the United States Government, including the Department of Veterans Affairs; h. Performed in association with a service that is not covered under this Plan; i. Performed as a result of a complication arising from a service that is not covered under this Plan. Routine vision examinations or testing; services to correct eye refractive disorders; radial keratotomy, refractive keratoplasty or any other surgery to correct myopia, hyperopia or stigmatic error; or, the purchase, fitting or repair of eyeglass frames and lenses or contact lenses, unless specifically provided under this Plan; 3. Vision therapy (eye exercises to strengthen the muscles of the eye); 4. Routine hearing examinations; Hearing aids, the fitting or repair of hearing aids or advice on their care; implantable hearing devices; Routine physical examinations and related services for occupation, employment, school, sports, camp, travel, purchase of insurance or premarital tests or examinations, unless specifically provided under this Plan; Immunizations required for foreign travel; 8. Elective medical or surgical abortion, unless: a. The pregnancy would endanger the life of the mother; or b. The pregnancy is a result of rape or incest; or c. The fetus has been diagnosed with a lethal or otherwise significant abnormality; 9. All fertility testing or services performed to achieve pregnancy or ovulation by artificial means, including but not limited to, artificial insemination, in vitro fertilization, spermatogenesis, gamete intra fallopian transfer (GIFT), zygote intra fallopian transfer (ZIFT), tubal ovum transfer, embryo freezing or transfer and sperm banking; 53 LIMITATIONS AND EXCLUSIONS (continued) 10. Services related to gender change; 11. Cosmetic surgery and cosmetic services or devices, unless for reconstructive surgery: a. Resulting from a bodily injury, infection or other disease of the involved part, when functional impairment is present; or b. Resulting from a congenital disease or anomaly of a covered dependent child which resulted in a functional impairment; c. Expense incurred for reconstructive surgery performed due to the presence of a psychological condition are not covered, unless the condition(s) described above are also met. 12. Hair prosthesis, hair transplants or hair implants; 13. Dental services or appliances for the treatment of the teeth, gums, jaws or alveolar processes, including but not limited to, implants and related procedures, routine dental extractions and orthodontic procedures, unless specifically provided under this Plan; 14. Dental osteotomies; 15. Surgical or non-surgical treatment including but not limited to, appliances and therapy, for any jaw joint problem including any temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull. Surgical or non-surgical treatment of the facial muscles used in expression and mastication functions, for symptoms including but not limited to, headaches; 16. Education or training, except for diabetes self-management training; 17. Educational or vocational therapy, testing, services or schools, including therapeutic boarding schools and other therapeutic environments. Educational or vocational videos, tapes, books and similar materials are also excluded; 54 LIMITATIONS AND EXCLUSIONS (continued) 18. Expenses for services that are primarily and customarily used for environmental control or enhancement (whether or not prescribed by a qualified practitioner) and certain medical devices including, but not limited to: a. Common household items including air conditioners, air purifiers, water purifiers, vacuum cleaners, waterbeds, hypoallergenic mattresses or pillows or exercise equipment; b. Motorized transportation equipment (e.g. scooters), escalators, elevators, ramps or modifications or additions to living/working quarters or transportation vehicles; c. Personal hygiene equipment including bath/shower chairs, transfer equipment or supplies or bed side commodes; d. Personal comfort items including cervical pillows, gravity lumbar reduction chairs, swimming pools, whirlpools, spas or saunas; e. Medical equipment including blood pressure monitoring devices, breast pumps, PUVA lights and stethoscopes; f. Communication system, telephone, television or computer systems and related equipment or similar items or equipment; g. Communication devices, except after surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx. 19. Any medical treatment, procedure, drug, biological product or device which is experimental, investigational or for research purposes, unless otherwise specified in the Plan; 20. Pre-existing conditions to the extent specified in the Definitions section; 21. Services not medically necessary for diagnosis and treatment of a bodily injury or sickness; 22. Charges in excess of the maximum allowable fee for the service; 23. Services provided by a person who ordinarily resides in your home or who is a family member; 24. Any expense incurred prior to your effective date under the Plan or after the date your coverage under the Plan terminates, except as specifically described in this Plan; 25. Expenses incurred for which you are entitled to receive benefits under your previous dental or medical plan; 26. Any expense due to the covered person's: a. Engaging in an illegal occupation; or b. Commission of or an attempt to commit a criminal act. 27. Any loss caused by or contributed to: a. War or any act of war, whether declared or not; b. Insurrection; or c. Any act of armed conflict, or any conflict involving armed forces of any authority. 28. Any expense incurred for services received outside of the United States while you are residing outside of the United States for more than six months in a year except as required by law for emergency care services; 55 LIMITATIONS AND EXCLUSIONS (continued) 29. Birth control pills; 30. Treatment of nicotine habit or addiction, including, but not limited to hypnosis, smoking cessation products, classes or tapes; 31. Vitamins, dietary supplements and dietary formulas (except enteral formulas for the treatment of genetic metabolic diseases, e.g. phenylketonuria (PKU)); 32. Over the counter, non-prescription medications; 33. Medications, drugs or hormones to stimulate growth unless there is a laboratory confirmed diagnosis of growth hormone deficiency, as determined by the Plan; 34. Therapy and testing for treatment of allergies including, but not limited to, services related to clinical ecology, environmental allergy and allergic immune system dysregulation and sublingual antigen(s), extracts, neutralization test and/or treatment UNLESS such therapy or testing is approved by: a. The American Academy of Allergy and Immunology, or b. The Department of Health and Human Services or any of its offices or agencies. 35. Professional pathology or radiology charges, including but not limited to, blood counts, multi- channel testing, and other clinical chemistry tests, when: a. The services do not require a professional interpretation; or b. The qualified practitioner did not provide a specific professional interpretation of the test results of the covered person. 36. Services related to the treatment and/or diagnosis of sexual dysfunction/impotence, unless specifically provided under the Prescription Drug Coverage; 37. Any treatment, including but not limited to, surgical procedures: a. For obesity, other than morbid obesity; b. For obesity, other than morbid obesity for the purpose of treating a sickness or bodily injury caused by, complicated by, or exacerbated by the obesity; 38. Services that are billed incorrectly or billed separately, but are an integral part of another billed service; 39. Expenses for health clubs or health spas, aerobic and strength conditioning, work-hardening programs or weight loss or similar programs, and all related material and product for these programs; 40. Alternative medicine; 41. Acupuncture, unless: a. The treatment is medically necessary and appropriate and is provided within the scope of the acupuncturist's license; b. You are directed to the acupuncturist for treatment by a licensed physician; and c. The acupuncture is performed in lieu of generally accepted anesthesia practices. 56 LIMITATIONS AND EXCLUSIONS (continued) 42. Services rendered in a premenstrual syndrome clinic or holistic medicine clinic; 43. Services of a midwife, unless provided by a Certified Nurse Midwife; 44. The following types of care of the feet: a. Shock wave therapy of the feet; b. The treatment of weak, strained, flat, unstable or unbalanced feet; c. Hygienic care, and the treatment of superficial lesions of the feet, such as corns, calluses or hyperkeratosis; d. The treatment of tarsalgia, metatarsalgia, or bunion, except surgically; e. The cutting of toenails, except the removal of the nail matrix; f. The provision of heel wedges, lifts or shoe inserts; and g. The provision of arch supports or orthopedic shoes, unless medically necessary because of diabetes or hammertoe. 45. Custodial care and maintenance care; 46. Weekend non-emergency hospital admissions, specifically admissions to a hospital on a Friday or Saturday at the convenience of the covered person or his or her qualified practitioner when there is no cause for an emergency admission and the covered person receives no surgery or therapeutic treatment until the following Monday; 47. Hospital inpatient services when yotic are in observation status; 48. Services rendered by a standby physician, surgical assistant, assistant surgeon, physician assistant, registered nurse or certified operating room technician unless medically necessary; 49. Private duty nursing; other than in an inpatient hospital; 50. Ambulance services for routine transportation to, from or between medical facilities and/or a qualified practitioner's office; 51. Preadmissionlprocedural testing duplicated during a hospital confinement; 52. Lodging accommodations or transportation, unless specifically provided under this Plan; 53. Communications or travel time; 57 LIMITATIONS AND EXCLUSIONS (continued) 54. No benefits will be provided for: a. Immunotherapy for recurrent abortion; b. Chemonucleolysis; c. Biliary lithotripsy; d. Home uterine activity monitoring; e. Sleep therapy; f. Light treatments for Seasonal Affective Disorder (S.A.D.); g. Immunotherapy for food allergy; h. Prolotherapy; i. Cranial banding; j. Hyperhydroosis surgery; k. Lactation therapy; or 1. Sensory integration therapy. 55. Sickness or bodily injairy for which medical payments/personal injury protection (PIP) coverage exists under any automobile, homeowner, marine, aviation, premise, or any other similar coverage, whether such coverage is in effect on a primary, secondary, or excess basis. This exclusion applies up to the available limit under the other coverage regardless of whether a claim is filed with the medical payments/PIP carrier. Whether medical payment or expense coverage is payable under another coverage is to be determined as if the coverages under this Plan did not exist; 56. Any covered expenses to the extent of any amount received from others for the bodily injarries or losses which necessitate such benefits. "Amounts received from others" specifically includes, without limitation, liability insurance, worker's compensation, uninsured motorists, underinsured motorists, "no-fault" and automobile med-pay payments; 57. Any bodily injury or sickness arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which: a. Benefits are provided or payable under any Workers' Compensation or Occupational Disease Act or Law, or b. Coverage was available under any Workers' Compensation or Occupational Disease Act or Law regardless of whether such coverage was actually purchased. NOTE: These limitations and exclusions apply even if a qualified practitioner has performed or prescribed a medically necessary procedure, treatment or supply. This does not prevent your gz~alified practitioner from providing or performing the procedure, treatment or supply, however, the procedure, treatment or supply will not be a covered expense. 58 TERMINATION OF COVERAGE Coverage terminates on the earliest of the following: The date the Plan terminates; 2. The end of the period for which any required contribution was due and not paid; The date you enter full-time military, naval or air service, except coverage may continue during an approved military leave of absence as indicated in the Special Provisions For Not Being in Active Status provision; The date you fail to be in an eligible class of persons according to the eligibility requirements of the employer; For all employees, immediately following termination of employment with your employer; For all employees, immediately following your retirement; 7. For any benefit, the date the benefit is removed from the Plan; For your dependents, the date your coverage terminates; For a dependent, the date the dependent enters full-time military, naval or air service; 10. For a dependent, the date such covered person no longer meets the definition of dependent; or 11. The date you request termination of coverage to be effective for yourself and/or your dependents. IF YOU OR ANY OF YOUR COVERED DEPENDENTS NO LONGER MEET THE ELIGIBILITY REQUIREMENTS, YOU AND YOUR EMPLOYER ARE RESPONSIBLE FOR NOTIFYING THE PLAN MANAGER OF THE CHANGE IN STATUS. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY EVEN IF NOTICE HAS NOT BEEN GIVEN TO THE PLAN MANAGER. 59 IMPORTANT NOTICES FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER Federal law may affect your coverage under this Plan. The Medicare as Secondary Payer rules were enacted by an amendment to the Social Security Act. Also, additional rules which specifically affect how a large group health plan provides coverage to employees (or their spouses) over age 65 were added to the Social Security Act and to the Internal Revenue Code. Generally, the health care plan of an employer that has at least 20 employees must operate in compliance with these rules in providing plan coverage to plan participants who have "current employment status" and are Medicare beneficiaries, age 65 and over. Persons who have "current employment status" with an employer are generally employees who are actively working and also persons who are NOT actively working as follows: Individuals receiving disability benefits from an employer for up to 6 months, or Individuals who retain employment rights and have not been terminated by the employer and for whom the employer continues to provide coverage under this Plan. (For example, employees who are on an approved leave of absence). ~~ If yoz~ are a person having "current employment status who is age 65 and over (or the dependent spouse age 65 and over of an employee of any age), your coverage under this Plan will be provided on the same terms and conditions as are applicable to employees (or dependent spouses) who are under the age of 65. Your rights under this Plan do not change because you (or your dependent spouse) are eligible for Medicare coverage on the basis of age, as long as you have "current employment status" with your employer. You have the option to reject plan coverage offered by your employer, as does any eligible employee. If you reject coverage under your employer's Plan, coverage is terminated and your employer is not permitted to offer you coverage that supplements Medicare covered services. If you (or your dependent spouse) obtain Medicare coverage on the basis of age, and not due to disability or end-stage renal disease, this Plan will consider its coverage to be primary to Medicare when you have elected coverage under this Plan and have "current employment status". If you have any questions about how coverage under this Plan relates to Medicare coverage, please contact your employer. 60 CONTINUATION OF MEDICAL BENEFITS THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986 (COBRA) CONTINUATION OF BENEFITS On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) was signed into law. This federal law applies to employers with 20 or more employees. The law requires that employers offer employees and/or their dependents continuation of medical coverage at group rates in certain instances where there is a loss of group insurance coverage. ELIGIBILITY A qualified beneficiary under COBRA law means an employee, employee's spouse or dependent child covered by the Plan on the day before a qualifying event. A qualified beneficiary under COBRA law also includes a child born to the employee during the coverage period or a child placed for adoption with the employee during the coverage period. EMPLOYEE: An employee covered by the employer's Plan has the right to elect continuation coverage if coverage is lost due to one of the following qualifying events: • Termination (for reasons other than gross misconduct, as defined by your employer) of the employee's employment or reduction in the hours of employee's employment; or • Termination of retiree coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. SPOUSE: A spouse covered by the employer's Plan has the right to elect continuation coverage if the group coverage is lost due to one of the following qualifying events: • The death of the employee; Termination of the employee's employment (for reasons other than gross misconduct, as defined by your employer) or reduction of the employee's hours of employment with the employer; • Divorce or legal separation from the employee; • The employee becomes entitled to Medicare benefits; or • Termination of a retiree spouse's coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. DEPENDENT CHII,D: A dependent child covered by the employer's Plan has the right to continuation coverage if group coverage is lost due to one of the following qualifying events: • The death of the employee parent; • The termination of the employee parent's employment (for reasons other than gross misconduct, as defined by your employer) or reduction in the employee parent's hours of employment with the employer; • The employee parent's divorce or legal separation; • Ceasing to be a "dependent child" under the Plan; • The employee parent becomes entitled to Medicare benefits; or • Termination of the retiree parent's coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. 61 CONTINUATION OF MEDICAL BENEFITS (continued) LOSS OF COVERAGE Coverage is lost in connection with the foregoing qualified events, when a covered employee, spouse or dependent child ceases to be covered under the same Plan terms and conditions as in effect immediately before the qualifying event (such as an increase in the premium or contribution that must be paid for employee, spouse or dependent child coverage). If coverage is reduced or eliminated in anticipation of an event (for example, an employer eliminating an employee's coverage in anticipation of the termination of the employee's employment, or an employee eliminating the coverage of the employee's spouse in anticipation of a divorce or legal separation), the reduction or elimination is disregarded in determining whether the event causes a loss of coverage. A loss of coverage need not occur immediately after the event, so long as it occurs before the end of the Maximum Coverage Period. NOTICES AND ELECTION The Plan provides that coverage terminates for a spouse due to legal separation or divorce or for a child -when that child loses dependent status. Under the law, the employee or qualified beneficiary has the responsibility to inform the Plan Administrator (see Plan Description Information) if one of the above events has occurred. The qualified beneficiary must give this notice within 60 days after the event occurs. (For example, an ex-spouse should make sure that the Plan Administrator is notified of his or her divorce, whether or not his or her coverage was reduced or eliminated in anticipation of the event). When the Plan Administrator is notified that one of these events has happened, it is the Plan Administrator's responsibility to notify the Plan Manager who has contracted with a COBRA Service Provider who will in turn notify the qualified beneficiary of the right to elect continuation coverage. For a qualified beneficiary who is determined under the Social Security Act to be disabled at any time during the first 60 days of COBRA coverage, the continuation coverage period may be extended 11 additional months. The disability that extends the 18-month coverage period must be determined under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the Social Security Act. To be entitled to the extended coverage period, the disabled qualified beneficiary must provide notice to the COBRA Service Provider within the initial 18 month coverage period and within 60 days after the date of the determination of disability under the Social Security Act. Failure to provide this notice will result in the loss of the right to extend the COBRA continuation period. For termination of employment, reduction in work hours, the death of the employee, the employee becoming covered by Medicare or loss of retiree benefits due to bankruptcy, it is the Plan Administrator's responsibility to notify the Plan Manager who has contracted with a COBRA Service Provider who will in turn notify the qualified beneficiary of the right to elect continuation coverage. Under the law, continuation coverage must be elected within 60 days after Plan coverage ends, or if later, 60 days after the date of the notice of the right to elect continuation coverage. If continuation coverage is not elected within the 60 day period, the right to elect coverage under the Plan will end. 62 CONTINUATION OF MEDICAL BENEFITS (continued) A covered employee or the spouse of the covered employee may elect continuation coverage for all covered dependents, even if the covered employee or spouse of the covered employee or all covered dependents are covered under another group health plan (as an employee or otherwise) prior to the election. The covered employee, his or her spouse and dependent child, however, each have an independent right to elect continuation coverage. Thus a spouse or dependent child may elect continuation coverage even if the covered employee does not elect it. Coverage will not be provided during the election period. However, if the individual makes a timely election, coverage will be provided from the date that coverage would otherwise have been lost. If coverage is waived before the end of the 60 day election period and the waiver revoked before the end of the 60 day election period, coverage will be effective on the date the election of coverage is sent to the COBRA Service Provider. On August 6, 2002, The Trade Act of 2002 (TAA), was signed in to law. Workers whose employment is adversely affected by international trade (increased import or shift in production to another country} may become eligible to receive TAA. TAA provides a second 60-day COBRA election period for those who become eligible for assistance under TAA. Pursuant to the Trade Act of 1974, an individual who is either an eligible TAA recipient or an eligible alternative TAA recipient and who did not elect continuation coverage during the 60-day COBRA election period that was a direct consequence of the TAA-related loss of coverage, may elect continuation coverage during a 60-day period that begins on the first day of the month in which. he or she is determined to be TAA-eligible individual, provided such election is made not later than 6 months after the date of the TAA-related loss of coverage. Any continuation coverage elected during the second election period will begin with the first day of the second election period and not on the date on which coverage originally lapsed. TAA created a new tax credit for certain individuals who became eligible for trade adjustment assistance (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Care Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626- 4282. The Plan Administrator shall require documentation evidencing eligibility of TAA benefits. The Plan need not require every available document to establish evidence of TAA. The burden for evidencing TAA eligibility is that of the individual applying for coverage under the Plan. MAXIMUM COVERAGE PERIOD Coverage may continue up to: 18 months for an employee and/or dependent whose group coverage ended due to termination of the employee's employment or reduction in hours of employment; 36 months for a spouse whose coverage ended due to the death of the employee or retiree, divorce, or the employee becoming entitled to Medicare at the time of the initial qualifying event; 63 CONTINUATION OF MEDICAL BENEFITS (continued) 36 months for a dependent child whose coverage ended due to the divorce of the employee parent, the employee becoming entitled to Medicare at the time of the initial qualifying event, the death of the employee, or the child ceasing to be a dependent under the Plan; For the retiree, until the date of death of the retiree who is on continuation due to loss of coverage within one year before or one year after the employer filed Chapter 11 bankruptcy. DISABILITY An 11-month extension of coverage may be available if any of the qualified beneficiaries are determined by the Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60t" day of COBRA continuation coverage and must last at least until the end of the 18- month period of continuation coverage. The qualified beneficiary must provide notice of such determination prior to the end of the initial 18-month continuation period to be entitled to the additional 11 months of coverage. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If a qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after SSA's determination. SECOND QUALIFYING EVENT An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months. Such second qualifying event may include the death of a covered employee, divorce or separation from the covered employee, the covered employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child's ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after the second qualifying event occurs if you want to extend your continuation coverage. TERMINATION BEFORE THE END OF MAXIMUM COVERAGE PERIOD Continuation coverage will terminate before the end of the maximum coverage period for any of the following reasons: The employer no longer provides group. health coverage to any of its employees; The premium for continuation is not paid timely; The individual on continuation becomes covered under another group health plan (as an employee or otherwise); however, if the new plan coverage contains any exclusion or limitation with respect to any pre-existing condition, then continuation coverage will end for this reason only after the exclusion or limitation no longer applies or prior creditable coverage satisfies the exclusion or limitation: 64 CONTINUATION OF MEDICAL BENEFITS (continued) NOTE: The federal Health Insurance Portability and Accountability Act of 1996 requires portability of health care coverage effective for plan years beginning after June 30, 1997, an exclusion or limitation under the other group health plan may not apply at all to the qualified beneficiary, depending on the length of his or her prior creditable coverage. Portability means once you obtain health insurance, you will be able to use evidence of that insurance to reduce or eliminate any pre-existing medical condition limitation period (under certain circumstances) when you move from one health plan to another. The individual on continuation becomes entitled to Medicare benefits; If there is a final determination under Title II or XVI of the Social Security Act that an individual is no longer disabled; however, continuation coverage will not end until the month that begins more than 30 days after the determination; The occurrence of any event (e.g. submission of a fraudulent claim) permitting termination of coverage for cause under the Plan. TYPE OF COVERAGE; PREMIUM PAYMENT If continuation coverage is elected, the coverage must be identical to the coverage provided under the employer's Plan to similarly situated non-COBRA beneficiaries. This means that if the coverage for similarly situated non-COBRA beneficiaries is modified, coverage for the individual on continuation will be modified. The initial premium payment for continuation coverage is due by the 45th day after coverage is elected. The initial premium includes charges back to the date the continuation coverage began. All other premiums are due on the first of the month for which the premium is paid, subject to a 31 day grace period. The COBRA Service Provider must provide the individual with a quote of the total monthly premium. Premium for continuation coverage may be increased, however, the premium may not be increased more than once in any determination period. The determination period is a 12 month period which is established by the Plan. The monthly premium payment to the Plan for continuing coverage must be submitted directly to the COBRA Service Provider. This monthly premium may include the employee's share and any portion previously paid by the employer. The monthly premium must be a reasonable estimate of the cost of providing coverage under the Plan for similarly situated non-COBRA beneficiaries. The premium for COBRA continuation coverage may include a 2% administration charge. However, for qualified beneficiaries who are receiving up to 11 months additional coverage (beyond the first 18 months) due to disability extension (and not a second qualifying event), the premium for COBRA continuation coverage may be up to 150% of the applicable premium for the additional months. Qualified beneficiaries who do not take the additional 11 months of special coverage will pay up to 102% of the premium cost. 65 THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) OTHER INFORMATION Additional information regarding rights and obligations under the Plan and under federal law may be obtained by contacting the COBRA Service Provider or the Plan Manager. It is important for the covered person or qualified beneficiary to keep the Plan Administrator, COBRA Service Provider and Plan Manger informed of any changes in marital status, or a change of address. PLAN CONTACT INFORMATION Preferred Health Plan Inc. P. O. Box 437017 Louisville KY 40253-7017 66 THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) CONTINUATION OF BENEFITS Effective October 13, 1994 federal law requires that health plans must offer to continue coverage for employees who are absent due to service in the uniformed services and/or their dependents. Coverage may continue for up to 18 or 24 months after the date the employee is first absent due to uniformed service. ELIGIBILITY An employee is eligible for continuation under USERRA if absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, -Air National Guard, the commissioned corps of the Public Health Service, or any other category of persons designated by the President of the United States of America in a time of war or national emergency. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training, full-time National Guard duty, and for the purpose of an examination to determine fitness for duty. An employee's dependents who have coverage under the Plan immediately prior to the date of the employee's covered absence are eligible to elect continuation under USERRA. PREMIUM PAYMENT If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for the cost will be payment of the applicable cost of coverage. If the employee is absent for 30 days or less, the cost the amount the employee would otherwise pay for coverage. For absences exceeding 30 days, may be up to 102% of the cost of coverage under the Plan. This includes the employee's share and any portion previously paid by the employer. DURATION OF COVERAGE Elected continuation coverage under USERRA will continue until the earlier of: 18 months beginning the first day of absence from employment due to service in the uniformed services for elections made prior to 12/10/04; or 24 months beginning the first day of absence from employment due to service in the uniformed services for elections beginning on or after 12/10/04; or The day after the employee fails to apply for or return to employment as required by USERRA, after completion of a period of service. Under federal law, the period of coverage available under USERRA shall run concurrently with the COBRA period available to an employee and/or eligible dependents. OTHER INFORMATION Employees should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status, or a change of address. 67 COORDINATION OF BENEFITS BENEFITS SUBJECT TO THIS PROVISION Benefits described in this Plan are coordinated with benefits provided by other plans under which you are also covered. The Prescription Drug benefit is not subject to these coordination provisions. This is to prevent duplication of coverage and a resulting increase in the cost of medical coverage. For this purpose, a plan is one which covers medical or dental expenses and provides benefits or services by group, franchise or blanket insurance coverage. This includes group-type contracts not available to the general public, obtained and maintained only because of the covered person's membership in, or connection with, a particular organization or group, whether or not designated as franchise, blanket, or in some other fashion. Plan also includes any coverage provided through the following: 1. Employer, trustee, union, employee benefit, or other association; or Z. Governmental programs, programs mandated by state statute, or sponsored or provided by an educational institution. This Coordination of Benefits provision does not apply to any individual policies or Blanket Student Accident Insurance provided by, or through, an educational institution. Allowable expense means any eligible expense, a portion of which is covered under one of the plans covering the person for whom claim is made. Each plan will determine what is an allowable expense according to the provisions of the respective plan. When a plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be deemed to be both an allowable expense and a benefit paid. EFFECT ON BENEFITS One of the plans involved will pay benefits first. This is called the primary plan. All other plans are called secondary plans. When this Plan is the secondary plan, the sum of the benefit payable will not exceed 100% of the total allowable expenses incurred under the Plan and any other plans included under this provision. ORDER OF BENEFIT DETERMINATION In order to pay claims, it must be determined which plan is primary and which plan(s) are secondary. A plan will pay benefits first if it.meets one of the following conditions: The plan has no coordination of benefits provision; The plan covers the person as an employee; For a child who is covered under both parents' plans, the plan covering the parent whose birthday (month and day) occurs first in the calendar year pays before the plan covering the other parent. If the birthdates of both parents are the same, the Plan which has covered the person for the longer period of time will be determined the primary plan; If a plan other than this Plan does not include provision 3, then the gender rule will be followed to determine which plan is primary. 68 COORDINATION OF BENEFITS (continued) 4. In the case of dependent children covered under the plans of divorced or separated parents, the following rules apply: a. The plan of a parent who has custody will pay the benefits first; b. The plan of astep-parent who has custody will pay benefits next; c. The plan of a parent who does not have custody will pay benefits next; d. The plan of astep-parent who does not have custody will pay benefits next. There may be a court decree which gives one parent financial responsibility for the medical or dental expenses of the dependent children. If there is a court decree, the rules stated above will not apply if they conflict with the court decree. Instead, the plan of the parent with financial responsibility will pay benefits first. 5. If a person is laid off or is retired or is a dependent of such person, that plan covers after the plan covering such person as an active employee or dependent of such employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule will be ignored. If the above rules do not apply or cannot be determined, then the plan that covered the person for the longest period of time will pay first. COORDINATION OF BENEFITS WITH MEDICARE When an employer employs 100 or more persons, the benefits of the Plan will be payable first for a covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable second. MEDICARE PART A means the Social Security program that provides hospital insurance benefits. MEDICARE PART B means the Social Security program that provides medical insurance benefits. For the purposes of determining benefits payable for any covered person who is eligible to enroll for Medicare Part B, but does not, the Plan Manager assumes the amount payable under Medicare Part B to be the amount the covered person would have received if he or she enrolled for it. A covered person is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her. OPTIONS Federal Law allows the Plan's actively working covered employees age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options: OPTION 1 -The benefits of the Plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 -Medicare benefits only. The covered person and his or her dependents, if any, will not be covered by the Plan. 69 COORDINATION OF BENEFITS (continued) Each covered employee and each covered spouse will be provided with the choice to elect one of these options at least one month before the covered employee or the covered spouse becomes age 65. All new covered employees and newly covered spouses age 65 or older will also be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for a covered employee or dependent who is under age 65. Under Federal law, there are two categories of persons eligible for Medicare. The calculation and payments of benefits by the Plan differs for each category. CATEGORY 1 Medicare Eligibles are actively working covered employees age 65 or older and their age 65 or older covered spouses, and age 65 or older covered spouses of actively working covered employees who are under age 65. CATEGORY 2 Medicare Eligibles are any other covered persons entitled to Medicare, whether or not they enrolled for it. This category includes, but is not limited to, retired covered employees and their spouses or covered dependents of a covered employee other than his or her spouse. CALCULATION AND PAYMENT OF BENEFITS For covered persons in Category 1, benefits are payable by the Plan without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the Plan. The benefits of the Plan will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not they were actually enrolled for Medicare. RIGHT OF RECOVERY The Plan reserves the right to recover benefit payments made for an allowable expense under the Plan in the amount which exceeds the maximum amount the Plan is required to pay under these provisions. This right of recovery applies to the Plan against: Any person(s) to, for or with respect to whom, such payments were made; or 2. Any other insurance companies, or organizations which according to these provisions, owe benefits due for the same allowable expense under any other plan. The Plan alone will determine against whom this right of recovery will be exercised. 70 REIMBURSEMENT/SUBROGATION The beneficiary agrees that by accepting and in return for the payment of covered expenses by the Plan in accordance with the terms of this Plan: 1. The Plan shall be repaid the full amount of the covered expenses it pays from any amount received from others for the bodily injuries or losses which necessitated such covered expenses. Without limitation, "amounts received from others specifically includes, but is not limited to, liability insurance, worker's compensation, uninsured motorists, underinsured motorists, "no- fault" and automobile med-pay payments or recovery from any identifiable fund regardless of whether the beneficiary was made whole. 2. The Plan's right to repayment is, and shall be, prior and superior to the right of any other person or entity, including the beneficiary. 3. The right to recover amounts from others for the injuries or losses which necessitate covered expenses is jointly owned by the Plan and the beneficiary. The Plan is subrogated to the beneficiary's rights to that extent. Regardless of who pursues those rights, the funds recovered shall be used to reimburse the Plan as prescribed above; the Plan has no obligation to pursue the rights for an amount greater than the amount that it has paid, or may pay in the future. The rights to which the Plan is subrogated are, and shall be, prior and superior to the rights of any other person or entity, including the beneficiary. 4. The beneficiary will cooperate with the Plan in any effort to recover from others for the bodily injuries and losses which necessitate covered expense payments by the Plan. The beneficiary will notify the Plan immediately of any claim asserted and any settlement entered into, and will do nothing at any time to prejudice the rights and interests of the Plan. Neither the Plan nor the beneficiary shall be entitled to costs or attorney fees from the other for the prosecution of the claim. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with the Plan Manager and when asked, assist the Plan Manager by: Authorizing the release of medical information including the names of all providers from whom you received medical attention; Obtaining medical information and/or records from any provider as requested by the Plan Manager; Providing information regarding the circumstances of your sickness or bodily injury; Providing information about other insurance coverage and benefits, including information related to any bodily injury or sickness for which another party may be liable to pay compensation or benefits; and Providing information the Plan Manager requests to administer the Plan. Failure to provide the necessary information will result in denial of any pending or subsequent claims, pertaining to a bodily inja~ry or sickness for which the information is sought, until the necessary information is satisfactorily provided. 71 REIMBURSEMENT/SUBROGATION (continued) DUTY TO COOPERATE IN GOOD FAITH You are obliged to cooperate with the Plan Manager in order to protect the Plan's recovery rights. Cooperation includes promptly notifying the Plan Manager that you may have a claim, providing the Plan Manager relevant information, and signing and delivering such documents as the Plan Manager reasonably request to secure the Plan's recovery rights. You agree to obtain the Plan's consent before releasing any party from liability for payment of medical expenses. You agree to provide the Plan Manager with a copy of any summons, complaint or any other process serviced in any lawsuit in which you seek to recover compensation for your bodily injury or sickness and its treatment. You will do whatever is necessary to enable the Plan Manager to enforce the Plan's recovery rights and will do nothing after loss to prejudice the Plan's recovery rights. You agree that you will not attempt to avoid the Plan's .recovery rights by designating all (or any disproportionate part) of any recovery as exclusively for pain and suffering. Failure of the covered person to provide the Plan Manager such notice or cooperation, or any action by the covered person resulting in prejudice to the Plan's rights will be a material breach of this Plan and will result in the covered person being personally responsible to make repayment. In such an event, the Plan may deduct from any pending or subsequent claim made under this Plan any amounts the covered person owes the Plan until such time as cooperation is provided and the prejudice ceases. 72 GENERAL PROVISIONS The following provisions are to protect your legal rights and the legal rights of the Plan. INCONTESTABILITY After you are covered under this Plan without interruption for two years, the Plan cannot contest the validity of your coverage except for: 1. Nonpayment of premium; 2. Yoz~r ineligibility under the Plan; 3. Any Plan provision; 4. Any fraudulent misrepresentation made by you; or 5. Any defenses the Plan may have by law. An independent incontestability period begins for each type of change in coverage or when the Plan requires a new employee enrollment form. This provision only limits the Plan's rights to void your coverage after you have been covered without interruption for two years. RIGHT TO REQUEST OVERPAYMENTS The Plan reserves the right to recover any payments made by the Plan that were: 1. Made in error; or 2. Made to you or any party on your behalf where the Plan determines the payment to you or any party is greater than the amount payable under this Plan. The Plan has the right to recover against you if the Plan has paid you or any other party on your behalf. WORKERS' COMPENSATION NOT AFFECTED The Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers' Compensation or Occupational Disease Act or Law. 73 GENERAL PROVISIONS (continued) WORKERS' COMPENSATION If benefits are paid by the Plan and the Plan determines you received Workers' Compensation for the same incident, the Plan has the right to recover as described under the Reimbursement/Subrogation provision. The Plan will exercise its right to recover against you even though: 1. The Workers' Compensation benefits are in dispute or are made by means of settlement or compromise; 2. No final determination is made that bodily injury or sickness was sustained in the course of or resulted from your employment; 3. The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by you or the Workers' Compensation carrier; 4. The medical or health care benefits are specifically excluded from the Workers' Compensation settlement or compromise. Yoz~ hereby agree that, in consideration for the coverage provided by the Plan, you will notify the Plan Manager of any Workers' Compensation claim you make, and that you agree to reimburse the Plan as described above. MEDICAID This Plan will not take into account the fact that an employee or dependent is eligible for medical assistance or Medicaid under state law with respect to enrollment, determining eligibility for benefits, or paying claims. If payment for Medicaid benefits has been made under a state Medicaid plan for which payment would otherwise be due under this Plan, payment of benefits under this Plan will be made in accordance with a state law which provides that the state has acquired the rights with respect to a covered employee to the benefits payment. CONSTRUCTION OF PLAN TERMS The Plan Manager has the sole right to construe and prescribe the meaning, scope and application of each and all of the terms of the Plan, including, without limitation, the benefits provided thereunder, the obligations of the beneficiary and the recovery rights of the Plan; such construction and prescription by the Plan Manager shall be final and uncontestable. THE WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy- related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: 74 GENERAL PROVISIONS (continued) • All stages of reconstruction of the breast on which the covered mastectomy was performed; • Sz~rgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. Contact your employer if you would like more information on WHCRA benefits PRIVACY OF PROTECTED HEALTH INFORMATION The Plan is required by law to maintain the privacy of your protected health information in all forms including written, oral and electronically maintained, stored and transmitted information and to provide individuals with notice of the Plan's legal duties and privacy practices with respect to protected health information. The Plan has policies and procedures specifically designed to protect your health information when it is in electronic format. This includes administrative, physical and technical safeguards to ensure that your health information cannot be inappropriately accessed while it is stored and transmitted to the Plan Manager and others that support the Plan. In order for the Plan to operate, it may be necessary from time to time for health care professionals, the Plan Administrator, individuals who perform Plan-related functions under the auspices of the Plan Administrator, the Plan Manager and other service providers that have been engaged to assist the Plan in discharging its obligations with respect to delivery of benefits, to have access to what is referred to as protected health information. A covered person will be deemed to have consented to use of protected health information about him or her by virtue of enrollment in the Plan. Any individual who may not have intended to provide this consent and who does not so consent must contact the Plan Administrator prior to filing any claim for Plan benefits, as coverage under the Plan is contingent upon consent. Individually identifiable health information will only be used or disclosed for purposes of Plan operation or benefits delivery. In that regard, only the minimum necessary disclosure will be allowed. The Plan Administrator, Plan Manager, and other entities given access to protected health information, as permitted by applicable law, will safeguard protected health information to ensure that the information is not improperly disclosed. Disclosure of protected health information is improper if it is not allowed by law or if it is made for any purpose other than Plan operation or benefits delivery. Disclosure for Plan purposes to persons authorized to receive protected health information may be proper, so long as the disclosure is allowed by law and appropriate under the circumstances. Improper disclosure includes disclosure to the employer for employment purposes, employee representatives, consultants, attorneys, relatives, etc. who have not executed appropriate agreements effective to authorize such disclosure. The Plan Manager will afford access to protected health information in its possession only as necessary to discharge its obligations as a service provider, within the restrictions noted above. However, Plan records that include protected health information are the property of the Plan. Information received by the Plan Manager is information received on behalf of the Plan. 75 GENERAL PROVISIONS (continued) The Plan Manager will afford access to protected health information as reasonably directed in writing by the Plan Administrator, which shall only be made with due regard for confidentiality. In that regard, the Plan Manager has been directed that disclosure of protected health information may be made to the person(s) designated by the Plan Administrator. Individuals who have access to protected health information in connection with their performance of Plan-related functions under the auspices of the Plan Administrator will be trained in these privacy policies and relevant procedures prior to being granted any access to protected health information. The Plan Manager and other Plan service providers will be required to safeguard protected health information against improper disclosure through contractual arrangements. In addition, yoa~ should know that the employer /Plan Sponsor may legally have access, on an as-needed basis, to limited health information for the purpose of determining Plan costs, contributions, Plan design, and whether Plan modifications are warranted. In addition, federal regulators such as the Department of Health and Human Services and the Department of Labor may legally require access to protected health information to police federal legal requirements about privacy. Covered persons may have access to protected health information about them that is in the possession of the Plan, and they may make changes to correct errors. Covered persons are also entitled to an accounting of all disclosures that may be made by any person who acquires access to protected health information concerning them and uses it other than for Plan operation or benefits delivery. In this regard, please contact the Plan Administrator. Covered persons are urged to contact the originating health care professional with respect to medical information that may have been acquired from them, as those items of information are relevant to medical care and treatment. And finally, covered persons may consent to disclosure of protected health information, as they please. 76 CLAIM PROCEDURES SUBMITTING A CLAIM This section describes what a covered person (or his or her authorized representative) must do to file a claim for Plan benefits. • A claim must be filed with the Plan Manager in writing and delivered to the Plan Manager, by mail, postage prepaid. However, a submission to obtain pre-authorization may also be filed with the Plan Manager by telephone (this applies to dental Plans only with respect to urgent care claims); • Claims must be submitted to the Plan Manager at the address indicated in the documents describing the Plan or claimant's identification card. Claims will not be deemed submitted for purposes of these procedures unless and until received at the correct address; • Also, claims submissions must be in a format acceptable to the Plan Manager and compliant with any applicable legal requirements. Claims that are not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by the Plan; • Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are incurred, and in no event later than 6 months after the date of loss, except if you were legally incapacitated. Plan benefits are only available for claims that are incurred by a covered person during the period that he or she is covered under the Plan; • Claims submissions must be complete. They must contain, at a minimum: a. The name of the covered person who incurred the covered expense; b. The name and address of the health care provider; c. The diagnosis of the condition; d. The procedure or nature of the treatment; e. The date of and place where the procedure or treatment has been or will be provided; £ The amount billed and the amount of the covered expense not paid through coverage other than Plan coverage, as appropriate; g. Evidence that substantiates the nature, amount, and timeliness of each covered expense in a format that is acceptable according to industry standards and in compliance with applicable law. Presentation of a prescription to a pharmacy does not constitute a claim. If a covered person is required to pay the cost of a covered prescription drug, however, he or she may submit a claim based on that amount to the Plan Manager. A general request for an interpretation of Plan provisions will not be considered to be a claim. Requests of this type, such as a request for an interpretation of the eligibility provisions of the Plan, should be directed to the Plan Administrator. 77 CLAIM PROCEDURES (continued) Mail medical claims and correspondence to: Preferred Health Plan, Inc., P. O. Box 437017 Louisville KY 40253-7017 MISCELLANEOUS MEDICAL CHARGES If you accumulate bills for medical items you purchase or rent yourself, send them to the Plan Manager at least once every three months during the year (quarterly). The receipts must include the patient name, name of item, date item purchased or rented and name of the provider of service. PROCEDURAL DEFECTS If apre-service claim submission is not made in accordance with the Plan's procedural requirements, the Plan Manager will notify the claimant of the procedural deficiency and how it may be cured no later than within five (5) days (or within 24 hours, in the case of an urgent care claim) following the failure. A post-service claim that is not submitted in accordance with these claims procedures will be returned to the submitter. ASSIGNMENTS AND REPRESENTATIVES A covered person may assign his or her right to receive Plan benefits to a health care provider only with the consent of the Plan Manager, in its sole discretion, except as may be required by applicable law. Assignments must be in writing. If a document is not sufficient to constitute an assignment, as determined by the Plan Manager, then the Plan will not consider an assignment to have been made. An assignment is not binding on the Plan until the Plan Manager receives and acknowledges in writing the original or copy of the assignment before payment of the benefit. If benefits are assigned in accordance with the foregoing paragraph and a health care provider submits claims on behalf of a covered person, benefits will be paid to that health care provider. In addition, a covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The designation must be explicitly stated in writing and it must authorize disclosure of protected health information with respect to the claim by the Plan, the Plan Manager and the authorized representative to one another. If a document is not sufficient to constitute a designation of an authorized representative, as determined by the Plan Manager, then the Plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Any document designating an authorized representative must be submitted to the Plan Manager in advance, or at the time an authorized representative commences a course of action on behalf of a claimant. At the same time, the authorized representative should also provide notice of commencement of the action on behalf of the claimant to the claimant, which the Plan Manager may verify with the claimant prior to recognizing the authorized representative status; 78 CLAIM PROCEDURES (continued) PAYMENT OF CLAIMS Many health care providers will request an assignment of benefits as a matter of convenience to both provider and patient. Also as a matter of convenience, the Plan Manager will, in its sole discretion, assume that an assignment of benefits has been made to certain Network Providers. In those instances, the Plan Manager will make direct payment to the hospital, clinic or physician's office, unless the Plan Manager is advised in writing that you have already~paid the bill. If you have paid the bill, please indicate on the original statement, "paid by employee," and send it directly to the Plan Manager. You will receive a written explanation of the benefit determination. The Plan Manager reserves the right to request any information required to determine benefits or process a claim. You or the provider of services will be contacted if additional information is needed to process your claim. When an employee's child is subject to a medical child support order, the Plan Manager will make reimbursement of eligible expenses paid by you, the child, the child's non-employee custodial parent, or legal guardian, to that child or the child's custodial parent, or legal guardian, or as provided in the medical child support order. Payment of benefits under this Plan will be made in accordance with an assignment of rights for you and your dependents as required under state Medicaid law. Benefits payable on behalf of you or your covered dependent after death will be paid, at the Plan's option, to any family member(s) or your estate. The Plan Manager will rely upon an affidavit to determine benefit payment, unless it receives written notice of valid claim before payment is made. The affidavit will release the Plan from further liability. Any payment made by the Plan Manager in good faith will fully discharge it to the extent of such payment. Payments due under the Plan will be paid upon receipt of written proof of loss INITIAL DENIAL NOTICES Notice of a claim denial (including a partial denial) will be provided to claimants by mail, postage prepaid, or by e-mail, as appropriate, within the time frames noted above. However, notices of adverse decisions involving urgent care claims may be provided to a claimant orally within the time frames noted above for expedited urgent care claim decisions. If oral notice is given, written notification will be provided to the claimant no later than 3 days after the oral notification. A claims denial notice will state the specific reason or reasons for the adverse determination, the specific Plan provisions on which the determination is based, and a description of the Plan's review procedures and associated timeline. The notice will also include a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. The notice will describe the Plan's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action. 81 CLAIM PROCEDURES (continued) The notice will also disclose any internal Plan rule, protocol or similar criterion that was relied onto deny the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free of charge upon request. If the adverse determination is based on medical necessity, experimental, investigational or for research purposes, or similar exclusion or limit, the notice will provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request. In the case of an adverse decision of an urgent care claim, the notice will provide a description of the Plan's expedited review procedures applicable to such claims. APPEALS OF ADVERSE DETERMINATIONS A claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). With the exception of urgent care claims and concurrent care decisions, the Plan uses a two level appeals process for all adverse determinations. The Plan Manager will make the determination on the first level of appeal. If the claimant is dissatisfied with the decision on this first level of appeal, or if the Plan Manager fails to make a decision within the time frame indicated below, the claimant may appeal again to the Plan Manager. Urgent care claims and concurrent care decisions are subject to a single level appeal process only, with the Plan Manager making the determination. A first level and second level appeal must be made by a claimant by means of written application, in person, or by mail (postage prepaid), addressed to: Preferred Health Plan, Inc. P. O. Box 437017 Louisville KY 40253-7017 Appeals of denied claims will be conducted promptly, will not defer to the initial determination, and will not be made by the person who made the initial adverse claim determination or a subordinate of that person. The determination will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim. A claimant may review relevant documents and may submit issues and comments in writing. A claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the adverse determination being appealed, as permitted under applicable law. 82 CLAIM PROCEDURES (continued) If the claims denial being appealed is based in whole, or in part, upon a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or for research purposes, or not medically necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person. Time Periods for Decisions on Appeal -- First Level Appeals of claims denials will be decided and notice of the decision provided as follows: Urgent Care Claims As soon as possible, but not later than 72 hours after the Plan Manager receives the appeal request. (If oral notification is given, written notification will follow in hard copy or electronic format within the next 3 days). Pre-Service Claims Within a reasonable period, but not later than 15 days after the Plan Manager receives the appeal request. Post-Service Claims Within a reasonable period, but no later than 30 days after the Plan Manager receives the appeal request. Concurrent Care Decisions Within the time periods specified above, depending upon the type of claim involved. Time Periods for Decisions on Appeal -- Second Level Appeals of claims denials will be decided and notice of the decision provided as follows: Pre-Service Claims Within a reasonable period, but not later than 15 days after the Plan Manager receives the appeal request. Post-Service Claims Within a reasonable period, but no later than 30 days after the Plan Manager receives the appeal request. 83 CLAIM PROCEDURES (continued) APPEAL DENIAL NOTICES Notice of a benefit determination on appeal will be provided to claimants by mail, postage prepaid, or by e-mail, as appropriate, within the time frames noted above. A notice that a claim appeal has been denied will convey the specific reason or reasons for the adverse determination and the specific Plan provisions on which the determination is based. The notice will also disclose any internal Plan rule, protocol or similar criterion that was relied on to deny the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free of charge upon request. If the adverse determination is based on medical necessity, experimental, investigational, or for research purposes or similar exclusion or limit, the notice will provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request. In the event of a denial of an appealed claim, the claimant on appeal will be entitled to receive, upon request and without charge, reasonable access to and copies of any document, record or other information: Relied on in making the determination; 2. Submitted, considered or generated in the course of making the benefit determination; 3. That demonstrates compliance with the administrative processes and safeguards required with respect to such determinations; 4. That constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment, without regard to whether the statement was relied on. RIGHT TO REQUIRE MEDICAL EXAMINATIONS (Applies only to medical Plans) The Plan has the right to require that a medical examination be performed on any claimant for whom a claim is pending as often as may be reasonably required. If the Plan requires a medical examination, it will be performed at the Plan's expense. The Plan also has a right to request an autopsy in the case of death, if state law so allows. EXHAUSTION Upon completion of the appeals process under this section, a claimant will have exhausted his or her administrative remedies under the Plan. If the Plan Manager fails to complete a claim determination or appeal within the time limits set forth above, the claimant may treat the claim or appeal as having been denied, and the claimant may proceed to the next level in the review process. After exhaustion, a claimant may pursue any other legal remedies available to him or her which may include bringing a civil action. Additional information may be available from a local U.S. Department of Labor Office. 84 CLAIM PROCEDURES (continued) LEGAL ACTIONS AND LIMITATIONS No action at law or inequity may be brought with respect to Plan benefits until all remedies under the Plan have been exhausted and then prior to the expiration of the applicable limitations period under applicable law. 85 PRESCRIPTION DRUG BENEFIT DEFINITIONS Brand name medication means a medication that is manufactured and distributed by only one pharmaceutical manufacturer, or as defined by the national pricing standard used by the Plan Manager. Copayment (prescription drug) means the amount to be paid by you toward the cost of each separate prescription or refill of a covered prescription drug when dispensed by a pharmacy. Dispensing limit means the monthly drug dosage limit and/or the number of months the drug usage is needed to treat a particular condition. Generic medication means a drug that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name; or as defined by the national pricing standard used by the Plan Manager. Legend drug means any medicinal substance the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: Caution: Federal Law Prohibits dispensing without prescription. Mail order pharmacy means a pharmaceutical vendor designated by the Plan Manager who is properly licensed to dispense and deliver covered prescriptions through the mail. Non participating pharmacy means a pharmacy, which has not entered into an agreement with the Plan Manager or has not been designated by the Plan Manager to provide services to covered persons. Orphan drug means a drug or biological used for the diagnosis, treatment, or prevention of rare diseases or conditions, which: 1. Affects less than 200,000 persons in the United States; or 2. Affects more than 200,000 persons in 'the United States, however, there is no reasonable expectation that the cost of developing the drug and making it available in the United States will be recovered from the sales of that drug in the United States. Participating pharmacy means a pharmacy which has entered into an agreement with or has been designated by the Plan Manager to provide services to covered persons. Pharmacist means a person who is licensed to prepare, compound and dispense medication and who is practicing within the scope of his or her license. Pharmacy means a licensed establishment where prescription medications are dispensed by a pharmacist. 86 PRESCRIPTION DRUG BENEFIT (continued) Prescription means a direct order for the preparation and use of a drug, medicine or medication. The drug, medicine or medication must be obtainable only by prescription. The prescription must be given verbally, electronically or in writing by a qualified practitioner to a pharmacist for the benefit of and use by a covered person. The prescription must include: The name and address of the covered person for whom the prescription is intended; The type and quantity of the drug, medicine or medication prescribed, and the directions for its use; The date the prescription was prescribed; and 4. The name, address and DEA number of the prescribing qualified practitioner. Prior aa~thorization means the required prior approval from the Plan Manager for the coverage of prescription drugs, medicines, medications, including the dosage, quantity and duration, as appropriate for the covered person's age and sex. Self-administered injectable drug means an FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous, or subcutaneous injection, and intended for use by you. SCHEDULE OF PRESCRIPTION DRUG BENEFITS NOTE: Additional drug information can be obtained by contacting Partners Rx at 800-711-4550. You are required to pay the applicable copayment per prescription as follows: 87 PRESCRIPTION DRUG BENEFIT (continued) RETAIL PHARMACY PARTICIPATING NON-PARTICIPATING PHARMACY PHARMACY Generic Medication $10 copayment per prescription $10 copayment plus 25% per copayment prescription Brand Name Medication $20 copayment per prescription $20 copayment plus 25% per copayment prescription Retail Prescription Drug 30 days 30 days Maximum Supply Fora 90-day maximum Two (2) times the applicable copayment as outlined under the Retail supply of a maintenance Pharmacy copayment Structure above. medication received from a retail pharmacy MAIL ORDER PHARMACY For up to a 90-day supply of a medication Two (2) times the applicable copayment as received from a mail order pharmacy outlined under the Retail Pharmacy copayment Structure above. Mail Order Pharmacy Drug Maximum Supply 90 days 88 PRESCRIPTION DRUG BENEFIT (continued) SPECIALTY OFFICE MEDICATION AND INJECTABLE DRUGS PER PRESCRIPTIONX For up to a 30 day supply $0 copayment *Specialty office medication and injectable drugs do not include self-administered injectable drugs ADDITIONAL PRESCRIPTION DRUG BENEFIT INFORMATION If an employee/eligible dependent purchases a brand name medication, and an equivalent generic medication is available, the employee/eligible dependent must pay the difference between the brand name medication and the generic medication plus any applicable generic medication copayment. If the physician indicates on the prescription "dispense as written", the drug will be dispensed as such, the employee/eligible dependent will only be responsible for the brand name medication copayment. Participating Pharmacy When a participating pharmacy is used and you do not present your I.D. card at the time of purchase, you must pay the pharmacy the full retail price and submit the pharmacy receipt to Preferred Health Plan Inc., at the address listed below. You will be reimbursed at 100% of billed charges after the charge has been reduced by the applicable copayment and 20%. Non-participating Pharmacy When a non participating pharmacy is used, yozc must pay the pharmacy the full price of the drug and submit the pharmacy receipt to Preferred Health Plan, Inc., at the address listed below. You will be responsible for 25% of the actual charge made by the dispensing pharmacy after this charge has been reduced by the applicable copayment. Mail pharmacy receipts to: Preferred Health Plan, Inc. P. O. Box 437017 Louisville KY 40253-7017 PRIOR AUTHORIZATION Some prescription drugs may be subject to prior authorization. To verify if a prescription drug requires prior authorization, call the toll free customer service phone number for Partners Rx on yozzr ID card. DISPENSING LIMITS Some prescription drugs may be subject to dispensing limits. To verify if a prescription drug has dispensing limits, call the toll free customer service phone number for Partners Rx on your ID card RETAIL PHARMACY Your Plan provisions include a retail prescription drug benefit. You will receive an identification (ID) 89 PRESCRIPTION DRUG BENEFIT (continued) card, which includes your name, group number and your effective date. Present your ID card at a participating pharmacy when purchasing a prescription. Prescriptions dispensed at a retail pharmacy are limited to a 30 day supply per prescription or refill. MAIL ORDER PHARMACY Yozcr prescription drug coverage also includes mail order pharmacy benefits, allowing participants an easy and convenient way to obtain prescription drugs. Mail order pharmacy prescriptions will only be filled with the quantity prescribed by your physician and are limited to a maximum of a: 90 day supply per prescription or refill for a drug received from a mail order pharmacy; or 30 day supply per prescription or refill for self-administered injectable medications or specialty office medications and injectables. Additional mail order pharmacy information can be obtained through your Human Resources Department or by calling the toll free customer service phone number for Partners Rx on your ID card. SPECIALTY OFFICE MEDICATIONS AND INJECTABLES Yozcr qualified practitioner has access to specialty office medications and injectables used to treat chronic conditions. These medications can be ordered specifically for you for administration in his/her office setting. This allows your physician a cost effective and convenient way to obtain high cost, high tech specialty medications and injectables. Additional information can be obtained through your Human Resources Department or by calling the toll-free customer service phone number on the back of your ID card. PRESCRIPTION DRUG COST SHARING Prescription drug benefits are payable for covered prescription expenses incurred by you and your covered dependents. Benefits for expenses made by a pharmacy are payable as shown on the Schedule of Prescription Drug Benefits. You are responsible for payment of: • The drug deductible, if any; • The copayment; The cost of medication not covered under the prescription drug benefit; The cost of any quantity of medication dispensed in excess of the day supply noted on the Schedule of Prescription Drug Benefits. 90 PRESCRIPTION DRUG BENEFIT (continued) ,. If the dispensing pharmacy's charge is less than the copayment, you will be responsible for the lesser amount. The amount paid by the Plan Manager to the dispensing pharmacy may not reflect the ultimate cost to the Plan Manager for the drug. Your copayment is made on a per prescription or refill basis and will not be adjusted if the Plan Manager or your employer receives any retrospective volume discounts or prescription drug rebates. PRESCRIPTION DRUG COVERAGE Because Partners Rx's drug list is continually updated with prescription drugs approved or not approved for coverage, you must call the toll free customer service phone number on your ID card to verify whether a prescription drug is covered or not covered under the Plan. 91 PRESCRIPTION DRUG BENEFIT (continued) PRESCRIPTION DRUG LIMITATIONS Expense incurred will not be payable for the following: 1. Any drug, medicine, medication or supply not approved for coverage under the Plan (call the toll free customer service phone number for Partners Rx on your ID card to verify whether a prescription drug is covered or not covered under the Plan); 2. Legend drugs which are not recommended and not deemed necessary by a qualified practitioner; 3. More than two fills for the same drug or therapeutic equivalent medication prescribed by one or more qualified practitioners and dispensed by one or more retail pharmacies; 4. Charges for the administration or injection of any drug; 5. Drug delivery implants; 6. Any drug, medicine or medication labeled "Caution-Limited by Federal Law to Investigational Use," or experimental drug, medicine or medication, even though a charge is made to you; 7. Any drug, medicine or medication that is consumed or injected at the place where the prescription is given, or dispensed by the gz~alified practitioner; 8. Prescriptions that are to be taken by or administered to the covered person, in whole or in part, while he or she is a patient in a facility where drugs are ordinarily provided by the facility on an inpatient basis. Inpatient facilities include, but are not limited to: a. Hospital; b. Skilled nursing facility; or c. Hospice facility. 9. Any drug prescribed for intended use other than for: a. Indications approved by the FDA; or b. Recognized off-label indications through peer-reviewed medical literature. 10. Prescription refills: a. In excess of the number specified by the qualified practitioner; or b. Dispensed more than one year from the date of the original order. 11. Any drug for which a charge is customarily not made; 12. Therapeutic devices or appliances, including: hypodermic needles and syringes (except needles and syringes for use with insulin, and covered self-administered injectable drugs); support garments; test reagents; mechanical pumps for delivery of medication; and other non-medical substances, unless otherwise specified by the Plan; 92 i PRESCRIPTION DRUG BENEFIT (continued) 13. Dietary supplements, nutritional products, fluoride supplements, minerals, herbs and vitamins (except pre-natal vitamins, including greater than one milligram of folic acid, and pediatric multi- vitamins with fluoride), unless otherwise specified by the Plan; 14. Injectable drugs, including but not limited to: immunizing agents; biological sera; blood; blood plasma; orself-administered injectable drugs not covered under the Plan; 15. Any drug prescribed for a sickness or bodily injury not covered under this Plan; 16. Any portion of a prescription or refill that exceeds a 30-day supply (or a 90-day supply for a prescription or refill that is received from a mail order pharmacy); 17. Any portion of a prescription refill that exceeds the drug specific dispensing limit, is dispensed to a covered person whose age is outside the drug specific age limits, or exceeds the duration- specific dispensing limit, if applicable; 18. Any drug, medicine or medication received by the covered person: a. Before becoming covered under the Plan; or b. After the date the covered person's coverage under the Plan has ended. 19. Any costs related to the mailing, sending, or delivery of prescription drugs; 20. Any fraudulent misuse of this benefit including prescriptions purchased for consumption by someone other than the covered person; 21. Prescription or refill for drugs, medicines, or medications that are lost, stolen, spilled, spoiled, or damaged; 22. Repackaged drugs; 23. Any drug or medicine that is: a. Lawfully obtainable without a prescription (over the counter drugs), except insulin; or b. Available in prescription strength without a prescription; 24. Any drug or biological that has received an "orphan drug" designation, unless approved by the Plan Administrator; 25. Any amount you paid for a prescription that has been filled, regardless of whether the prescription is revoked or changed due to adverse reaction or change in dosage or prescription; 26. More than one prescription within a 23-day period for the same drug or therapeutic equivalent medication prescribed by one or more qualified practitioners and dispensed by one or more pharmacies, unless received from a mail order pharmacy. For drugs received from a mail order pharmacy, more than one prescription within a 20-day period fora 1-30 day supply; or a 60-day period fora 61-90 day supply. (Based on the dosage schedule prescribed by the qualified practitioner). 93 ~~ -~uruaNa ~~~~. S~~ 2~0~ H~VIANAs C~utt CI?7['C* wEt€n }^ot~ nccd it mast SUMMARY PLAN DESCRIPTION For the PPO PLAN A Sponsored by CITY OF JEFFERSONVILLE The Plan Sponsor has established and continues to maintain this Group Health Plan (the "Plan") for the benefit of its employees and their eligible dependents as provided in this document. Benefits under this Plan are provided on aself-insured basis, which means that payment for benefits is ultimately the sole financial responsibility of the Plan Sponsor. Certain administrative services with respect to the Plan, such as claims processing, are provided under a services agreement. The Plan Manager is not responsible, nor will it assume responsibility, for benefits payable under the Plan. Any changes in the Plan, as presented in this Summary Plan Description, must be properly adopted by the Plan Sponsor, and material modifications must be timely disclosed in writing and included in or attached to this document. A verbal modification of the Plan, or promise having the same effect, made by any person will not be binding with respect to the Plan. Services are subject to all provisions of the Plan, including the limitations and exclusions. Italicized terms within the text are defined in the Definitions section of this booklet. Plan Number(s): 662493 Package ID Number: SFCOJ001 ,~ TABLE OF CONTENTS Page Number PLAN DESCRIPTION INFORMATION ........................................................................................... 3 DEFINITIONS ........................................................................................................................................ ... 5 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE ...................................................... . 15 PRECERTIFICATION ......................................................................................................................... . 21 UTILIZATION MANAGEMENT ..................................................................................................... . 23 SCHEDULE OF BENEFITS ............................................................................................................... . 26 OTHER COVERED EXPENSES ....................................................................................................... . 50 LIMITATIONS AND EXCLUSIONS ............................................................................................... . 53 TERMINATION OF COVERAGE ................................................................................................... . 59 IMPORTANT NOTICE FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER ......... . 60 THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986.......... . 61 THE UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 (USERRA) ..................................................................................................................... . 67 COORDINATION OF BENEFITS .................................................................................................... . 68 REIMBURSEMENT/SUBROGATION ........................................................................................... . 71 GENERAL PROVISIONS ................................................................................................................... . 73 CLAIM PROCEDURES ....................................................................................................................... . 77 PRESCRIPTION DRUG BENEFIT ........................................................................................................ . 86 I PLAN DESCRIPTION INFORMATION Proper Name of Plan: City of Jeffersonville Employee Health Plan 2. Plan Sponsor and Employer: City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 This Plan is maintained under a collective bargaining agreement. A copy of the agreement may be obtained on written request and is available for examination. 3. Plan Administrator and Named Plan Fiduciary: City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 4. Employer Identification Number: 35-6001067 5. The Plan provides medical and prescription drug benefits for participating employees and their enrolled dependents. 6. Plan benefits described in this booklet are effective January 1, 2009. 7. The Plan year and fiscal year are January 1 through December 31 of each year. 8. Service of legal process may be served upon the Plan Administrator as shown above or the following agent for service of legal process: City Attorney City of Jeffersonville 500 Quartermaster Court Jeffersonville, IN 47130 9. The Plan Manager is responsible for performing certain delegated administrative duties, including the processing of claims. The Plan Manager and Claim Fiduciary is: Humana Insurance Company 500 West Main Street Louisville, KY 40202 Telephone: Refer to your ID card 3 1 PLAN DESCRIPTION INFORMATION (continued) 10. This is aself-insured and self-administered health benefit plan. The cost of the Plan is paid with contributions shared by the employer and employee. Benefits under the Plan are provided from the general assets of the employer and are used to fund payment of covered claims under the Plan plus administrative expenses. Please see your employer for the method of calculating contributions and the funding mechanism used for the accumulation of assets through which benefits are provided under this Plan. 11. Each employee of the employer who participates in the Plan receives a Summary Plan Description, which is this booklet. This booklet will be provided to employees by the employer. It contains information regarding eligibility requirements, termination provisions, a description of the benefits provided and other Plan information. 12. The Plan benefits and/or contributions may be modified or amended from time to time, or may be terminated at any time by the Plan Sponsor. Significant changes to the Plan, including termination, will be communicated to participants as required by applicable law. 13. Upon termination of the Plan, the rights of the participants to benefits are limited to claims incurred and payable by the Plan up to the date of termination. Plan assets, if any, will be allocated and disposed of for the exclusive benefit of the participating employees and their dependents covered by the Plan, except that any taxes and administration expenses may be made from the Plan assets. 14. The Plan does not constitute a contract between the employer and any covered person and will not be considered as an inducement or condition of the employment of any employee. Nothing in the Plan will give any employee the right to be retained in the service of the employer, or for the employer to discharge any employee at any time. It is provided, however, that the foregoing will not modify the provisions of any collective bargaining agreement which may be made by the employer with the bargaining representative of any employees. A copy of the collective bargaining agreement will be made available by the employer for review, upon written request. 15. This Plan is not in lieu of and does not affect any requirement for coverage by Workers' Compensation insurance. DEFINITIONS A Active status means performing on a regular, full-time basis all customary occupational duties, for 30 hours per week, at the employer's business locations or when required to travel for the employer's business purposes. Each day of a regular paid vacation and any regular non-working holiday will be deemed active statz~s if you were in an active status on your last regular working day prior to the vacation or holiday. Alternative medicine means an approach to medical diagnosis, treatment or therapy that has been developed or practiced NOT using the generally accepted scientific methods in the United States of America. For purposes of this definition, alternative medicine shall include, but is not limited to: acupressure, acupuncture, aroma therapy, ayurveda, biofeedback, faith healing, guided mental imagery, herbal medicine, holistic medicine, homeopathy, hypnosis, macrobiotics, naturopathy, ozone therapy, reflexotherapy, relaxation response, rolfing, shiatsu and yoga. B Beneficiary means yozi and your covered dependent(s), or legal representative of either, and anyone to whom the rights of you or yoa~r covered dependent(s) may pass. Bodily injury means injury due directly to an accident and independent of all other causes. Muscle strain due to athletic or physical activity is considered a sickness. C Calendar year means a period of time beginning on January 1 and ending on December 31. Claimant means a covered person (or authorized representative) who files a claim. COBRA Service Provider means a provider of COBRA administrative services retained by the Plan Manager to provide specific COBRA administrative services. Complications of pregnancy means: 1. Conditions whose diagnoses are distinct from pregnancy but adversely affected by pregnancy or caused by pregnancy. Such conditions include: acute nephritis, nephrosis, cardiac decompensation, hyperemesis gravidarum, puerperal infection, toxemia, eclampsia and missed abortion; 2. A nonelective cesarean section surgical procedure; 3. Terminated ectopic pregnancy; or 4. Spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible. DEFINITIONS (continued) Complications of pregnancy does not mean: 1. False labor; 2. Occasional spotting; 3. Prescribed rest during the period of pregnancy; 4. Conditions associated with the management of a difficult pregnancy but which do not constitute distinct complications of pregnancy; or 5. An elective cesarean section. Concurrent care decision means a decision by the Plan to reduce or terminate benefits otherwise payable for a course of treatment that has been approved by the Plan (other than by Plan amendment or termination) or a decision with respect to a request by a claimant to extend a course of treatment beyond the period of time or number of treatments that has been approved by the Plan. Concurrent review means the process of assessing the continuing medical necessity, appropriateness, or utility of additional days of hospital confinement, outpatient care, and other health care services. Confinement means being a resident patient in a hospital or a qualified treatment facility for at least 15 consecutive hours per day. Successive confinements are considered one confinement if: 1. Due to the same bodily injury or sickness; and 2. Separated by fewer than 30 consecutive days when yozi are not confined. Copayment, if applicable, means the amount to be paid by you for each applicable medical service. Cosmetic surgery means surgery performed to reshape structures of the body in order to change your appearance or improve self-esteem. Covered expense means services incurred by you or your covered dependents due to bodily injury or sickness for which benefits may be available under the Plan. Covered expenses are subject to all provisions of the Plan, including the limitations and exclusions. Covered person means the employee or any of the employee's covered dependents. Creditable coverage means the total time of prior continuous health plan coverage periods used to reduce the length of any pre-existing condition limitation period applicable to you or your dependents under this Plan where these prior continuous health coverages) existed with no more than a 63-consecutive day lapse in coverage. Custodial care means services provided to assist in the activities of daily living which are not likely to improve your condition. Examples include, but are not limited to, assistance with dressing, bathing, toileting, transferring, eating, walking and taking medication. These services are considered cz~stodial care regardless if a qualified practitioner or provider has prescribed, recommended or performed the services. DEFINITIONS (continued) D Dental injury is an injury caused by a sudden, violent, and external force that could not be predicted in advance and could not be avoided. Dental injz~ry does not include chewing injuries. Dependent means a covered employee's: Legally recognized spouse; Unmarried natural blood related child, step-child, legally adopted child or child placed with the employee for adoption, or child for which the employee has legal guardianship whose age is less than the limiting age. Each child must legally qualify as a dependent as defined by the United States Internal Revenue Service and be declared on and legally qualify as a dependent on the employee's federal personal income tax return filed for each year of coverage. The limiting age for each dependent child is: a. to the end of the month of his/her 23`d birthday; or b. to the end of the month of his/her 25"' birthday, if such child is in regular full-time attendance at an accredited secondary school, college or university. The dependent child must be enrolled for sufficient course credits to maintain full-time status as defined by that school. A dependent child continues to be eligible for coverage for up to four months following the close of a school term only if enrolled as a full-time student for the following school term. Adopted children and children placed for adoption are subject to all terms and provisions of the Plan, with the exception of the pre-existing condition limitation. A covered employee's child whose age is less than the limiting age and is entitled to coverage under the provisions of this Plan because of a medical child support order; You must furnish satisfactory proof, upon request, to the Plan Manager that the above conditions continuously exist. If satisfactory proof is not submitted to the Plan Manager, the child's coverage will not continue beyond the last date of eligibility. A covered dependent child who attains the limiting age while covered under the Plan will remain eligible for benefits if all of the following exist at the same time: Mentally retarded or permanently physically handicapped; Incapable of self-sustaining employment; The child meets all of the qualifications of a dependent as determined by the United States Internal Revenue Service; 4. Declared on and legally qualify as a dependent on the employee's federal personal income tax return filed for each year of coverage; and Unmarried. DEFINITIONS (continued) Yoz~ must furnish satisfactory proof to the Plan Manager that the above conditions continuously exist on and after the date the limiting age is reached. The Plan Manager may not request such proof more often than annually after two years from the date the first proof was furnished. If satisfactory proof is not submitted to the Plan Manager, the child's coverage will not continue beyond the last date of eligibility. Durable medical e~c~ipment (DME) means equipment that is medically necessary and able to withstand repeated use. It must also be primarily and customarily used to serve a medical purpose and not be generally useful to a person except for the treatment of a bodily injzzry or sickness. E Emergency means an acute, sudden onset of a sickness or bodily injury which is life threatening or will significantly worsen without immediate medical or surgical treatment. Employee means you, as an employee, when you are permanently employed and paid a salary or earnings and are in an active status at your employer's place of business. Employer means the sponsor of the Group Plan or any subsidiary(s). Expense incurred means the fee charged for services provided to you. The date a service is provided is the expense incurred date. Experimental, investigational or for research purposes: A service is experimental, investigational or for research purposes if the Plan Manager determines; The service cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the service is furnished; or 2. The service or your informed consent document utilized with the service was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review and approval; or 3. Reliable evidence shows that the service is the subject of on-going phase I or phase II clinical trials; is the research, experimental, study or investigational arm of ongoing phase III clinical trials; or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis; or 4. Reliable evidence shows that the prevailing opinion among experts regarding the service is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or Reliable evidence will mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same service; or the written informed consent used by the treating facility or by another facility studying substantially the same service. DEFINITIONS (continued) F Family member means you or yoa~r spouse, or yoa~ or your spouse's child, brother, sister, parent, grandchild or grandparent. Free-standing surgical facility means a public or private establishment licensed to perform surgery and which has permanent facilities that are equipped and operated primarily for the purpose of performing surgery. It does not provide services or accommodations for patients to stay overnight. Functional impairment means a direct and measurable reduction in physical performance of an organ or body part. H Hospital means an institution which: Maintains permanent full-time facilities for bed care of resident patients; 2. Has a physician and surgeon in regular attendance; 3. Provides continuous 24 hour a day nursing services; 4. Is primarily engaged in providing diagnostic and therapeutic facilities for medical or surgical care of sick or injured persons; 5. Is legally operated in the jurisdiction where located; and 6. Has surgical facilities on its premises or has a contractual agreement for surgical services with an institution having a valid license to provide such surgical services; or 7. Is a lawfully operated qualified treatment facility certified by the First Church of Christ Scientist, Boston, Massachusetts. Hospital does not include an institution which is principally a rest home, skilled nursing facility, convalescent home or home for the aged. Hospital does not include a place principally for the treatment of alcoholism, chemical dependence or mental disorders. I. Late applicant means an employee and/or an employee's eligible dependent who applies for medical coverage more than 31 days after the eligibility date. DEFINITIONS (continued) M Maintenance care means any service or activity which seeks to prevent bodily injury or sickness, prolong life, promote health or prevent deterioration of a covered person who has reached the maximum level of improvement or whose condition is resolved or stable. Maxima~n: allowable fee for a service means the lesser of: The fee most often charged in the geographical area where the service was performed; The fee most often charged by the provider; The fee which is recognized as reasonable by a prudent person; 4. The fee determined by comparing charges for similar services to a national data base adjusted to the geographical area where the services or procedures were performed; or 5. The fee determined by using a national relative value scale. Relative value scale means a methodology that values medical procedures and services relative to each other that includes, but is not limited to, a scale in terms of difficulty, work, risk, as well as the material and outside costs of providing the service, as adjusted to the geographic area where the services or procedures were performed. Maximum benefit means the maximum amount that may be payable for each covered person, for expense incurred. The applicable maximum benefit is shown on the Schedule of Benefits. No further benefits are payable once the maximum benefit is reached. Medically necessary or medical necessity means the extent of services required to diagnose or treat a bodily injury or sickness which is known to be safe and effective by the majority of ga~alified practitioners who are licensed to diagnose or treat that bodily injury or sickness. Such services must be: Performed in the least costly setting required by yoa~r condition; Not provided primarily for the convenience of the patient or the gz~alified practitioner, Appropriate for and consistent with your symptoms or diagnosis of the sickness or bodily injury under treatment; 4. Furnished for an appropriate duration and frequency in accordance with accepted medical practices, and which are appropriate for your symptoms, diagnosis, sickness or bodily injury; and 5. Substantiated by the records and documentation maintained by the provider of service. Medicare means Title XVIII, Parts A and B of the Social Security Act, as enacted or amended. Mental disorder means a mental, nervous, or emotional disease or disorder of any type as classified in the Diagnostic and Statistical Manual of Mental Disorders, regardless of the cause or causes of the disease or disorder. 10 DEFINITIONS (continued) Morbid obesity means a body mass index (BMI) of 40 kilograms per mass squared or 100 pounds or more over yoz~r ideal weight as determined by the Metropolitan Life Height and Weight Tables for Men and Women, as of the date of service. Orthotic means acustom-fitted or custom-made braces, splints, casts, supports and other devices used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body when prescribed by a qualified practitioner. P Partial hospitalization means those services offered by a program: 1. Must be medically necessary; and 2. Not custodial care; and 3. Not day-care; and 4. Accredited by the Joint Commission on the Accreditation of Hospitals or in compliance with equivalent standards. Licensed drug abuse rehabilitation programs and alcohol rehabilitation programs accredited by the Joint Commission on the Accreditation of Health Care Organizations or approved by the appropriate state agency are also considered to be partial hospitalization services. Personal Nurse® means a service provided to members where by one nurse is assigned to seriously ill members. This nurse becomes the member's primary contact and access to system navigation while they are a member of the Plan. The Personal Nurse® (PN) facilitates coordination of care with vendors, customer service, providers, web services and community resources. Plan Manager means Humana Insurance Company (HIC). The Plan Manager provides services to the Plan Administrator, as defined under the Plan Management Agreement. The Plan Manager is not the Plan Administrator or the Plan Sponsor. Plan year means a period of time beginning on the Plan anniversary date of any year and ending on the day before the same date of the succeeding year. Post-service claim means any claim for a benefit under a group health plan that is not apre-service claim. Preadmission testing means only those outpatient x-ray and laboratory tests made within seven days before admission as a registered bed patient in a hospital. The tests must be for the same bodily injury or sickness causing the patient to be hospital confined. The tests must be accepted by the hospital in lieu of like tests made during confinement. Preadmission testing does not mean tests for a routine physical check-up. 11 DEFINITIONS (continued) Precertification means the process of assessing the medical necessity, appropriateness, or utility of proposed non-emergency hospital admissions, surgical procedures, outpatient care, and other health care services. Predetermination of benefits means a review by the Plan Manager of a qualified practitioner's treatment plan, specific diagnostic and procedure codes and expected charges prior to the rendering of services. Pre-existing condition means a physical or mental condition for which you have received medical attention (medical attention includes, but is not limited to: services or care) during the six month period immediately prior to the enrollment date of yozzr medical coverage under this Plan. Pre-existing conditions are covered after the end of a period of twelve months after the enrollment date (first day of coverage or, if there is a waiting period, the first day of the waiting period). Pre-existing condition limitations will be waived or reduced for pre-existing conditions that were satisfied under previous creditable coverage. Pre-service claim means a claim with respect to which the terms of the Plan condition receipt of a Plan benefit, in whole or in part, on approval of the benefit by the Plan Manager in advance of obtaining medical care. Protected lrealt/r information means individually identifiable health information about a covered person, including: (a) patient records, which includes but is not limited to all health records, physician and provider notes and bills and claims with respect to a covered person; (b) patient information, which includes patient records and all written and oral information received about a covered person; and (c) any other individually identifiable health information about covered persons. Q Qualified practitioner means a practitioner, professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or sickness, and who provides services within the scope of that license. Qa~alified treatment facility means only a facility, institution or clinic duly licensed by the appropriate state agency, and is primarily established and operating within the scope of its license. s Services means procedures, surgeries, examinations, consultations, advice, diagnosis, referrals, treatment, tests, supplies, drugs, devices or technologies. Sickness means a disturbance in function or structure of yozzr body which causes physical signs or symptoms and which, if left untreated, will result in a deterioration of the health state of the structure or system(s) of yozzr body. 12 DEFINITIONS (continued) Sound natccral toot/: means a tooth that: Is organic and formed by the natural development of the body (not manufactured); 2. Has not been extensively restored; Has not become extensively decayed or involved in periodontal disease; and Is not more susceptible to injury than a whole natural tooth. Sr~rgery means excision or incision of the skin or mucosal tissues, or insertion for exploratory purposes into a natural body opening. This includes insertion of instruments into any body opening, natural or otherwise, done for diagnostic or other therapeutic purposes. T Tlmely applicant means an employee and/or an employee's eligible dependent who applies for medical coverage within 31 days of the eligibility date. Total disability or totally disabled means: During the first twelve months of disability you or yoz~r employed covered spouse are at all times prevented by bodily injury or sickness from performing each and every material duty of yozzr respective job or occupation; After the first twelve months, total disability or totally disabled means that you or your employed covered spouse are at all times prevented by bodily injury or sickness from engaging in any job or occupation for wage or profit for which yozz or your employed covered spouse are reasonably qualified by education, training or experience; For anon-employed spouse or a child, total disability or totally disabled means the inability to perform the normal activities of a person of similar age and gender. A totally disabled person also may not engage in any job or occupation for wage or profit. U Urgent care claim means a claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations: Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or 2. In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim; or 13 t DEFINITIONS (continued) 3. Generally, whether a claim is a claim involving urgent care will be determined by the Plan Manager. However, any claim that a physician with knowledge of a claimant's medical condition determines is a "claim involving urgent care" will be treated as a "claim involving urgent care." Utilization review means the process of assessing the medical necessity, appropriateness, or utility of hospital admissions, surgical procedures, outpatient care, and other health care services. Utilization review includes precertification and concz~rrent review. Y You and your means you as the employee and any of your covered dependents, unless otherwise indicated. 14 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE OPEN ENROLLMENT Once annually you will have a choice of enrolling yourself and your eligible dependents in this Plan. You will be notified in advance when the open enrollment period is to begin and how long it will last. If yozz decline coverage for yourself or your dependents at the time you are initially eligible for coverage, you will be able to enroll yozrself and/or eligible dependents during the Open Enrollment Period. Yoz~r coverage will be subject to the pre-existing condition limitation. EMPLOYEE ELIGIBILITY Yoz~ are eligible for coverage if the following conditions are met: Yozz are an eligible employee as defined in the Personnel Policy Manual or City Ordinance. Temporary, seasonal, or part-time employees are not eligible for health benefits; or Yozz are an elected or appointed official; and You are in active status. Your eligibility date is your date of hire. EMPLOYEE EFFECTIVE DATE OF COVERAGE Yoz~ must enroll in a manner acceptable to the Plan Manager. If your completed enrollment is received by the Plan Manager before your eligibility date or within 31 days after your eligibility date, your coverage is effective on your eligibility date; 2. If yozzr completed enrollment is received by the Plan Manager more than 31 days after your eligibility date, you are a late applicant and your coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Coverage will be effective immediately following receipt of yozzr completed enrollment. EMPLOYEE DELAYED EFFECTIVE DATE If the employee is not in active status on the effective date of coverage, coverage will be effective the day the employee returns to active status. The employer must notify the Plan Manager in writing of the employee's return to active status. DEPENDENT ELIGIBILITY Each dependent is eligible for coverage on: The date the employee is eligible for coverage, if he or she has dependents who may be covered on that date; or The date of the employee's marriage for any dependent acquired on that date; or The date of birth of the employee's natural-born child; or 15 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) 4. The date a child is placed for adoption under the employee's legal guardianship, or the date which the employee incurs a legal obligation for total or partial support in anticipation of adoption; or 5. The date a covered employee's child is determined to be eligible as an alternate recipient under the terms of a medical child support order. The covered employee may cover dependents only if the employee is also covered. Check with your employer immediately on how to enroll for dependent coverage. Late enrollment will result in your dependents' coverage being subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. No person may be simultaneously covered as both an employee and a dependent. If both parents are eligible for coverage, only one may enroll for dependent coverage. DEPENDENT EFFECTIVE DATE OF COVERAGE If the employee wishes to add a newborn dependent to the Plan and a change in the employee's level of coverage is not required, enrollment must be completed and submitted to the Plan Manager. The newborn dependent will be covered on the date he or she is eligible. If the employee wishes to add a dependent (other than a newborn) to the Plan and a change in the employee's level of coverage is not required, the dependent's effective date of coverage is determined as follows: If the completed enrollment is received by the Plan Manager before the dependent's eligibility date or within 31 days after the dependent's eligibility date, that dependent is covered on the date he or she is eligible; 2. If the completed enrollment is received by the Plan Manager more than 31 days after the dependent's eligibility date, the dependent is a late applicant. The dependent's coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Coverage will be effective the first of the month following receipt of the dependent's completed enrollment. No dependent's effective date will be prior to the covered employee's effective date of coverage. A dependent child who becomes eligible for other group coverage through any employment is no longer eligible for coverage under this Plan. If your dependent child becomes an eligible employee of the employer, he or she is no longer eligible as your dependent and must make application as an eligible employee. MEDICAL CHILD SUPPORT ORDERS An individual who is a child of a covered employee shall be enrolled for coverage under the Plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN). 16 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) A QMCSO is a state court order or judgment, including approval of a settlement agreement that: (a) provides for support of a covered employee's child; (b) provides for health care coverage for that child; (c) is made under state domestic relations law (including a community property law); (d) relates to benefits under the Plan; and (e) is "qualified" in that it meets the technical requirements of applicable state law. QMCSO also means a state court order or judgment that enforces a state Medicaid law regarding medical child support required by Social Security Act § 1908 (as added by Omnibus Budget Reconciliation Act of 1993). An NMSN is a notice issued by an appropriate agency of a state or local government that is similar to a QMCSO that requires coverage under the Plan for the dependent child of anon-custodial parent who is (or will become) a covered person by a domestic relations order that provides for health care coverage. Procedures for determining the qualified status of medical child support orders are available at no cost upon request from the Plan Administrator. PRE-EXISTING CONDITION LIMITATION Benefits for pre-existing conditions are limited under the Plan. Pre-existing condition is defined in the Definitions section of this booklet. Once you or your dependents obtain health plan coverage, you are entitled to use evidence of that coverage to reduce or eliminate any pre-existing condition limitation period that might otherwise be imposed when yozi become covered under a subsequent health plan. Evidence may include a certificate of prior creditable coverage. The length of any pre-existing condition limitation period under the subsequent health plan must be reduced by the number of days of creditable coverage. Prior to imposing apre-existing condition limitation, the Plan Manager will: 1. Notify you in writing of the existence and terms of any pre-existing condition limitation; 2. Notify you of your right to request a certificate of creditable coverage from any applicable prior plans; Notify yogi of your right to submit evidence of creditable coverage to the Plan Manager to reduce the length of any pre-existing condition limitation; and 4. Offer to request a certificate of prior creditable coverage on yoa~r behalf. If, after receiving evidence of creditable coverage, the Plan Manager determines the creditable coverage is not sufficient to completely offset the Plan's pre-existing condition limitation period, the Plan Manager will: Notify you in writing of its determination; 2. Notify you of the source and substance of any information on which it relied; and Provide an explanation of appeal procedures and allow a reasonable opportunity to submit additional evidence of creditable coverage. 17 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) The Plan Manager may modify an initial determination of creditable coverage if it determines the individual did not have the claimed creditable coverage, provided the Plan Manager: Notifies you of such reconsideration in writing disclosing its determination; Notifies yozc with the source and substance of any information on which it relied; and Provides an explanation of appeal procedures and allows a reasonable opportunity to submit additional evidence of creditable coverage. Alternate means of providing evidence of creditable coverage may include an explanation of benefits, correspondence from a plan, pay stubs showing a payroll deduction of premium for health plan coverage, third party statements verifying period(s) of coverage, information obtained by telephone, and any other relevant document providing evidence of period(s) of health coverage. SPECIAL PROVISIONS FOR NOT BEING IN ACTIVE STATUS If your employer continues to pay required contributions and does not terminate the Plan, your coverage will remain in force for: No longer than the end of the calendar month during part-time status; 2. No longer than the end of the calendar month during an approved leave of absence; No longer than the end of 18 months or the duration of an approved military leave of absence, whichever is shorter; 4. No longer than the end of the calendar month of a layoff; No longer than the end of the calendar month during a period of total disability. REINSTATEMENT OF COVERAGE FOLLOWING INACTIVE STATUS If your coverage under the Plan was terminated after a period of layoff, total disability, approved leave of absence, approved military leave of absence (other than USERRA) or during part-time status, and you are now returning to work, your coverage is effective immediately on the day you return to work, subject to any pre-existing condition limitation. The eligibility period requirement will be waived with respect to the reinstatement of your coverage. If your coverage under the Plan was terminated due to a period of service in the uniformed services covered under the Uniformed Services Employment and Reemployment Rights Act of 1994, your coverage is effective immediately on the day you return to work. Eligibility waiting periods and pre- existing condition limitations will be imposed only to the extent they were applicable prior to the period of service in the uniformed services. 18 ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE (continued) FAMILY AND MEDICAL LEAVE ACT (FMLA) If you are granted a leave of absence (Leave) by the employer as required by the Federal Family and Medical Leave Act, yozc may continue to be covered under the Plan for the duration of the Leave under the same conditions as other employees who are in active status and covered by the Plan. If you choose to terminate coverage during the Leave, or if coverage terminates as a result of nonpayment of any required contribution, coverage may be reinstated on the date yozc return to active status immediately following the end of the Leave. Charges incurred after the date of reinstatement will be paid as if yozc had been continuously covered. RETIREE COVERAGE If you are an early retiree under age 65 with at least 20 years of continuous service, yozc may continue coverage under the Plan with retiree benefits for you and any of your eligible dependents until yozc turn age 65, provided such coverage was effective at the time of your retirement. Please see your employer for more details. SURVIVORSHIP COVERAGE If the employee dies while covered under the Plan, the surviving spouse and any eligible dependents may continue coverage under the Plan as per federal, state stature, or city ordinance. Any dependents acquired through the remarriage of the employee's surviving spouse will not be eligible for coverage under the Plan. SPECIAL ENROLLMENT If yozc previously declined coverage under this Plan for yourself or any eligible dependents, due to the existence of other health coverage (including COBRA), and that coverage is now lost, this Plan permits yozc, your dependent spouse, and any eligible dependents to be enrolled for medical benefits under this Plan due to any of the following qualifying events: Loss of eligibility for the coverage due to any of the following: a. Legal separation; b. Divorce; c. Cessation of dependent status (such as attaining the limiting age); d. Death; e. Termination of employment; £ Reduction in the number of hours of employment; g. Meeting or exceeding a lifetime limit on all benefits; h. Plan no longer offering benefits to a class of similarly situated individuals, which includes the employee; i. Any loss of eligibility after a period that is measured by reference to any of the foregoing. However, loss of eligibility does not include a loss due to failure of the individual or the participant to pay premiums on a timely basis or termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). 19 ELIGIBII.ITY AND EFFECTIVE DATE OF COVERAGE (continued) 2. Employer contributions towards the other coverage have been terminated. Employer contributions include contributions by any current or former employer (of the individual or another person) that was contributing to coverage for the individual. 3. COBRA coverage under the other plan has since been exhausted. The previously listed qualifying events apply only if yozc stated in writing at the previous enrollment the other health coverage was the reason for declining enrollment, but only if your employer requires a written waiver of coverage which includes a warning of the penalties imposed on late enrollees. If yozc are a covered employee or an otherwise eligible employee, who either did not enroll or did not enroll dependents when eligible, you now have the opportunity to enroll yourself and/or any previously eligible dependents or any newly acquired dependents when due to any of the following changes: Marriage; Birth; Adoption or placement for adoption; 4. Effective April 1, 2009: Loss of eligibility due to termination of Medicaid or State Children's Health Insurance Program (SCHIP) coverage; or 5. Effective April 1, 2009: Eligibility for premium assistance subsidy under Medicaid or SCHIP. You may elect coverage under this Plan provided enrollment is within 31 days from the qualifying event or 60 days from such event as identified in #4 and #5 above. Yozc MUST provide proof that the qualifying event has occurred due to one of the reasons listed before coverage under this Plan will be effective. Coverage under this Plan will be effective the date immediately following the date of the qualifying event, unless otherwise specified in this section. In the case of a dependent's birth, enrollment is effective on the date of such birth. In the case of a dependent's adoption or placement for adoption, enrollment is effective on the date of such adoption or placement for adoption. If yozc become eligible for coverage under this Plan through the special enrollment provision, benefits under the Plan will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. If yozc apply more than 31 days after a qualifying event or 60 days from such event as identified in #4 and #5 above, you are considered a late applicant and coverage will be subject to the pre-existing condition limitation as defined within the Definitions section of this booklet. Please see your employer for more details. 20 PRECERTIFICATION PRECERTIFICATION REQUIREMENTS Medical Management is a Utilization RevietivlPersonal Nzzrse~ service provided by the Plan Manager. The Medical Management unit will provide precertification as required by your Plan. Medical Management recommends calling as soon as possible to receive proper precertification. For precertification please call the toll-free number on the back of your ID card. The following benefits require precertification: INPATIENT HOSPITAL (INCLUDING INPATIENT BEHAVIORAL HEALTH) The Plan Manager must be notified at least 7 days in advance. If the admission is on an emergency basis, the Plan Manager must be notified within 48 hours or the first business day following admission. If the admission is not precertified, benefits for the hospital or qualified treatment facility will be subject to a $500 penalty per confinement. The penalty does not apply to the deductible or out-of-pocket maximums. OUTPATIENT SPEECH PHYSICAL AND OCCUPATIONAL THERAPY (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If therapy services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. OUTPATIENT SLEEP APENA (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible orout-of-pocket maximums. 21 PRECERTIFICATION (continued) OUTPATIENT PAIN MANAGEMENT (QUALIFIED PRACTITIONER OFFICE OR OUTPATIENT FACILITY) The Plan Manager must be notified in advance. If services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. DURABLE MEDICAL EQUIPMENT The Plan Manager must be notified if the purchase or rental of durable medical equipment is expected to be $750 or more. If the purchase or rental of durable medical equipment does not have the Plan Manager's prior approval, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. HOME HEALTH CARE The Plan Manager must be notified prior to services being rendered. If home health care services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. SHILLED NURSING FACILITY The Plan Manager must be notified prior to services being rendered. If a skilled nursing facility is not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. HOSPICE CARE The Plan Manager must be notified prior to services being rendered. If hospice care services are not precertified, benefits will be subject to a $500 penalty per occurrence. The penalty does not apply to the deductible or out-of-pocket maximums. ORGAN TRANSPLANTS The Plan Manager must be notified prior to organ transplant services being rendered. If organ transplant services are not precertified, they are not covered. 22 UTILIZATION MANAGEMENT Utilization management and Personal Nzzrse® services are designed to assist covered persons in making informed medical care decisions resulting in the delivery of appropriate levels of Plan benefits for each proposed course of treatment. These decisions are based on the medical information provided by the patient and the patient's physician. The patient and his or her physician determine the course of treatment. The assistance provided through these services does not constitute the practice of medicine. Payment of Plan benefits is not determined through these processes. PRECERTIFICATION Utilization review may include precertification and concurrent revietiv. This provision will not provide benefits to cover a confinement or service which is not medically necessary or otherwise would not be covered under the Plan. Precertification is not a guarantee of coverage. If yozz or yozzr covered dependent are to receive a service which requires precertification, yozz or your qualified practitioner must contact the Plan Manager, by telephone or in writing. Refer to the Precertification Requirements for time requirements. After you or your qualified practitioner have provided the Plan Manager, with yozzr diagnosis and treatment plan, the Plan Manager will: 1. Advise you by telephone, electronically, or in writing if the proposed treatment plan is medically necessary; and 2. Conduct concurrent review as necessary. If your admission is precertified by the Plan Manager, benefits are subject to all Plan provisions and are payable as shown on the Schedule of Benefits. If it is determined at any time your proposed treatment plan, either partially or totally, is not a covered expense under the terms and provisions of the Plan, benefits for services may be reduced or services may not be covered. PENALTY FOR NOT OBTAINING PRECERTIFICATION If you do not obtain precertification for services being rendered, your benefits for the qualified practitioner and hospital or gz~alified treatment facility may be reduced. Refer to the Precertification Requirements for the applicable penalty. 23 UTILIZATION MANAGEMENT (continued) SECOND SURGICAL OPINION A second surgical opinion may be required, as provided in the Plan, before the confinement will be precertified. Benefits for the second surgical opinion, including any medically necessary x-ray and laboratory tests performed by the second qualified practitioner, are payable as shown below. PAR Provider 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. If the two opinions disagree, you may obtain a third opinion. Benefits for the third opinion are payable the same as for the second opinion. The qualified practitioners providing the surgical opinions MUST NOT be in the same group practice or clinic. The qualified practitioner providing the second or third surgical opinion may confirm the need for surgery or present other treatment options. The decision whether or not to have the surgery is always yours. DISEASE MANAGEMENT The Disease Management Programs listed in this section are available to yozc and any eligible dependents covered by this Plan. These Disease Management Programs are provided at no cost to yozc. • Congestive Heart Failure: This program combines intervention, monitoring and education, which will enable you to take a more active role in managing your health. • Coronary Artery Disease: This program's objective is to promote good health through education, counseling and support. This program offers educational materials on diet, medication management, exercise and, if appropriate, smoking cessation. • End Stage Renal Disease: This program is designed to educate you and coordinate the multiple facets of your care. • Neonatal Intensive Care: This program combines care coordination and parent education to help improve the patient's outcome and reduce stress on the family. • Cancer: This program provides education, support and assistance regarding diagnosis and treatment of the patient's disease. • Chronic Kidney Disease: This program combines care coordination and education as the patient is guided through a 5-step process during the course of their treatment. 24 UTILIZATION MANAGEMENT (continued) Asthma: This program was developed to provide education and environmental assessment of the patient's disease. This program also provides collaboration with the patient's physician to develop an appropriate treatment plan for controlling asthma. Diabetes: This program is designed to educate yoa~ and coordinate the multiple facets of yoa~r care. Rare Diseases (Amyotrophic Lateral Sclerosis, or Lou Gehrig's Disease; Chronic Inflammatory Demyelinating Disease (CIDP); Cystic Fibrosis; Dermatomyositis; Hemophilia; Multiple Sclerosis; Myasthenia Gravis; Parkinson's Disease; Polymyositis; Rheumatoid Arthritis; Scleroderma; Sickle Cell Disease; and Systemic Lupus): You will be educated on the specifics of your disease, the possible complications and the treatment options available. Certain programs may not be available in all areas. Specific programs and vendors may change at Humana's sole discretion. If you have any questions regarding the Disease Management Programs listed in this section, contact the Medical Management team at 1-800-626-2738 and one of the nurses will assist you. PREDETERMINATION OF MEDICAL BENEFITS Yoz~ or your qualified practitioner may submit a written request for a predetermination of benefits. The written request should contain the treatment plan, specific diagnostic and procedure codes, as well as the expected charges. The Plan Manager will provide a written response advising if the services are a covered or non-covered expense under the Plan, what the applicable Plan benefits are and if the expected charges are within the maximum allowable fee. The predetermination of benefits is not a guarantee of benefits. Services will be subject to all terms and provisions of the Plan applicable at the time treatment is provided. If treatment is to commence more than 90 days after the date treatment is authorized, the Plan Manager will require you to submit another treatment plan. 25 SCHEDULE OF BENEFITS COVERED AND NON-COVERED EXPENSES Benefits are payable only if services are considered to be a covered expense and are subject to the specific conditions, limitations and applicable maximums of the Plan. The benefit payable for covered expenses will not exceed the maximum allotivable fee(s). A covered expense is deemed to be incurred on the date a covered service is received. The bill submitted by the provider, if any, will determine which benefit provision is applicable for payment of covered expenses. One copayment will be taken per visit per qualified practitioner. If you incur non-covered expenses, whether from a PAR provider or a Non-PAR provider, you are responsible for making the full payment to the health care provider. The fact that a qualified practitioner has performed or prescribed a medically appropriate procedure, treatment, or supply, or the fact that it may be the only available treatment for a bodily injury or sickness, does not mean that the procedure, treatment or supply is covered under the Plan. Please refer to the "Schedule of Benefits" and the "Limitations and Exclusions" sections of this Summary Plan Description for more information about covered expenses and non-covered expenses. PARTICIPATING AND NON-PARTICIPATING PROVIDERS The covered person has two (2) levels of benefits available -Participating Provider (PAR provider) benefits and Non-Participating Provider (Non-PAR provider) benefits. You may select any provider to provide yozzr medical care. In most cases, if you receive services from a PAR provider, the Plan will pay a higher percentage of benefits and you will incur lower out-of-pocket costs. Yozz are responsible for any applicable deductible, coinsurance and/or copayment. If you receive services from aNon-PAR provider, the Plan will pay benefits at a lower percentage and you will pay a larger share of the costs. Since Non-PAR providers do not have contractual arrangements with the Plan Manager to accept discounted or negotiated fees, they may bill you for charges in excess of the maximzzm allowable fee. You are responsible for charges in excess of the maximum allotivable fee in addition to any applicable deductible, coinsurance and/or copayment. Any amount you pay to the provider in excess of yozzr coinsurance or copayment will not apply to your out-of-pocket limit or deductible. Not all qualified practitioners including, but not limited to, pathologists, anesthesiologists, radiologists, assistant surgeons and emergency room physicians, who provide services at PAR hospitals are PAR qualified practitioners. If services are provided to you by such Non-PAR qualified practitioners at a PAR hospital, the Plan will pay for those services at the PAR provider benefit percentage subject to the maximum allowable fee. Non-PAR qualified practitioners may require payment from you for any amount not paid by the Plan. If possible, you may want to verify whether services are available from a PAR qualified practitioner. 26 SCHEDULE OF BENEFITS (continued) PAR PROVIDER DIRECTORY The Plan Administrator will automatically provide, without charge, information to you about how you can access a directory of PAR providers appropriate to your service area. An online directory of PAR providers is available to yotc and accessible via the Plan Manager's website at www.humana.com. This directory is subject to change. Due to the possibility of PAR providers changing status, please check the online directory of PAR providers prior to obtaining services. If yoz~ do not have access to the online directory, contact the Plan Manager at the customer service number on the back of your identification (ID) card prior to services being rendered or to request a directory. LIFETIME MAXIMUM BENEFIT Lifetime Maximum Benefit $2,000,000 per covered person. Lifetime maximum means the maximum amount of benefits available while you are covered under the Plan. Under no circumstances does lifetime mean during the lifetime of the covered person. INDIVIDUAL DEDUCTIBLE PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-SZ~rgery No deductible. Hospital Physician Services No deductible. Other Medical Services $100 per covered person per calendar year. Non-PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services $200 per covered person per calendar year. Other Medical Services $200 per covered person per calendar year. 27 SCHEDULE OF BENEFITS (continued) The deductible applies to each covered person each calendar year. Only charges which qualify as a covered expense may be used to satisfy the deductible. The amount of the deductible is stated above. Yoz~ must satisfy the separate PAR or Non-PAR deductible before the Plan will pay any benefits. Copayments are not applied to the Individual Deductible limit. FAMILY DEDUCTIBLE PAR Provider Inpatient Hospital No deductible. Outpatient Surgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services No deductible. Other Medical Services $200 per covered person per calendar year. Non-PAR Provider Inpatient Hospital No deductible. Outpatient Szzrgery No deductible. Outpatient Non-Surgery No deductible. Hospital Physician Services $400 per covered person per calendar year. Other Medical Services $400 per covered person per calendar year. The total deductible applied to all covered persons in one family in a calendar year is subject to the maximum shown above. Only charges which qualify as a covered expense may be used to satisfy the deductible. You and your covered dependents must satisfy the separate PAR or Non-PAR deductible before the Plan will pay any benefits. Copayments are not applied to the Family Deductible limit. 28 SCHEDULE OF BENEFITS (continued) INDIVIDUAL OUT-OF-POCKET LIMIT PAR Provider Non-PAR Provider $500 per calendar year. $500 per calendar year. When the amount of combined covered expenses paid by yoz~ satisfies the separate deductible and separate out-of-pocket limits as shown above, the Plan will pay 100% of covered expenses for the remainder of the calendar year, unless specifically indicated, subject to any calendar year maximums and the lifetime maximum of the Plan. If you use a combination of PAR and Non-PAR providers, the out-of-pocket amounts will track separately. Copayments, penalties, mental disorder, chemical dependence and alcoholism expenses are not applied to the Individual Out-of-Pocket Limit. FAMILY OUT-OF-POCKET LIMIT PAR Provider ~ $1,000 per calendar year. Non-PAR Provider ~ $1,000 per calendar year. When the amount of combined covered expenses paid by you and/or all your covered dependents satisfy the separate deductible and separate out-of-pocket limits as shown above, the Plan will pay 100% of covered expenses for the remainder of the calendar year, unless specifically indicated, subject to any calendar year maximums and the lifetime maximum of the Plan. If you and your covered dependents use a combination of PAR and Non-PAR providers, the out-of-pocket amounts will track separately. Copayments, penalties, mental disorder, chemical dependence and alcoholism expenses are not applied to the Family Out-of-Pocket Limit. INPATIENT HOSPITAL Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Covered expenses are payable as shown below and include charges made by a: Hospital for daily semi-private, ward, intensive care or coronary care room and board charges for each day of confinement. Benefits for a private or single-bed room are limited to the maximum allowable fee charged for asemi-private room in the hospital while a registered bed patient; Hospital for services furnished for yotcr treatment during confinement. 29 SCHEDULE OF BENEFITS (continued) PAR Provider 100%. Non-PAR Provider (All services indicated above, 80% after $500 copayment per admission, unless except for the following.) otherwise specified. • Ancillary Services 80%• OUTPATIENT HOSPITAL Precertification is required for outpatient non-emergency surgery. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Covered expenses are payable as shown below. Covered expenses include charges made by a hospital for: 1. Treatment of a bodily injury, including the emergency room charge if rendered within 48 hours of an accident; 2. Treatment of a sickness following an emergency, including the emergency room charge; 3. Preadmission testing; 4. A surgical procedure; 5. Outpatient tests, laboratory tests and x-rays; 6. MRI, MRA, PET, CAT, SPECT Scans; 7. Outpatient physical, speech, occupational, cognitive and hearing therapy; 8. Regularly scheduled treatment such as chemotherapy, inhalation therapy, radiation therapy as ordered by your attending physician. 30 SCHEDULE OF BENEFITS (continued) PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Emergency Room (Facility) 100% after $40 copayment per visit. If you are admitted to the hospital, the copayment will be waived. • Outpatient Surgery 100%. • Physical, Speech, Occupational and Cognitive 80% after deductible. Therapy • Outpatient Surgical/Non-surgical Ancillary 100%. Services • MRI, MRA, PET, CAT, SPECT Scans 80% after deductible. • Chemotherapy and Radiation Therapy 80% after deductible. Non-PAR Provider 80% after deductible, unless otherwise specified. (All services indicated above, except for the following.) • Emergency Room 80% after $40 copayment per visit. If yoz~ are admitted to the hospital, the copayment will be waived. • Outpatient Sa~rgery 80% after $250 copayment per visit. • Physical, Speech, Occupational and Cognitive 60% after deductible. • Outpatient Surgical/Non-surgical Ancillary 80%. Services • MRI, MRA, PET, CAT, SPECT Scans 60% after deductible. • Chemotherapy and Radiation Therapy 60% after deductible. 31 SCHEDULE OF BENEFITS (continued) URGENT CARE CENTER Facility charges made by an urgent care center are payable as shown below. Outpatient sz~rgery, diagnostic x-ray, laboratory tests and any additional services other than the facility charge are not payable under this benefit. Please refer to the other provisions of this Plan for available coverage. PAR Provider 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. FREE-STANDING SURGICAL FACILITY Precertification is required for outpatient non-emergency sz~rgery. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Charges made by afree-standing surgical facility for surgical procedures performed and for services rendered in the facility are payable as shown below. PAR Provider 100%. Non-PAR Provider 80% after $250 copayment per visit. QUALIFIED PRACTITIONER Covered expenses are payable as shown below and include charges made by a qualified practitioner when incurred for: Office, home, emergency room physician or inpatient hospital visits; 2. Diagnostic x-ray or laboratory tests; Professional services of a radiologist or pathologist for diagnostic x-ray examination or laboratory tests, including x-ray, radon, radium and radioactive isotope therapy; 4. Other covered medical services received from or at the direction of a qualified practitioner; Administration of anesthesia; 32 SCHEDULE OF BENEFITS (continued) 6. A surgical procedure, including pre-operative and post-operative care; If multiple or bilateral surgical procedures are performed at one operative session, the amount payable for these procedures will be limited to the nzaximzzm allotivable fee for the primary surgical procedure and: a. 50% of the maximum allowable fee for the secondary procedure; and b. 25% of the maximum allotivable fee for the third and subsequent procedures. No benefits will be payable for incidental procedures. 7. Assistant surgeon, payable at 20% of the maximum allowable fee allowed for the primary surgeon; 8. Physician assistant, payable at 20% of the maximzzm allowable fee allowed for the primary surgeon; 9. Allergy testing and vials; 10. Injections, other than routine, contraceptive and allergy injections; 1 1. MRI, MRA, PET, CAT, SPECT Scans; 12. Charges made by a gzzalified practitioner for services in performing certain oral surgical operations due to bodily injury or sickness are covered as follows: a• Excision of partially or completely unerupted impacted teeth; b. Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth when such conditions require pathological examination; c. Surgical procedures required to correct accidental injuries of the jaws, cheeks, lips, tongue, roof and floor of the mouth; d• Mandibular staple implant when not done to prepare the mouth for dentures; e. Removal of full bony impactions; f. Frenectomy (the cutting of the tissue in the midline of the tongue); g. Alveolectomyand alveoplasty related to tooth extraction; h. Orthognathic surgery if severe handicapping malocclusion is present and proved. 33 SCHEDULE OF BENEFITS (continued) unless otherwise specified. 100% PAR Provider (All services indicated above, except for the , following.) • Office V isit (Internal Medicine, Pediatrician, 100% after $20 copayment per visit. General & Family Practice), including Surgery Performed in an Office Setting and Injections Office Visit (Obstetrician and Gynecology, 100% after $20 copayment per visit. Chiropractic, Surgeon and all others), including Surgery Performed in an Office Setting and Injections Payable the same as any other sickness. • Dental/Oral Surgeries 80%after deductible, unless otherwise specified. Non-PAR Provider (All services indicated above, except for the following.) Office Visit (Internal Medicine, Pediatrician, • 80% after deductible. General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others), including Surgery performed in an office setting • Diagnostic X-ray and Laboratory Tests 80% after deductible. performed in an office setting • Diagnostic X-ray and Laboratory Tests 80%• performed in an outpatient setting Payable the same as any other sickness. • Dental/Oral Surgeries *Radiology, Pathology, Anesthesia and Emergency Room Physician services rendered by a Non-PAR t the PAR level of benefits. id a Physician but performed at a PAR facility are automatically pa 34 SCHEDULE OF BENEFITS (continued) ALLERGY INJECTIONS Allergy injections and supplies are payable as shown below. PAR Provider 100% after $3 copayment per visit. Non-PAR Provider ROUTINE CARE - UP TO AGE 17 80% after deductible. The following expenses are payable for your covered dependent, as shown below, subject to all terms and provisions of the Plan, except the exclusion for services which are not medically necessary, if your covered dependent is not confined in a hospital or qualified treatment facility and if such expenses are not incurred for diagnosis of a specific bodily injarry or sickness. Benefits include: 1. Routine examinations; 2. Immunizations and Flu/Pneumonia; 3. Routine hearing exams and testing, limited to one per calendar year; 4. Routine x-ray and laboratory tests; 5. HPV Vaccine (i.e. Gardasil), covered beginning at age 9. No benefits are payable under this benefit for: 1. Any dental examinations; 2. Medical examination for bodily injury or sickness; 3. Routine vision screening. 35 SCHEDULE OF BENEFITS (continued) PAR Provider 100%, unless otherwise specified. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 100% after $20 copayment per visit. General & Family Practice) • Office Visit (Obstetrician and Gynecology, 100% after $20 copayment per visit. Chiropractic, Surgeon and all others) Flu/Pneumonia and HPV Immunizations 100% after $3 copayment per injection. , Vaccine (i.e. Gardasil) • Routine Hearing Exam and Testing 100% after $20 copayment per visit. Non-PAR Provider 80% after deductible. (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, 80% after deductible. General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others) • Immunizations and Flu/Pneumonia Not covered. • Routine Hearing Exam and Testing 80% after deductible. ROUTINE CARE -AGE 18 AND OVER The following expenses are payable for you or your covered dependent, as shown below, subject to all hich are not medically necessary, if i ces w terms and provisions of the Plan, except the exclusion for serv oz~ are not confined in a hospital or gzzalified treatment facility and if such expenses are not incurred for y diagnosis of a specific bodily injury or sickness. Benefits include: Routine physical examinations, limited to one per calendar year, 2, Well woman examinations, not limited; Routine x-ray and laboratory tests; 4. Mammograms; 36 SCHEDULE OF BENEFITS (continued) 5 • Pap smears; 6. Flu/pneumonia immunizations; 7. Prostate antigen testing; 8. Routine immunizations; 9• Routine hearing exams and testing, limited to one per calendar year; 10. Routine cancer screenings (colonoscopy, sigmoidoscopy and proctosigmoidoscopy); 11. HPV Vaccine (i.e. Gardasil), covered through age 26; 12. Shingles Vaccine (i.e. Zostavax), covered persons age 60 and over; 13. Meningitis Vaccine, covered persons through age 21. No benefits are payable under this benefit for: 1 • Any dental examinations; 2• Medical examination for bodily injury or sickness; 3• Medical examination caused by or resulting from pregnancy; 4• Routine vision screening. PAR Provider (All services indicated above, except for the following.) • Office Visit (Internal Medicine, Pediatrician, General & Family Practice) 100%, unless otherwise specified. 100%after $20 copayment per visit. • Office Visit (Obstetrician and Gynecology, Chiropractic, Surgeon and all others) • Immunizations, Flu/Pneumonia, HPV Vaccine, Shingles Vaccine and Meningitis Vaccine • Routine Hearing Exam and Testing 100% after $20 copayment per visit. 100% after $3 copayment per injection. 100% after $20 copayment per visit. 37 SCHEDULE OF BENEFITS (continued) Non-PAR Provider 80% after deductible. (All services indicated above, except for the following.) 80% after deductible. Office Visit (Internal Medicine, Pediatrician, General & Family Practice, Obstetrician and Gynecology, Chiropractic, Surgeon and all others) Not covered. Immunizations and Flu/Pneumonia 80% after deductible. Routine Hearing Exam and Testing CHIROPRACTIC CARE Chiropractic care for the treatment of a bodily injury or sickness is payable as shown below. Maintenance care is not covered. PAR Provider (All services indicated above, except for the following.) 100% after $20 copayment per visit, unless otherwise specified. Diagnostic X-ray and Laboratory Tests Non-PAR Provider 100%. 80% after deductible. *PAR and Non-PAR provider covered expees re agdlegs of the number of ~ervi0ces rendered.vered person, per calendar year. Only 1 copayment app g SUPPLEMENTAL ACCIDENT BENEFIT This provision provides benefits for you °of the date of the ac~ dentan Eligible expen~e~lare payable as expense must be incurred within 3 days shown below and are not subject to the dedunderlthas dro~isionance. Dental x-rays and dental surgical procedures are included as eligible expenses u p No benefits are payable under this provision for expenses incurred to treat a sickness. Supplemental Accident Benefit Payable at 100%, up to a maximum benefit of $500. Charges exceeding the $500 maximum benefit are payable the same as any other sickness. 38 SCHEDULE OF BENEFITS (continued) AMBULANCE SERVICE Local professional ambulance service to the nearest hospital equipped to provide the necessary treatment is covered as shown below. Ambulance service must not be provided primarily for the convenience of the patient or the gzzalified practitioner. If you receive treatment from aNon-PAR provider, and your condition is an emergency as defined in the Definitions section of this Plan, benefits will be paid at the PAR Provider level. The "HumanaBeginnings© Program" is a service provided to employees and their eligible dependents of this Plan by the Plan Manager. This program is designed as a special service that helps mothers receive appropriate prenatal care. First, call the precertification phone number shown on the back of your ID card as soon as your pregnancy has been confirmed by a gzzalified practitioner. When yozz call, one of the nurses will ask you questions such as: your estimated date of delivery, if yozz had any problems with previous pregnancies, and your ongoing medical conditions, just to name a few. These questions are held in confidence between yozz and the nurse yozz are speaking to. Answers to these questions, along with yozrr approval, will help the nurse and yozzr doctor decide whether you need special care during your pregnancy. If yozc and/or your baby need special care before or after delivery, a nurse is available to assist in managing your care. The nurse will obtain the necessary consents from yozc to manage your care. The nurse case manager will then monitor the treatment plan and facilitate with yozrr health care professional to ensure yozz are receiving the best care while getting the most out of your health insurance benefits. If yozrr health care professional admits yozz to a hospital during yozzr pregnancy, please follow the precertification requirements defined in your benefit booklet for emergency and planned admissions. When yozc deliver yozzr baby, yozc may not feel up to calling the Plan Manager. Remind your partner, relative or health care professional to call for yozz. If yozc have any questions, call the Plan Manager and one of our nurses will help you. PREGNANCY BENEFITS Pregnancy is a covered expense for any covered person payable as shown below. Complications of pregnancy are payable as any other covered sickness at the point the complication sets in for any covered person. 39 HUMANA.BEGINNINGS'® SCHEDULE OF BENEFITS (continued) Group health plans and health insurance iss ith clgieldbirth for the motherror newborn ch ld to less than 48 any hospital length of stay in connection w hours following a vaginal delivery, or less thao9newbornollattending prov der,eafter consult ng~with the ]aw generally does not prohibit the mother s mother, from discharging the mother or her n ewuoe thatla prow deg obtain authorhzat on from thebPlan or any case, plans may not, under Federal law, q the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Pregnancy benefits are subject to all terms and provisions of the Plan, with the exception of the pre- existing condition limitation as defined within the Definitions section of this booklet. PAR Provider 100%. Non-PAR Provider 80% after $500 copayment per admission. NEWBORN BENEFITS Covered expenses incurred during a newborn child's initial inpatient hospitaualinedemractitionerd's hospital expenses for nursery room and board and miscellaneous services; q f P expenses for circumcision; and qualified practitioner's expenses for routine examination before release from the hospital. PAR Provider 100%. 80% after deductible, unless otherwise specified. Non-PAR Provider (All services indicated above, except the following.) • Facility Charge 80% after $500 copayment per admission. BIRTHING CENTERS A birthing center is a free standing facilio 'the newborn child ate, which provides prenatal care, delivery and immediate postpartum care, and care Expense incurred within 48 hours after confinement in a birthing center for services and supplies furnished for prenatal care and delivery of child(ren) are payable as shown below. 40 SCHEDULE OF BENEFITS (continued) PAR Provider 100%. Non-PAR Provider (All sel-vices indicated above, except the following.) • Facility Charge • Ancillary Charge 80% after deductible, unless otherwise specified. 80% after $500 copayment per admission. 80%. PHYSICAL, SPEECH, OCCUPATIONAL, AND COGNITIVE THERAPY BENEFIT Precertifrcation is required. If precertification is not received, benefits are subject to the penalty described in the Precertifrcation section of this booklet. Covered expenses received for physical, speech, occupational, cognitive and hearing therapy are payable as shown below. PAR Provider 80% after deductible. Non-PAR Provider SKILLED NURSING FACILITY 60% after deductible. Precertifrcation is required. If precertification is not received, benefits are subject to the penalty described in the Precertifrcation section of this booklet. Expenses incairred for daily room and board and general nursing services for each day of confinement in a skilled nursing facility are payable as shown below. The daily rate will not exceed the maximum daily rate established for licensed skilled nursing care facilities by the Department of Health and Social Services. Covered expenses for a skilled nursing facility confinement are payable when the confinement: 1 • Begins while yozi or an eligible dependent are covered under this Plan; 2• Begins after discharge from a hospital confinement or a prior covered skilled nursing facility confinement; Is necessary for care or treatment of the same bodily injury or sickness which caused the prior confinement; and 4• Occurs while you or an eligible dependent are under the regular care of a physician. 41 SCHEDULE OF BENEFITS Skilled nursing facility means only an institution licensed as a skilled nursing facility and lawfully operated in the jurisdiction where located. It must maintain and provide: 1. Permanent and full-time bed care facilities for resident patients; 2, A physician's services available at all times; 3, 24-hour-a-day skilled nursing services under the full-time supervision of a physician or registered nurse (R.N.); 4. A daily record for each patient; 5, Continuous skilled nursing care for sick or injured persons during their convalescence from sickness or bodily injury; and (, A utilization review plan. A skilled nursing facility is not except by incident, a rest a dence o~alcoholism. of the aged, or engaged in the care and treatment of mental disorders, chemical dep PAR Provider Non-PAR Provider 80% after deductible. 60% after deductible. *PAR and Non-PAR provider covered expenses aggregate to a maximum of 60 days per calendar year. HOME HEALTH CARE Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Expenses incurred for home health care as d exceed thel maximum allowableoweekly cost forrcarenin a weekly benefit for such coverage may not skilled nursing facility. Each visit by a home health care provider for evaluating the need for, developing a plan, or providing services under a home health care plan will b tiered oneehome health care visit A lvis t by a home health hours of service in a 24-hour period is cons care provider of 4 hours or more is considered one visit for every 4 hours or part thereof. Home health care provider means an agency licensed by the proper authority as a home health agency or Medicare approved as a home health agency. Home health care will not be reimbursed unless the Plan determines: 1, Hospitalization or confinement in a skilled nursing facility would otherwise be required if home care were not provided; 42 SCHEDULE OF BENEFITS (continued) 2• Necessary care and treatment are not available from a family member or other persons residing with yozz; and The home health care services will be provided or coordinated by astate-licensed or Medicare- certified home health agency or certified rehabilitation agency. The home health care plan must be reviewed and approved by the gzalified practitioner under whose care yozz are currently receiving treatment for the bodily injzrry or sickness which requires the home health care. The home health care plan consists o£ Care by or under the supervision of a registered nurse (R.N.); 2. Physical, speech, occupational, cognitive, hearing and respiratory therapy and home health aide services; and 3. Medical supplies and dzzrable medical egzzipment, laboratory services and nutritional counseling, if such services and supplies would have been covered if you were hospital confined. LIMITATIONS ON HOME HEALTH CARE BENEFITS Home health care benefits do not include: 1 • Charges for mileage or travel time to and from the covered person's home; 2• Wage or shift differentials for home health care providers; or 3. Charges for supervision of home health care providers. PAR Provider 80% after deductible. Non-PAR Provider 60% after deductible. *PAR and Non-PAR provider covered expenses aggregate to a maximum of 40 visits per calendar year. HOSPICE CARE Precertification is required. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Hospice services must be furnished in a hospice facility or in your home. A qualified practitioner must certify you are terminally ill with a life expectancy of six months or less. For hospice services only, yozzr immediate family is considered to be your parent, spouse, and your children or step-children. 43 SCHEDULE OF BENEFITS (continued) Covered expenses are payable as shown below for the following hospice services: l , Room and board and other services and supplies; 2. Part-time nursing care by or supervised by a R.N. for up to 8 hours per day; 3, Counseling services by a qualified practitioner for the hospice patient and the immediate family; 4. Medical social services provided to yoz~ or your immediate family under the direction of a qualified practitioner, which include the following: a. Assessment of social, emotional and medical needs, and the home and family situation; b. Identification of the community resources available; and c, Assistance in obtaining those resources. Nutritional counseling; Physical or occupational therapy; Part-time home health aide service for up to 8 hours in any one day; and Medical supplies, drugs and medicines prescribed by a qualified practitioner. LIMITATIONS ON HOSPICE CARE BENEFITS Hospice care benefits do NOT include: (1) private duty nursing services when confined in a hospice facility; (2) a confinement not required for pain control or other acute chronic symptom management; (3) funeral arrangements; (4) financial or legal counseling, including estate planning or drafting of a will; (5) homemaker or caretaker services, including a sitter or companion services; (6) housecleaning and household maintenance; (7) services of a social worker other than a licensed clinical social worker; (8) services by volunteers or persons caber of h ~tor heracongregat on when services are in thescoursesof the licensed pastoral counselor to a mem duties to which he or she is called as a pastor or minister. Hospice care program means a written plan of hospice care, established and reviewed by the qualified practitioner attending the patient and the hospice care agency, for providing palliative and supportive care to hospice patients. It offers supportive care to the families of hospice patients, an assessment of the hospice patient's medical and social needs, and a description of the care to meet those needs. Hospice facility means a licensed facility or part of a facility which principally provides hospice care, keeps medical records of each patient, has an ongoing quality assurance program and has a physician on call at all times. A hospice facility provides 24-hour-a-day nursing services under the direction of a R.N. and has afull- time administrator. 44 SCHEDULE OF BENEFITS (continued) Hospice care agency means an agency which has the primary purpose of providing hospice services to hospice patients. It must be licensed and operated according to the laws of the state in which it is located and meets all of these requirements: (1) has obtained any required certificate of need; (2) provides 24- hours aday, 7 day-a-week service supervised by a qualified practitioner; (3) has afull-time coordinator; (4) keeps written records of services provided to each patient; (5) has a nurse coordinator who is a R.N., who has four years of full-time clinical experience, of which at least two involved caring for terminally ill patients; and, (6) has a licensed social service coordinator. A hospice care agency will establish policies for the provision of hospice care, assess the patient's medical and social needs and develop a program to meet those needs. It will provide an ongoing quality assurance program, permit area medical personnel to use its services for their patients, and use volunteers trained in care of and services for non-medical needs. PAR Provider 80% after deductible. Non-PAR Provider ORGAN TRANSPLANT BENEFIT 60% after deductible. Precertification is required. If precertification is not received, organ transplant services will not be covered. The Plan will pay benefits for the expense of a transplant as defined below for a covered person when approved in advance by the Plan Manager, subject to those terms, conditions and limitations described below and contained in the Plan. Please contact the Plan Manager at our toll free number (866) 421-5663 when in need of these services. COVERED ORGAN TRANSPLANT Only the services, care and treatment received for, or in connection with, the pre-approved transplant of the organs identified hereafter, which are determined by the Plan Manager to be medically necessary services and which are not experimental, investigational or for research purposes will be covered by the Plan. The transplant includes: pre-transplant services, transplant inclusive of any chemotherapy and associated services, post-discharge services and treatment of complications after transplantation of the following organs or procedures only: ~ • Heart; 2• Lung(s); 3 • Liver; 4• Kidney; 5• Bone Marrow*; 45 SCHEDULE OF BENEFITS (, Intestine; ~, Pancreas; Auto islet cell; 9, Multivisceral; 10. Any combination of the above listed organs; 11. Any organ not listed above required by federal law. *The term bone marrow refers to the transplant of uum esiveo ohemotherapyellSuch oellse ay besder'a ed a patient following high-dose, ablative or myelos pp from bone marrow, circulating blood, or a combinata mat hed re at d or unrelatedldono bo~~ o d blood. the term bone from the patient m an autologous transplant or from If chemotherapy is an inteestinp the transplantat onlandlthe chemotherapy component ~wStorage of cord marrow includes the harv g, blood and stem cells will not be covered unless as an integral part of a transplant of one marrow approved by the Plan Manager. Corneal transplants and porcine heart valve implants, wl cable e rovis ons tof the Planrgans, are considered part of regular plan benefits and are subject to other app P For a transplant to be considered fully approved, prior written approval from the Plan Manager is required in advance of the transplant. You or youluationl in o~der fo the PlantManlageh to determa ne iif the advance of your need for an initial transplant eva iven a transplant will be covered. For approva al r sults of the evaluation beforle renderingea determinag on. reasonable opportunity to review the clinic Once the transplant is approved, the Plan Ma~ agsrlantlservices, the transplant and post-discharge practitioner. Benefits are payable only if the pre p services are approved by the Plan Manager. EXCLUSIONS No benefit is payable for, or in connection with, a transplant if: l , It is experimental, investigational or for research purposes as defined in the Definitions section of this booklet; 2, The Plan Manager is not contacted forived borthe Pla nManager,•ferral for evaluation of the transplant, unless such authorization is wa y 3, The Plan Manager does not approve coverage for the transplant, based on its established criteria; 4, Expenses are eligible to be paid under any private or public research fund, government program, except Medicaid, or another funding program, whether or not such funding was applied for or received; 46 SCHEDULE OF BENEFITS (continued) Tl~e expense relates to the transplantation of any non-human organ or tissue, unless otherwise stated in the Plan; 6. The expense relates to the donation or acquisition of an organ for a recipient who is not covered by the Plan; 7. A denied transplant is performed; this includes the pre-transplant evaluation, pre-transplant services, the transplant procedure, post-discharge services, immunosuppressive drugs and complications of such transplant; 8. The covered person for whom a transplant is requested has not met pre-transplant criteria as established by the Plan Manager. COVERED SERVICES For approved transplants, and all related complications, the Plan will cover only the following expenses: l . Hospital and qualified practitioner benefits, payable as shown below. If services are rendered at a Humana National Transplant Network (NTN) facility, covered expenses are paid in accordance to the NTN contracted rates; 2. Organ acquisition and donor costs. Except for bone marrow transplants, donor costs are not payable under the Plan if they are payable in whole or in part by any other group plan, insurance company, organization or person other than the donor's family or estate. Coverage for bone marrow transplants procedures will include costs associated with the donor-patient to the same extent and limitations associated with the covered person; Direct, non-medical costs* for the covered person, when the transplant is performed at a Humana National Transplant Network facility, will be paid for: (a) transportation to and from the hospital where the transplant is performed; and (b) temporary lodging at a prearranged location up to $75 per day when requested by the hospital and approved by the Plan Manager. Transportation costs for the covered person to and from the hospital where the transplant is performed will be payable as shown below. These direct, non-medical costs are only available if the covered person lives more than 100 miles from the transplant facility;** 4• Direct, non-medical costs* for one member of the covered person's immediate family (two members if the patient is under age 1 S years), when the transplant is performed at a Humana National Transplant Network facility, will be paid for: (a) transportation to and from the approved facility where the transplant is performed; and (b) temporary lodging at a prearranged location up to $75 per day during the covered person's confinement in the hospital. Transportation costs for the covered person's immediate family member(s) to and from the hospital where the transplant is performed will be payable as shown below. These direct, non-medical costs are only available if the covered person's immediate family member(s) live more than 100 miles from the transplant facility.** *Non-medical costs are not covered if a transplant is performed at a facility that is not a Humana National Transplant Network facility. **All direct, non-medical expenses for the covered person receiving the transplant and his/her family member(s) are limited to a combined maximum benefit of $10,000 per transplant. 47 SCHEDULE OF BENEFITS (continued) Humana National Transplant Network facility (payable at the PAR benefit level) • Lodging and Transportation Services Payable the same as any other sickness. 80% after deductible. Other than a Humana National Transplant Network facility (payable at the Non-PAR benefit level) • Lodging and Transportation Services Payable the same as any other sickness. Covered expenses are limited to a maximum benefit of $35,000 per transplant. 60% after deductible. Covered expenses for organ transplants performed at a Humana National Transplant Network facility aggregate toward the out-of-pocket limits described in the Schedule of Benefits. Covered expenses for organ transplants performed at a facility other than a Humana National Transplant Network facility do not aggregate toward the out-of-pocket limits described in the Schedule of Benefits. BEHAVIORAL HEALTH BENEFIT (MENTAL DISORDER, CHEMICAL DEPENDENCE OR ALCOHOLISM) Precertification is required for inpatient behavioral health care. If precertification is not received, benefits are subject to the penalty described in the Precertification section of this booklet. Expense incurred by you during a plan of treatment for mental disorder, chemical dependence or alcoholism is payable for: Charges made by a qualified practitioner; Charges made by a hospital; Charges made by a qualified treatment facility. INPATIENT BENEFITS Covered expenses while confined ct to then fetime maximum of the P an. l or qualified treatment facility, are payable as shown below, sub~e Covered expenses for inpatient treatment do not aggregate toward the out-of-pocket limits described on the Schedule of Benefits. 48 SCHEDULE OF BENEFITS (continued) PAR Provider 80%• Non-PAR Provider Not covered. T__.. ~___,. *Covered expenses aggregate to a maximum of 20 days per covered person, per cacenaar year. ~ w~ uay~ of partial hospitalization equals one inpatient day of treatment. OUTPATIENT BENEFITS Covered expenses for outpatient treatment received while not confined in a hospital or qualified treatment facility are payable as shown below, subject to the lifetime maximum of the Plan. Covered expenses for outpatient treatment do not aggregate toward the out-of-pocket limits described on the Schedule of Benefits. PAR Provider 100% after$20 copayment per visit. Non-PAR Provider Not covered. *Covered expenses aggregate to a maximum of 20 visits per covered person, per cacenaar year. LIMITATIONS ON MENTAL DISORDER, CHEMICAL DEPENDENCE OR ALCOHOLISM BENEFITS No benefits .are payable under this provision for marriage counseling, treatment of nicotine habit or addiction, or for treatment of being obese or overweight. No benefits are payable under this provision for services performed at a Residential Treatment Facility. Treatment must be provided for the cause for which benefits are payable under this provision of the Plan. 49 OTHER COVERED EXPENSES The following are other covered expenses payable as shown below: 1. Blood and blood plasma are payable as long as it is NOT replaced by donation, and administration of blood and blood products including blood extracts or derivatives; 2. Oxygen and rental of equipment for its administration; Drugs and medicines that are provided to, or administered to yoz~, while yoa~ are confined in a hospital or skilled nursing facility, by a qualified practitioner during an office visit or from a home health care provider; 4. Drugs and medicines required by law to be obtained on the written prescription of a gz~alified practitioner when not rendered by a pharmacy; Initial prosthetic devices or supplies, including but not limited to, limbs and eyes. Coverage will be provided for prosthetic devices necessary to restore minimal basic function. Replacement is a covered expense if due to pathological changes. Covered expense includes repair of the prosthetic device if not covered by the manufacturer; Supplies, up to a 30-day supply, when prescribed by your attending physician; Casts, trusses, crutches, orthotics, splints and braces. Orthotics must be custom made or custom fitted, made of rigid or semi-rigid material. Oral or dental splints and appliances must be custom made and for the treatment of documented obstructive sleep apnea. Unless specifically stated otherwise, fabric supports, replacement orthotics and braces, oral splints and appliances, dental splints and appliances, and dental braces are not a covered expense; 8. Initial contact lenses or eyeglasses following cataract surgery; 9. The rental, up to but not to exceed the purchase price, of a wheelchair, hospital bed, ventilator, hospital type equipment or other durable medical equipment (DME). The Plan, at its option, may authorize the purchase of DME in lieu of its rental, if the rental price is projected to exceed the purchase price. Repair, maintenance or duplicate DME rental is not considered a covered expense. Refer to the precertification requirements of this Plan if the rental or purchase price is expected to be $750 or more; 10. Wigs for cancer patients due to hair loss resulting from chemotherapy or radiation therapy; 11. Services for the treatment of a dental injury to a sound natural tooth, including but not limited to extraction and initial replacement. Services must begin within 90 days and be completed within 24 months after the date of the dental injury. Benefits will be paid only for expense incurred for the least expensive service that will, in the Plan Manager's opinion, produce a professionally adequate result; 12. Installation and use of an insulin infusion pump, diabetic self-management education programs and other equipment or supplies in the treatment of diabetes, except as specifically described within the Prescription Drug Benefit section; 50 OTHER COVERED EXPENSES (continued) 13. Reconstructive surgery due to bodily injury, infection or other disease of the involved part or congenital disease or anomaly of a covered dependent child which resulted in a functional impairment; 14. Reconstructive services following a covered mastectomy, including but not limited to: a. Reconstruction of the breast on which the mastectomy was performed; b. Reconstruction of the other breast to achieve symmetry; c. Prosthesis; and d. Treatment of physical complications of all stages of the mastectomy, including lymphedemas. 15. Respiratory therapy; 16. Chemotherapy and radiation therapy; 17. Cardiac rehabilitation, limited to phases I and II; 18. Surgical and non-surgical services for morbid obesity; 19. Private duty nursing (inpatient hospital only). The following services are considered other covered expenses and are payable as shown below, subject to all terms and provisions of the Plan, except the exclusion for services which are not medically necessary: 1. Elective sterilizations; reversal of sterilizations are not covered; and 2. Birth control devices, injections, implant systems and the removal of implant systems. PAR Provider (All services indicated above, 80% after deductible, unless otherwise specified. except the following.) • Birth control devices, injections, implant systems and the removal of implant systems • Elective sterilizations • Services for Morbid Obesity Payable the same as any other sickness. Payable the same as any other sickness. Payable the same as any other sickness. • Private Duty Nursing (inpatient hospital only) 100%. • Dental Injz~ry Payable the same as any other sickness. • Diabetic/Nutritional Counseling Payable the same as any other sickness. 51 OTHER COVERED EXPENSES (continued) Non-PAR Provider (All services indicated above, 60% after deductible, unless otherwise specified. except the following.) • Birth control devices, injections, implant Payable the same as any other sickness. systems and the removal of implant systems • Elective Sterilizations Payable the same as any other sickness. • Services for Morbid Obesity Payable the same as any other sickness. • Private Duty Nursing (Inpatient hospital only) 80% after deductible. • Dental injury • Diabetic/Nutritional Counseling Payable the same as any other sickness. Payable the same as any other sickness. 52 LIMITATIONS AND EXCLUSIONS The Plan does not provide benefits for: Services: a. Not furnished by a qualified practitioner or qualified treatment facility; b. Not authorized or prescribed by a qualified practitioner; c. Not covered by this Plan whether or not prescribed by a qualified practitioner; d. Which are not provided; e. For which no charge is made, or for which you would not be required to pay if yozc were not covered under this Plan unless charges are received from and reimbursable to the United States Government or any of its agencies as required by law; or f. Furnished by or payable under any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); g. Furnished for a military service connected sickness or bodily injury by or under an agreement with a department or agency of the United States Government, including the Department of Veterans Affairs; h. Performed in association with a service that is not covered under this Plan; i. Performed as a result of a complication arising from a service that is not covered under this Plan. 2. Routine vision examinations or testing; services to correct eye refractive disorders; radial keratotomy, refractive keratoplasty or any other surgery to correct myopia, hyperopia or stigmatic error; or, the purchase, fitting or repair of eyeglass frames and lenses or contact lenses, unless specifically provided under this Plan; Vision therapy (eye exercises to strengthen the muscles of the eye); 4. Routine hearing examinations; Hearing aids, the fitting or repair of hearing aids or advice on their care; implantable hearing devices; 6. Routine physical examinations and related services for occupation, employment, school, sports, camp, travel, purchase of insurance or premarital tests or examinations, unless specifically provided under this Plan; 7. Immunizations required for foreign travel; 8. Elective medical or surgical abortion, unless: a. The pregnancy would endanger the life of the mother; or b. The pregnancy is a result of rape or incest; or c. The fetus has been diagnosed with a lethal or otherwise significant abnormality; 9. All fertility testing or services performed to achieve pregnancy or ovulation by artificial means, including but not limited to, artificial insemination, in vitro fertilization, spermatogenesis, gamete intra fallopian transfer (GIFT), zygote intra fallopian transfer (ZIFT), tubal ovum transfer, embryo freezing or transfer and sperm banking; 53 LIMITATIONS AND EXCLUSIONS (continued) 10. Services related to gender change; 11. Services for a reversal of sterilization; 12. Cosmetic szrrgery and cosmetic services or devices, unless for reconstructive surgery: a. Resulting from a bodily injury, infection or other disease of the involved part, when fimctional impairment is present; or b. Resulting from a congenital disease or anomaly of a covered dependent child which resulted in a functional impairment; c. Expense incurred for reconstructive surgery performed due to the presence of a psychological condition are not covered, unless the condition(s) described above are also met. 13. Hair prosthesis, hair transplants or hair implants; 14. Dental services or appliances for the treatment of the teeth, gums, jaws or alveolar processes, including but not limited to, implants and related procedures, routine dental extractions and orthodontic procedures, unless specifically provided under this Plan; 15. Dental osteotomies; 16. Surgical or non-surgical treatment including but not limited to, appliances and therapy, for any jaw joint problem including any temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull. Surgical or non-surgical treatment of the facial muscles used in expression and mastication functions, for symptoms including but not limited to, headaches; 17. Services which are: a. Rendered in connection with a mental disorder not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services; b. Extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation. Specifically excluded are marriage counseling and services for pervasive developmental disorders. 18. Court ordered mental disorder, chemical dependence or alcoholism services; 19. Education or training, except for diabetes self-management training; 20. Educational or vocational therapy, testing, services or schools, including therapeutic boarding schools and other therapeutic environments. Educational or vocational videos, tapes, books and similar materials are also excluded; 54 LIMITATIONS AND EXCLUSIONS (continued 21. Expenses for services that are primarily and customarily used for enviromnental control or enhancement (whether or not prescribed by a qualified practitioner) and certain medical devices including, but not limited to: a. Common household items including air conditioners, air purifiers, water purifiers, vacuum cleaners, waterbeds, hypoallergenic mattresses or pillows or exercise equipment; b. Motorized transportation equipment (e.g. scooters), escalators, elevators, ramps or modifications or additions to living/working quarters or transportation vehicles; c. Personal hygiene equipment including bath shower chairs, transfer equipment or supplies or bed side commodes; d. Personal comfort items including cervical pillows, gravity lumbar reduction chairs, swimming pools, whirlpools, spas or saunas; e. Medical equipment including blood pressure monitoring devices, breast pumps, PUVA lights and stethoscopes; £ Communication system, telephone, television or computer systems and related equipment or similar items or equipment; g. Communication devices, except after surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx. 22. Any medical treatment, procedure, drug, biological product or device which is experimental, investigational or for research pzzrposes, unless otherwise specified in the Plan; 23. Pre-existing conditions to the extent specified in the Definitions section; 24. Services not medically necessary for diagnosis and treatment of a bodily injzzry or sickness; 25. Charges in excess of the maximzzm allowable fee for the service; 26. Services provided by a person who ordinarily resides in your home or who is a family member; 27. Any expense inczrred prior to your effective date under the Plan or after the date your coverage under the Plan terminates, except as specifically described in this Plan; 28. Expenses incurred for which you are entitled to receive benefits under your previous dental or medical plan; 29. Any expense due to the covered person's: a. Engaging in an illegal occupation; or b. Commission of or an attempt to commit a criminal act. 30. Any loss caused by or contributed to: a. War or any act of war, whether declared or not; b. Insurrection; or c. Any act of armed conflict, or any conflict involving armed forces of any authority. 31. Any expense incurred for services received outside of the United States while you are residing outside of the United States for more than six months in a year except as required by law for emergency care services; 55 LIMITATIONS AND EXCLUSIONS (continued) 32. Birth control pills; 33. Treatment of nicotine habit or addiction, including, but not limited to hypnosis, smoking cessation products, classes or tapes; 34. Vitamins, dietary supplements and dietary formulas (except enteral formulas for the treatment of genetic metabolic diseases, e.g. phenylketonuria (PKU)); 35. Over the counter, non-prescription medications; 36. Medications, drugs or hormones to stimulate growth unless there is a laboratory confirmed diagnosis of growth hormone deficiency, as determined by the Plan; 37. Therapy and testing for treatment of allergies including, but not limited to, services related to clinical ecology, environmental allergy and allergic immune system dysregulation and sublingual antigen(s), extracts, neutralization test and/or treatment UNLESS such therapy or testing is approved by: a. The American Academy of Allergy and Immunology, or b. The Department of Health and Human Services or any of its offices or agencies. 38. Professional pathology or radiology charges, including but not limited to, blood counts, multi- channel testing, and other clinical chemistry tests, when: a. The services do not require a professional interpretation; or b. The qualified practitioner did not provide a specific professional interpretation of the test results of the covered person. 39. Services related to the treatment and/or diagnosis of sexual dysfunction/impotence, unless specifically provided under the Prescription Drug Coverage; 40. Any treatment, including but not limited to, surgical procedures: a. For obesity, other than morbid obesity; b. For obesity, other than morbid obesity for the purpose of treating a sickness or bodily injury caused by, complicated by, or exacerbated by the obesity; 41. Services that are billed incorrectly or billed separately, but are an integral part of another billed service; 42. Expenses for health clubs or health spas, aerobic and strength conditioning, work-hardening programs or weight loss or similar programs, and all related material and product for these programs; 43. Alternative medicine; 44. Acupuncture, unless: a. The treatment is medically necessary and appropriate and is provided within the scope of the acupuncturist's license; b. You are directed to the acupuncturist for treatment by a licensed physician; and c. The acupuncture is performed in lieu of generally accepted anesthesia practices. 56 LIMITATIONS AND EXCLUSIONS (continued) 45. Services rendered in a premenstrual syndrome clinic or holistic medicine clinic; 46. Services of a midwife, unless provided by a Certified Nurse Midwife; 47. The following types of care of the feet: a. Shock wave therapy of the feet; b. The treatment of weak, strained, flat, unstable or unbalanced feet; c. Hygienic care, and the treatment of superficial lesions of the feet, such as corns, calluses or hyperkeratosis; d. The treatment of tarsalgia, metatarsalgia, or bunion, except surgically; e. The cutting of toenails, except the removal of the nail matrix; f. The provision of heel wedges, li8s or shoe inserts; and g. The provision of arch supports or orthopedic shoes, unless medically necessary because of diabetes or hammertoe. 48. Custodial care and maintenance care; 49. Weekend non-emergency hospital admissions, specifically admissions to a hospital on a Friday or Saturday at the convenience of the covered person or his or her qualified practitioner when there is no cause for an emergency admission and the covered person receives no surgery or therapeutic treatment until the following Monday; 50. Hospital inpatient services when yozz are in observation status; 51. Services rendered by a standby physician, surgical assistant, assistant surgeon, physician assistant, registered nurse or certified operating room technician unless medically necessary; 52. Private duty nursing; other than in an inpatient hospital; 53. Ambulance services for routine transportation to, from or between medical facilities and/or a gzalified practitioner's office; 54. Preadmissionlprocedural testing duplicated during a hospital confinement; 55. Lodging accommodations or transportation, unless specifically provided under this Plan; 56. Communications or travel time; 57 LIMITATIONS AND EXCLUSIONS (continued) 57. No benefits will be provided for: a. Immunotherapy for recurrent abortion; b. Chemonucleolysis; c. Biliary lithotripsy; d. Home uterine activity monitoring; e. Sleep therapy; f. Light treatments for Seasonal Affective Disorder (S.A.D.); g. Immunotherapy for food allergy; h. Prolotherapy; i. Cranial banding; j. Hyperhydroosis surgery; k. Lactation therapy; or 1. Sensory integration therapy. 58. Sickness or bodily injury for which medical payments/personal injury protection (PIP) coverage exists under any automobile, homeowner, marine, aviation, premise, or any other similar coverage, whether such coverage is in effect on a primary, secondary, or excess basis. This exclusion applies up to the available limit under the other coverage regardless of whether a claim is filed with the medical payments/PIP carrier. Whether medical payment or expense coverage is payable under another coverage is to be determined as if the coverages under this Plan did not exist; 59. Any covered expenses to the extent of any amount received from others for the bodily inja~ries or losses which necessitate such benefits. "Amounts received from others" specifically includes, without limitation, liability insurance, worker's compensation, uninsured motorists, underinsured motorists, "no-fault" and automobile med-pay payments; 60. Any bodily injury or sickness arising from or sustained in the course of any occupation or employment for compensation, profit or gain for which: a. Benefits are provided or payable under any Workers' Compensation or Occupational Disease Act or Law, or b. Coverage was available under any Workers' Compensation or Occupational Disease Act or Law regardless of whether such coverage was actually purchased. NOTE: These limitations and exclusions apply even if a qualified practitioner has performed or prescribed a medically necessary procedure, treatment or supply. This does not prevent your ga~alifred practitioner from providing or performing the procedure, treatment or supply, however, the procedure, treatment or supply will not be a covered expense. 58 TERMINATION OF COVERAGE Coverage terminates on the earliest of the following: 1. The date the Plan terminates; 2. The end of the period for which any required contribution was due and not paid; The date yoz~ enter full-time military, naval or air service, except coverage may continue during an approved military leave of absence as indicated in the Special Provisions For Not Being in Active Status provision; 4. The date yoz~ fail to be in an eligible class of persons according to the eligibility requirements of the employer; For all employees, immediately following termination of employment with your employer; 6. For all employees, immediately following yoa~r retirement; 7. For any benefit, the date the benefit is removed from the Plan; 8. For yoacr dependents, the date yoz~r coverage terminates; 9. For a dependent, the date the dependent enters full-time military, naval or air service; 10. For a dependent, the date such covered person no longer meets the definition of dependent; or 11. The date you request termination of coverage to be effective for yourself and/or yoz~r dependents. IF YOU OR ANY OF YOUR COVERED DEPENDENTS NO LONGER MEET THE ELIGIBILITY REQUIREMENTS, YOU AND YOUR EMPLOYER ARE RESPONSIBLE FOR NOTIFYING THE PLAN MANAGER OF THE CHANGE IN STATUS. COVERAGE WILL NOT CONTINUE BEYOND THE LAST DATE OF ELIGIBILITY EVEN IF NOTICE HAS NOT BEEN GIVEN TO THE PLAN MANAGER. 59 IMPORTANT NOTICES FOR EMPLOYEES AND SPOUSES AGE 65 AND OVER Federal law may affect your coverage under this Plan. The Medicare as Secondary Payer rules were enacted by an amendment to the Social Security Act. Also, additional rules which specifically affect how a large group health plan provides coverage to employees (or their spouses) over age 65 were added to the Social Security Act and to the Internal Revenue Code. Generally, the health care plan of an employer that has at least 20 employees must operate in compliance with these rules in providing plan coverage to plan participants who have "current employment status" and are Medicare beneficiaries, age 65 and over. Persons who have "current employment status" with an employer are generally employees who are actively working and also persons who are NOT actively working as follows: Individuals receiving disability benefits from an employer for up to 6 months, or Individuals who retain employment rights and have not been terminated by the employer and for whom the employer continues to provide coverage under this Plan. (For example, employees who are on an approved leave of absence). If yoa~ are a person having "current employment status" who is age 65 and over (or the dependent spouse age 65 and over of an employee of any age), your coverage under this Plan will be provided on the same terms and conditions as are applicable to employees (or dependent spouses) who are under the age of 65. Your rights under this Plan do not change because you (or your dependent spouse) are eligible for Medicare coverage on the basis of age, as long as you have "current employment status" with yoz~r employer. You have the option to reject plan coverage offered by your employer, as does any eligible employee. If you reject coverage under your employer's Plan, coverage is terminated and your employer is not permitted to offer you coverage that supplements Medicare covered services. If you (or your dependent spouse) obtain Medicare coverage on the basis of age, and not due to disability or end-stage renal disease, this Plan will consider its coverage to be primary to Medicare when you have elected coverage under this Plan and have "current employment status". If you have any questions about how coverage under this Plan relates to Medicare coverage, please contact your employer. 60 CONTINUATION OF MEDICAL BENEFITS THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1986 (COBRA) CONTINUATION OF BENEFITS On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) was signed into law. This federal law applies to employers with 20 or more employees. The law requires that employers offer employees and/or their dependents continuation of medical coverage at group rates in certain instances where there is a loss of group insurance coverage. ELIGIBILITY A qualified beneficiary under COBRA law means an employee, employee's spouse or dependent child covered by the Plan on the day before a qualifying event. A qualified beneficiary under COBRA law also includes a child born to the employee during the coverage period or a child placed for adoption with the employee during the coverage period. EMPLOYEE: An employee covered by the employer's Plan has the right to elect continuation coverage if coverage is lost due to one of the following qualifying events: Termination (for reasons other than gross misconduct, as defined by your employer) of the employee's employment or reduction in the hours of employee's employment; or Termination of retiree coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. SPOUSE: A spouse covered by the employer's Plan has the right to elect continuation coverage if the group coverage is lost due to one of the following qualifying events: The death of the employee; Termination of the employee's employment (for reasons other than gross misconduct, as defined by your employer) or reduction of the employee's hours of employment with the employer; Divorce or legal separation from the employee; The employee becomes entitled to Medicare benefits; or Termination of a retiree spouse's coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. DEPENDENT CHILD: A dependent child covered by the employer's Plan has the right to continuation coverage if group coverage is lost due to one of the following qualifying events: The death of the employee parent; • The termination of the employee parent's employment (for reasons other than gross misconduct, as defined by yoa~r employer) or reduction in the employee parent's hours of employment with the employer; • The employee parent's divorce or legal separation; Ceasing to be a "dependent child" under the Plan; The employee parent becomes entitled to Medicare benefits; or Termination of the retiree parent's coverage when the former employer discontinues retiree coverage within one year before or one year after filing for Chapter 11 bankruptcy. 61 CONTINUATION OF MEDICAL BENEFITS (continued) LOSS OF COVERAGE Coverage is lost in connection with the foregoing qualified events, when a covered employee, spouse or dependent child ceases to be covered under the same Plan terms and conditions as in effect immediately before the qualifying event (such as an increase in the premium or contribution that must be paid for employee, spouse or dependent child coverage). If coverage is reduced or eliminated in anticipation of an event (for example, an employer eliminating an employee's coverage in anticipation of the termination of the employee's employment, or an employee eliminating the coverage of the employee's spouse in anticipation of a divorce or legal separation), the reduction or elimination is disregarded in determining whether the event causes a loss of coverage. A loss of coverage need not occur immediately after the event, so long as it occurs before the end of the Maximum Coverage Period. NOTICES AND ELECTION The Plan provides that coverage terminates for a spouse due to legal separation or divorce or for a child when that child loses dependent status. Under the law, the employee or qualified beneficiary has the responsibility to inform the Plan Administrator (see Plan Description Information) if one of the above events has occurred. The qualified beneficiary must give this notice within 60 days after the event occurs. (For example, an ex-spouse should make sure that the Plan Administrator is notified of his or her divorce, whether or not his or her coverage was reduced or eliminated in anticipation of the event). When the Plan Administrator is notified that one of these events has happened, it is the Plan Administrator's responsibility to notify the Plan Manager who has contracted with a COBRA Service Provider who will in turn notify the qualified beneficiary of the right to elect continuation coverage. For a qualified beneficiary who is determined under the Social Security Act to be disabled at any time during the first 60 days of COBRA coverage, the continuation coverage period may be extended 11 additional months. The disability that extends the 18-month coverage period must be determined under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the Social Security Act. To be entitled to the extended coverage period, the disabled qualified beneficiary must provide notice to the COBRA Service Provider within the initial 18 month coverage period and within 60 days after the date of the determination of disability under the Social Security Act. Failure to provide this notice will result in the loss of the right to extend the COBRA continuation period. For termination of employment, reduction in work hours, the death of the employee, the employee becoming covered by Medicare or loss of retiree benefits due to bankruptcy, it is the Plan Administrator's responsibility to notify the Plan Manager who has contracted with a COBRA Service Provider who will in turn notify the qualified beneficiary of the right to elect continuation coverage. Under the law, continuation coverage must be elected within 60 days after Plan coverage ends, or if later, 60 days after the date of the notice of the right to elect continuation coverage. If continuation coverage is not elected within the 60 day period, the right to elect coverage under the Plan will end. 62 CONTINUATION OF MEDICAL BENEFITS (continued) A covered employee or the spouse of the covered employee may elect continuation coverage for all covered dependents, even if the covered employee or spouse of the covered employee or all covered dependents are covered under another group health plan (as an employee or otherwise) prior to the election. The covered employee, his or her spouse and dependent child, however, each have an independent right to elect continuation coverage. Thus a spouse or dependent child may elect continuation coverage even if the covered employee does not elect it. Coverage will not be provided during the election period. However, if the individual makes a timely election, coverage will be provided from the date that coverage would otherwise have been lost. If coverage is waived before the end of the 60 day election period and the waiver revoked before the end of the 60 day election period, coverage will be effective on the date the election of coverage is sent to the COBRA Service Provider. On August 6, 2002, The Trade Act of 2002 (TAA), was signed in to law. Workers whose employment is adversely affected by international trade (increased import or shift in production to another country) may become eligible to receive TAA. TAA provides a second 60-day COBRA election period for those who become eligible for assistance under TAA. Pursuant to the Trade Act of 1974, an individual who is either an eligible TAA recipient or an eligible alternative TAA recipient and who did not elect continuation coverage during the 60-day COBRA election period that was a direct consequence of the TAA-related loss of coverage, may elect continuation coverage during a 60-day period that begins on the first day of the month in which he or she is determined to be TAA-eligible individual, provided such election is made not later than 6 months after the date of the TAA-related loss of coverage. Any continuation coverage elected during the second election period will begin with the first day of the second election period and not on the date on which coverage originally lapsed. TAA created a new tax credit for certain individuals who became eligible for trade adjustment assistance (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Care Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626- 4282. The Plan Administrator shall require documentation evidencing eligibility of TAA benefits. The Plan need not require every available document to establish evidence of TAA. The burden for evidencing TAA eligibility is that of the individual applying for coverage under the Plan. MAXIMUM COVERAGE PERIOD Coverage may continue up to: 18 months for an employee and/or dependent whose group coverage ended due to termination of the employee's employment or reduction in hours of employment; 36 months for a spouse whose coverage ended due to the death of the employee or retiree, divorce, or the employee becoming entitled to Medicare at the time of the initial qualifying event; 63 CONTINUATION OF MEDICAL BENEFITS (continued) 36 months for a dependent child whose coverage ended due to the divorce of the employee parent, the employee becoming entitled to Medicare at the time of the initial qualifying event, the death of the employee, or the child ceasing to be a dependent under the Plan; For the retiree, until the date of death of the retiree who is on continuation due to loss of coverage within one year before or one year after the employer filed Chapter 11 bankruptcy. DISABILITY An 11-month extension of coverage may be available if any of the qualified beneficiaries are determined by the Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60`'' day of COBRA continuation coverage and must last at least until the end of the 18- month period of continuation coverage. The qualified beneficiary must provide notice of such determination prior to the end of the initial 18-month continuation period to be entitled to the additional 11 months of coverage. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If a qualified beneficiary is determined by SSA to no longer be disabled, yoz~ must notify the Plan of that fact within 30 days after SSA's determination. SECOND QUALIFYING EVENT An 18-month extension of coverage will be available to spouses and dependent children wlio elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months. Such second qualifying event may include the death of a covered employee, divorce or separation from the covered employee, the covered employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child's ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after the second qualifying event occurs if you want to extend your continuation coverage. TERMINATION BEFORE THE END OF MAXIMUM COVERAGE PERIOD Continuation coverage will terminate before the end of the maximum coverage period for any of the following reasons: The employer no longer provides group health coverage to any of its employees; The premium for continuation is not paid timely; The individual on continuation becomes covered under another group health plan (as an employee or otherwise); however, if the new plan coverage contains any exclusion or limitation with respect to any pre-existing condition, then continuation coverage will end for this reason only after the exclusion or limitation no longer applies or prior creditable coverage satisfies the exclusion or limitation: 64 CONTINUATION OF MEDICAL BENEFITS (continued) NOTE: The federal Health Insurance Portability and Accountability Act of 1996 requires portability of health care coverage effective for plan years beginning after June 30, 1997, an exclusion or limitation under the other group health plan may not apply at all to the qualified beneficiary, depending on the length of his or her prior creditable coverage. Portability means once yoa~ obtain health insurance, yoz~ will be able to use evidence of that insurance to reduce or eliminate any pre-existing medical condition limitation period (under certain circumstances) when yotc move from one health plan to another. The individual on continuation becomes entitled to Medicare benefits; If there is a final determination under Title II or XVI of the Social Security Act that an individual is no longer disabled; however, continuation coverage will not end until the month that begins more than 30 days after the determination; The occurrence of any event (e.g. submission of a fraudulent claim) permitting termination of coverage for cause under the Plan. TYPE OF COVERAGE; PREMIUM PAYMENT If continuation coverage is elected, the coverage must be identical to the coverage provided under the employer's Plan to similarly situated non-COBRA beneficiaries. This means that if the coverage for similarly situated non-COBRA beneficiaries is modified, coverage for the individual on continuation will be modified. The initial premium payment for continuation coverage is due by the 45th day after coverage is elected. The initial premium includes charges back to the date the continuation coverage began. All other premiums are due on the first of the month for which the premium is paid, subject to a 31 day grace period. The COBRA Service Provider must provide the individual with a quote of the total monthly premium. Premium for continuation coverage may be increased, however, the premium may not be increased more than once in any determination period. The determination period is a 12 month period which is established by the Plan. The monthly premium payment to the Plan for continuing coverage must be submitted directly to the COBRA Service Provider. This monthly premium may include the employee's share and any portion previously paid by the employer. The monthly premium must be a reasonable estimate of the cost of providing coverage under the Plan for similarly situated non-COBRA beneficiaries. The premium for COBRA continuation coverage may include a 2% administration charge. However, for qualified beneficiaries who are receiving up to 11 months additional coverage (beyond the first 18 months) due to disability extension (and not a second qualifying event), the premium for COBRA continuation coverage may be up to 150% of the applicable premium for the additional months. Qualified beneficiaries who do not take the additional 11 months of special coverage will pay up to 102% of the premium cost. 65 CONTINUATION OF MEDICAL BENEFITS (continued) OTHER INFORMATION Additional information regarding rights and obligations under the Plan and under federal law may be obtained by contacting the COBRA Service Provider or the Plan Manager. It is important for the covered person or qualified beneficiary to keep the Plan Administrator, COBRA Service Provider and Plan Manger informed of any changes in marital status, or a change of address. PLAN CONTACT INFORMATION Ceridian COBRA Continuation Services 3201 34"' Street South St. Petersburg, FL 33711-3828 Toll Free: 1-800-488-8757 Humana Insurance Company Billing/Enrollment Department 101 E. Main Street Louisville, KY 40201 Toll Free: 1-800-872-7207 66 THE UNIFORMED SERVICES. EMPLOYMENT AND REEMYLU Y lvllrav r RIGHTS ACT OF 1994 (USERRA) CONTINUATION OF BENEFITS Effective October 13, 1994 federal law requires that health plans must offer to continue coverage for employees who are absent due to service in the uniformed services and/or their dependents. Coverage may continue for up to 18 or 24 months after the date the employee is first absent due to uniformed service. ELIGIBILITY An employee is eligible for continuation under USERRA if absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard, the commissioned corps of the Public Health Service, or any other category of persons designated by the President of the United States of America in a time of war or national emergency. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training, full-time National Guard duty, and for the purpose of an examination to determine fitness for duty. An employee's dependents who have coverage under the Plan immediately prior to the date of the employee's covered absence are eligible to elect continuation under USERRA. PREMIUM PAYMENT If continuation of Plan coverage is elected under USERRA, the employee or dependent is responsible for payment of the applicable cost of coverage. If the employee is absent for 30 days or less, the cost will be the amount the employee would otherwise pay for coverage. For absences exceeding 30 days, the cost may be up to 102% of the cost of coverage under the Plan. This includes the employee's share and any portion previously paid by the employer. DURATION OF COVERAGE Elected continuation coverage under USERRA will continue until the earlier of: 18 months beginning the first day of absence from employment due to service in the uniformed services for elections made prior to 12/10/04; or 24 months beginning the first day of absence from employment due to service in the uniformed services for elections beginning on or after 12/10/04; or The day after the employee fails to apply for or return to employment as required by USERRA, after completion of a period of service. Under federal law, the period of coverage available under USERRA shall run concurrently with the COBRA period available to an employee and/or eligible dependents. OTHER INFORMATION Employees should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status, or a change of address. 67 COORDINATION OF BENEFITS BENEFITS SUBJECT TO THIS PROVISION Benefits described in this Plan are coordinated with benefits provided by other plans under which yoa~ are also covered. The Prescription Drug benefit is not subject to these coordination provisions. Tllis is to prevent duplication of coverage and a resulting increase in the cost of medical coverage. For this purpose, a plan is one which covers medical or dental expenses and provides benefits or services by group, franchise or blanket insurance coverage. This includes group-type contracts not available to the general public, obtained and maintained only because of the covered person's membership in, or connection with, a particular organization or group, whether or not designated as franchise, blanket, or in some other fashion. Plan also includes any coverage provided through the following: 1. Employer, trustee, union, employee benefit, or other association; or 2. Governmental programs, programs mandated by state statute, or sponsored or provided by an educational institution. This Coordination of Benefits provision does not apply to any individual policies or Blanket Student Accident Insurance provided by, or through, an educational institution. Allowable expense means any eligible expense, a portion of which is covered under one of the plans covering the person for whom claim is made. Each plan will determine what is an allowable expense according to the provisions of the respective plan. When a plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered will be deemed to be both an allowable expense and a benefit paid. EFFECT ON BENEFITS One of the plans involved will pay benefits first. This is called the primary plan. All other plans are called secondary plans. When this Plan is the secondary plan, the sum of the benefit payable will not exceed 100% of the total allowable expenses incurred under the Plan and any other plans included under this provision. ORDER OF BENEFIT DETERMINATION In order to pay claims, it must be determined which plan is primary and which plan(s) are secondary. A plan will pay benefits first if it meets one of the following conditions: 1. The plan has no coordination of benefits provision; 2. The plan covers the person as an employee; 3. For a child who is covered under both parents' plans, the plan covering the parent whose birthday (month and day) occurs first in the calendar year pays before the plan covering the other parent. If the birthdates of both parents are the same, the Plan which has covered the person for the longer period of time will be determined the primary plan; If a plan other than this Plan does not include provision 3, then the gender rule will be followed to determine which plan is primary. 68 COORDINATION OF BENEFITS (continued) 4. In the case of dependent children covered under the plans of divorced or separated parents, the following rules apply: a. The plan of a parent who has custody will pay the benefits first; b. The plan of astep-parent who has custody will pay benefits next; c. The plan of a parent who does not have custody will pay benefits next; d. The plan of astep-parent who does not have custody will pay benefits next. There may be a court decree which gives one parent financial responsibility for the medical or dental expenses of the dependent children. If there is a court decree, the rules stated above will not apply if they conflict with the court decree. Instead, the plan of the parent with financial responsibility will pay benefits first. 5. If a person is laid off or is retired or is a dependent of such person, that plan covers after the plan covering such person as an active employee or dependent of such employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule will be ignored. If the above rules do not apply or cannot be determined, then the plan that covered the person for the longest period of time will pay first. COORDINATION OF BENEFITS WITH MEDICARE When an employer employs 100 or more persons, the benefits of the Plan will be payable first for a covered person who is under age 65 and eligible for Medicare. The benefits of Medicare will be payable second. MEDICARE PART A means the Social Security program that provides hospital insurance benefits. MEDICARE PART B means the Social Security program that provides medical insurance benefits. For the purposes of determining benefits payable for any covered person who is eligible to enroll for Medicare Part B, but does not, the Plan Manager assumes the amount payable under Medicare Part B to be the amount the covered person would have received if he or she enrolled for it. A covered person is considered to be eligible for Medicare on the earliest date coverage under Medicare could become effective for him or her. OPTIONS Federal Law allows the Plan's actively working covered employees age 65 or older and their covered spouses who are eligible for Medicare to choose one of the following options: OPTION 1 -The benefits of the Plan will be payable first and the benefits of Medicare will be payable second. OPTION 2 -Medicare benefits only. The covered person and his or her dependents, if any, will not be covered by the Plan. 69 CUURDINATION OF BENEFITS (continued) Eacli covered employee and each covered spouse will be provided with the choice to elect one of these options at least one month before the covered employee or the covered spouse becomes age 65. All new covered employees and newly covered spouses age 65 or older will also be offered these options. If Option 1 is chosen, its issue is subject to the same requirements as for a covered employee or dependent who is under age 65. Under Federal law, there are two categories of persons eligible for Medicare. The calculation and payments of benefits by the Plan differs for each category. CATEGORY 1 Medicare Eligibles are actively working covered employees age 65 or older and their age 65 or older covered spouses, and age 65 or older covered spouses of actively working covered employees who are under age 65. CATEGORY 2 Medicare Eligibles are any other covered persons entitled to Medicare, whether or not they enrolled for it. This category includes, but is not limited to, retired covered employees and their spouses or covered dependents of a covered employee other than his or her spouse. CALCULATION AND PAYMENT OF BENEFITS For covered persons in Category 1, benefits are payable by the Plan without regard to any benefits payable by Medicare. Medicare will then determine its benefits. For covered persons in Category 2, Medicare benefits are payable before any benefits are payable by the Plan. The benefits of the Plan will then be reduced by the full amount of all Medicare benefits the covered person is entitled to receive, whether or not they were actually enrolled for Medicare. RIGHT OF RECOVERY The Plan reserves the right to recover benefit payments made for an allowable expense under the Plan in the amount which exceeds the maximum amount the Plan is required to pay under these provisions. This right of recovery applies to the Plan against: 1. Any person(s) to, for or with respect to whom, such payments were made; or 2. Any other insurance companies, or organizations which according to these provisions, owe benefits due for the same allowable expense under any other plan. The Plan alone will determine against whom this right of recovery will be exercised. 70 REIMBURSEMENT/SUBROGATION The beneficiary agrees that by accepting and in return for the payment of covered expenses by the Plan in accordance with the terms of this Plan: The Plan shall be repaid the full amount of the covered expenses it pays from any amount received from others for the bodily injz~ries or losses which necessitated such covered expenses. Without limitation, "amounts received from others specifically includes, but is not limited to, liability insurance, worker's compensation, uninsured motorists, underinsured motorists, "no- fault" and automobile med-pay payments or recovery from any identifiable fund regardless of whether the beneficiary was made whole. 2. The Plan's right to repayment is, and shall be, prior and superior to the right of any other person or entity, including the beneficiary. 3. The right to recover amounts from others for the injuries or losses which necessitate covered expenses is jointly owned by the Plan and the beneficiary. The Plan is subrogated to the beneficiary's rights to that extent. Regardless of who pursues those rights, the funds recovered shall be used to reimburse the Plan as prescribed above; the Plan has no obligation to pursue the rights for an amount greater than the amount that it has paid, or may pay in the future. The rights to which the Plan is subrogated are, and shall be, prior and superior to the rights of any other person or entity, including the beneficiary. 4. The beneficiary will cooperate with the Plan in any effort to recover from others for the bodily injuries and losses which necessitate covered expense payments by the Plan. The beneficiary will notify the Plan immediately of any claim asserted and any settlement entered into, and will do nothing at any time to prejudice the rights and interests of the Plan. Neither the Plan nor the beneficiary shall be entitled to costs or attorney fees from the other for the prosecution of the claim. RIGHT TO COLLECT NEEDED INFORMATION You must cooperate with the Plan Manager and when asked, assist the Plan Manager by: Authorizing the release of medical information including the names of all providers from whom you received medical attention; • Obtaining medical information and/or records from any provider as requested by the Plan Manager; Providing information regarding the circumstances of your sickness or bodily injury; Providing information about other insurance coverage and benefits, including information related to any bodily injury or sickness for which another party may be liable to pay compensation or benefits; and Providing information the Plan Manager requests to administer the Plan. Failure to provide the necessary information will result in denial of any pending or subsequent claims, pertaining to a bodily injury or sickness for which the information is sought, until the necessary information is satisfactorily provided. 71 1 ~ REIMBURSEMENT/SUBROGATION (continued) DUTY TO COOPERATE IN GOOD FAITH Yotc are obliged to cooperate with the Plan Manager in order to protect the Plan's recovery rights. Cooperation includes promptly notifying the Plan Manager that you may have a claim, providing the Plan Manager relevant information, and signing and delivering such documents as the Plan Manager reasonably request to secure the Plan's recovery rights. Yoac agree to obtain the Plan's consent before releasing any party from liability for payment of medical expenses. You agree to provide the Plan Manager with a copy of any summons, complaint or any other process serviced in any lawsuit in which you seek to recover compensation for your bodily injury or sickness and its treatment. You will do whatever is necessary to enable the Plan Manager to enforce the Plan's recovery rights and will do nothing after loss to prejudice the Plan's recovery rights. You agree that yoac will not attempt to avoid the Plan's recovery rights by designating all (or any disproportionate part) of any recovery as exclusively for pain and suffering. Failure of the covered person to provide the Plan Manager such notice or cooperation, or any action by the covered person resulting in prejudice to the Plan's rights will be a material breach of this Plan and will result in the covered person being personally responsible to make repayment. In such an event, the Plan may deduct from any pending or subsequent claim made under this Plan any amounts the covered person owes the Plan until such time as cooperation is provided and the prejudice ceases. 72 r ~ ~ ~ GENERAL PROVISIONS The following provisions are to protect yozzr legal rights and the legal rights of the Plan. INCONTESTABILITY After yoz~ are covered under this Plan without interruption for two years, the Plan cannot contest the validity of your coverage except for: 1. Nonpayment of premium; 2. Your ineligibility under the Plan; 3. Any Plan provision; 4. Any fraudulent misrepresentation made by you•, or 5. Any defenses the Plan may have by law. An independent incontestability period begins for each type of change in coverage or when the Plan requires a new employee enrollment form. This provision only limits the Plan's rights to void your coverage after you have been covered without interruption for two years. RIGHT TO REQUEST OVERPAYMENTS The Plan reserves the right to recover any payments made by the Plan that were: 1. Made in error; or 2. Made to you or any party on yozzr behalf where the Plan determines the payment to yozz or any party is greater than the amount payable under this Plan. The Plan has the right to recover against you if the Plan has paid yoz~ or any other party on yozzr behalf. WORKERS' COMPENSATION NOT AFFECTED The Plan is not issued in lieu of, nor does it affect any requirement for coverage by any Workers' Compensation or Occupational Disease Act or Law. 73 M ~ ~ GENERAL PROVISIONS (continued) WORKERS' COMPENSATION If benefits are paid by the Plan and the Plan determines yozz received Workers' Compensation for the same incident, the Plan has the right to recover as described under the Reimbursement/Subrogation provision. The Plan will exercise its right to recover against you even though: I. The Workers' Compensation benefits are in dispute or are made by means of settlement or compromise; 2. No final determination is made that bodily injury or sickness was sustained in the course of or resulted from your employment; 3. The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by you or the Workers' Compensation carrier; 4. The medical or health care benefits are specifically excluded from the Workers' Compensation settlement or compromise. Yozz hereby agree that, in consideration for the coverage provided by the Plan, you will notify the Plan Manager of any Workers' Compensation claim yozz make, and that yoz~ agree to reimburse the Plan as described above. MEDICAID This Plan will not take into account the fact that an employee or dependent is eligible for medical assistance or Medicaid under state law with respect to enrollment, determining eligibility for benefits, or paying claims. If payment for Medicaid benefits has been made under a state Medicaid plan for which payment would otherwise be due under this Plan, payment of benefits under this Plan will be made in accordance with a state law which provides that the state has acquired the rights with respect to a covered employee to the benefits payment. CONSTRUCTION OF PLAN TERMS The Plan Manager has the sole right to construe and prescribe the meaning, scope and application of each and all of the terms of the Plan, including, without limitation, the benefits provided thereunder, the obligations of the beneficiary and the recovery rights of the Plan; such construction and prescription by the Plan Manager shall be final and uncontestable. THE WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 (WHCRA) If you have had or are going to have a mastectomy, yoz~ may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy- related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: 74 i ' 4 GENERAL PROVISIONS (continued) All stages of reconstruction of the breast on which the covered mastectomy was performed; • Sz~rgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. Contact your employer if you would like more information on WHCRA benefits. PRIVACY OF PROTECTED HEALTH INFORMATION The Plan is required by law to maintain the privacy of yoacr protected health information in all forms including written, oral and electronically maintained, stored and transmitted information and to provide individuals with notice of the Plan's legal duties and privacy practices with respect to protected health information. The Plan has policies and procedures specifically designed to protect your health information when it is in electronic format. This includes administrative, physical and technical safeguards to ensure that your health information cannot be inappropriately accessed while it is stored and transmitted to the Plan Manager and others that support the Plan. In order for the Plan to operate, it may be necessary from time to time for health care professionals, the Plan Administrator, individuals who perform Plan-related functions under the auspices of the Plan Administrator, the Plan Manager and other service providers that have been engaged to assist the Plan in discharging its obligations with respect to delivery of benefits, to have access to what is referred to as protected health information. A covered person will be deemed to have consented to use of protected health information about him or her by virtue of enrollment in the Plan. Any individual who may not have intended to provide this consent and who does not so consent must contact the Plan Administrator prior to filing any claim for Plan benefits, as coverage under the Plan is contingent upon consent. Individually identifiable health information will only be used or disclosed for purposes of Plan operation or benefits delivery. In that regard, only the minimum necessary disclosure will be allowed. The Plan Administrator, Plan Manager, and other entities given access to protected health information, as permitted by applicable law, will safeguard protected health information to ensure that the information is not improperly disclosed. Disclosure of protected health information is improper if it is not allowed by law or if it is made for any purpose other than Plan operation or benefits delivery. Disclosure for Plan purposes to persons authorized to receive protected health information may be proper, so long as the disclosure is allowed by law and appropriate under the circumstances. Improper disclosure includes disclosure to the employer for employment purposes, employee representatives, consultants, attorneys, relatives, etc. who have not executed appropriate agreements effective to authorize such disclosure. The Plan Manager will afford access to protected health information in its possession only as necessary to discharge its obligations as a service provider, within the restrictions noted above. However, Plan records that include protected health information are the property of the Plan. Information received by the Plan Manager is information received on behalf of the Plan. 75 GENERAL PROVISIONS (continued) The Plan Manager will afford access to protected health information as reasonably directed in writing by the Plan Administrator, which shall only be made with due regard for confidentiality. In that regard, the Plan Manager has been directed that disclosure of protected health information may be made to the person(s) designated by the Plan Administrator. Individuals who have access to protected health information in connection with their performance of Plan-related functions under the auspices of the Plan Administrator will be trained in these privacy policies and relevant procedures prior to being granted any access to protected health information. The Plan Manager and other Plan service providers will be required to safeguard protected health information against improper disclosure through contractual arrangements. In addition, you should know that the employer /Plan Sponsor may legally have access, on an as-needed basis, to limited health information for the purpose of determining Plan costs, contributions, Plan design, and whether Plan modifications are warranted. In addition, federal regulators such as the Department of Health and Human Services and the Department of Labor may legally require access to protected health information to police federal legal requirements about privacy. Covered persons may have access to protected health information about them that is in the possession of the Plan, and they may make changes to correct errors. Covered persons are also entitled to an accounting of all disclosures that may be made by any person who acquires access to protected health information concerning them and uses it other than for Plan operation or benefits delivery. In this regard, please contact the Plan Administrator. Covered persons are urged to contact the originating health care professional with respect to medical information that may have been acquired from them, as those items of information are relevant to medical care and treatment. And finally, covered persons may consent to disclosure of protected health information, as they please. 76 r ~ i CLAIM PROCEDURES SUBMITTING A CLAIM This section describes what a covered person (or his or her authorized representative) must do to file a claim for Plan benefits. • A claim must be filed with the Plan Manager in writing and delivered to the Plan Manager, by mail, postage prepaid. However, a submission to obtain pre-authorization may also be filed with the Plan Manager by telephone (this applies to dental Plans only with respect to argent care claims); • Claims must be submitted to the Plan Manager at the address indicated in the documents describing the Plan or claimant's identification card. Claims will not be deemed submitted for purposes of these procedures unless and until received at the correct address; • Also, claims submissions must be in a format acceptable to the Plan Manager and compliant with any applicable legal requirements. Claims that are not submitted in accordance with the requirements of applicable federal law respecting privacy of protected health information and/or electronic claims standards will not be accepted by the Plan; • Claims submissions must be timely. Claims must be filed as soon as reasonably possible after they are incurred, and in no event later than 6 months after the date of loss, except if you were legally incapacitated. Plan benefits are only available for claims that are incurred by a covered person during the period that he or she is covered under the Plan; • Claims submissions must be complete. They must contain, at a minimum: a. The name of the covered person who incurred the covered expense; b. The name and address of the health care provider; c. The diagnosis of the condition; d. The procedure or nature of the treatment; e. The date of and place where the procedure or treatment has been or will be provided; f. The amount billed and the amount of the covered expense not paid through coverage other than Plan coverage, as appropriate; g. Evidence that substantiates the nature, amount, and timeliness of each covered expense in a format that is acceptable according to industry standards and in compliance with applicable law. Presentation of a prescription to a pharmacy does not constitute a claim. If a covered person is required to pay the cost of a covered prescription drug, however, he or she may submit a claim based on that amount to the Plan Manager. A general request for an interpretation of Plan provisions will not be considered to be a claim. Requests of this type, such as a request for an interpretation of the eligibility provisions of the Plan, should be directed to the Plan Administrator. 77 CLAIM PROCEDURES {continued) Mail medical claims and correspondence to: Humana Claims Office P.O. Box 14610 Lexington, KY 405 1 2-46 1 0 MISCELLANEOUS MEDICAL CHARGES If yoa~ accumulate bills for medical items yozc purchase or rent yourself, send them to the Plan Manager at least once every three months during the year (quarterly). The receipts must include the patient name, name of item, date item purchased or rented and name of the provider of service. PROCEDURAL DEFECTS If apre-service claim submission is not made in accordance with the Plan's procedural requirements, the Plan Manager will notify the claimant of the procedural deficiency and how it may be cured no later than within five (5) days (or within 24 hours, in the case of an urgent care claim) following the failure. A post-service claim that is not submitted in accordance with these claims procedures will be returned to the submitter. ASSIGNMENTS AND REPRESENTATIVES A covered person may assign his or her right to receive Plan benefits to a health care provider only with the consent of the Plan Manager, in its sole discretion, except as may be required by applicable law. Assignments must be in writing. If a document is not sufficient to constitute an assignment, as determined by the Plan Manager, then the Plan will not consider an assignment to have been made. An assignment is not binding on the Plan until the Plan Manager receives and acknowledges in writing the original or copy of the assignment before payment of the benefit. If benefits are assigned in accordance with the foregoing paragraph and a health care provider submits claims on behalf of a covered person, benefits will be paid to that health care provider. In addition, a covered person may designate an authorized representative to act on his or her behalf in pursuing a benefit claim or appeal. The designation must be explicitly stated in writing and it must authorize disclosure of protected health information with respect to the claim by the Plan, the Plan Manager and the authorized representative to one another. If a document is not sufficient to constitute a designation of an authorized representative, as determined by the Plan Manager, then the Plan will not consider a designation to have been made. An assignment of benefits does not constitute designation of an authorized representative. Any document designating an authorized representative must be submitted to the Plan Manager in advance, or at the time an authorized representative commences a course of action on behalf of a claimant. At the same time, the authorized representative should also provide notice of commencement of the action on behalf of the claimant to the claimant, which the Plan Manager may verify with the claimant prior to recognizing the authorized representative status; 78 ~ ~ ~ CLAIM PROCEDURES (continues) In any event, a health care provider with knowledge of a claimant's medical condition acting in connection with an urgent care claim will be recognized by the Plan as the claimant's authorized representative. Covered persons should carefully consider whether to designate an authorized representative. An authorized representative may make decisions independent of the covered person, such as whether and how to appeal a claim denial. CLAIMS DECISIONS After submission of a claim by a claimant, the Plan Manager will notify the claimant within a reasonable time, as follows: PRE-SERVICE CLAIMS The Plan Manager will notify the claimant of a favorable or adverse determination within a reasonable time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim by the Plan. However, this period may be extended by an additional 15 days, if the Plan Manager determines that the extension is necessary due to matters beyond the control of the Plan. The Plan Manager will notify the affected claimant of the extension before the end of the initial 15-day period, the circumstances requiring the extension, and the date by which the Plan expects to make a decision. If the reason for the extension is because of the claimant's failure to submit information necessary to decide the claim, the notice of extension will describe the required information. The claimant will have at least 45 days from the date the notice is received to provide the specified information. URGENT CARE CLAIMS The Plan Manager will determine whether a claim is an urgent care claim. This determination will be made on the basis of information furnished by or on behalf of a claimant. In making this determination, the Plan Manager will exercise its judgment, with deference to the judgment of a physician with knowledge of the claimant's condition. Accordingly, the Plan Manager may require a claimant to clarify the medical urgency and circumstances that support the urgent care claim for expedited decision-making. The Plan Manager will notify the claimant of a favorable or adverse determination as soon as possible, taking into account the medical exigencies particular to the claimant's situation, but not later than 72 hours after receipt of the urgent care claim by the Plan. However, if a claim is submitted that does not provide sufficient information to determine whether, or to what extent, expenses are covered or payable under the Plan, notice will be provided by the Plan Manager as soon as possible, but not more than 24 hours after receipt of the urgent care claim by the Plan. The notice will describe the specific information necessary to complete the claim. 79 ~ f ~ CLAIM PROCEDURES (cnntin~~Prll The claimant will have a reasonable amount of time, taking into account his or her circumstances, to provide the necessary information but not less than 48 hours; The Plan Manager will notify the claimant of the Plan's urgent care claim determination as soon as possible, but in no event more than 48 hours after the earlier of: The Plan's receipt of the specified information; or 2. The end of the period afforded the claimant to provide the specified additional information. CONCURRENT CARE DECISIONS The Plan Manager will notify a claimant of a conczzrrent care decision that involves a reduction in or termination of benefits that have been pre-authorized. The Plan Manager will provide the notice sufficiently in advance of the reduction or termination to allow the claimant to appeal and obtain a determination on review of the adverse determination before the benefit is reduced or terminated. A request by a claimant to extend a course of treatment beyond the period of time or number of treatments that is a claim involving urgent care will be decided by the Plan Manager as soon as possible, taking into account the medical exigencies. The Plan Manager will notify a claimant of the benefit determination, whether adverse or not within 24 hours after receipt of the claim by the Plan, provided that the claim is submitted to the Plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments. POST-SERVICE CLAIMS The Plan Manager will notify the claimant of a favorable or adverse determination within a reasonable time, but not later than 30 days after receipt of the claim by the Plan. However, this period may be extended by an additional 15 days, if the Plan Manager determines that the extension is necessary due to matters beyond the control of the Plan. The Plan Manager will notify the affected claimant of the extension before the end of the initial 30-day period, the circumstances requiring the extension, and the date by which the Plan expects to make a decision. If the reason for the extension is because of the claimant's failure to submit information necessary to decide the claim, the notice of extension will describe the required information. The claimant will have at least 45 days from the date the notice is received to provide the specified information. The Plan Manager will make a decision no later than 15 days after the earlier of the date on which the information provided by the claimant is received by the Plan or the expiration of the time allowed for submission of the additional information. TIMES FOR DECISIONS The periods of time for claims decisions presented above begin when a claim is received by the Plan, in accordance with these claims procedures. 80 f 4 t CLAIM PROCEDURES (continued) PAYMENT OF CLAIMS Many health care providers will request an assignment of benefits as a matter of convenience to both provider and patient. Also as a matter of convenience, the Plan Manager will, in its sole discretion, assume that an assignment of benefits has been made to certain Network Providers. In those instances, the Plan Manager will make direct payment to the hospital, clinic or physician's office, unless the Plan Manager is advised in writing that yozi have already paid the bill. If you have paid the bill, please indicate on the original statement, "paid by employee," and send it directly to the Plan Manager. You will receive a written explanation of the benefit determination. The Plan Manager reserves the right to request any information required to determine benefits or process a claim. You or the provider of services will be contacted if additional information is needed to process your claim. When an employee's child is subject to a medical child support order, the Plan Manager will make reimbursement of eligible expenses paid by you, the child, the child's non-employee custodial parent, or legal guardian, to that child or the child's custodial parent, or legal guardian, or as provided in the medical child support order. Payment of benefits under this Plan will be made in accordance with an assignment of rights for you and your dependents as required under state Medicaid law. Benefits payable on behalf of you or your covered dependent after death will be paid, at the Plan's option, to any family member(s) or your estate. The Plan Manager will rely upon an affidavit to determine benefit payment, unless it receives written notice of valid claim before payment is made. The affidavit will release the Plan from further liability. Any payment made by the Plan Manager in good faith will fully discharge it to the extent of such payment. Payments due under the Plan will be paid upon receipt of written proof of loss. INITIAL DENIAL NOTICES Notice of a claim denial (including a partial denial) will be provided to claimants by mail, postage prepaid, or by e-mail, as appropriate, within the time frames noted above. However, notices of adverse decisions involving urgent care claims may be provided to a claimant orally within the time frames noted above for expedited z~rgent care claim decisions. If oral notice is given, written notification will be provided to the claimant no later than 3 days after the oral notification. A claims denial notice will state the specific reason or reasons for the adverse determination, the specific Plan provisions on which the determination is based, and a description of the Plan's review procedures and associated timeline. The notice will also include a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. The notice will describe the Plan's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action. 81 7 i 1 CLAIM PROCEDURES (continued) The notice will also disclose any internal Plan rule, protocol or similar criterion that was relied on to deny the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free of charge upon request. If the adverse determination is based on medical necessity, experimental, investigational or for research pa~rposes, or similar exclusion or limit, the notice will provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request. In the case of an adverse decision of an urgent care claim, the notice will provide a description of the Plan's expedited review procedures applicable to such claims. APPEALS OF ADVERSE DETERMINATIONS A claimant must appeal an adverse determination within 180 days after receiving written notice of the denial (or partial denial). With the exception of urgent care claims and concurrent care decisions, the Plan uses a two level appeals process for all adverse determinations. The Plan Manager will make the determination on the first level of appeal. If the claimant is dissatisfied with the decision on this first level of appeal, or if the Plan Manager fails to make a decision within the time frame indicated below, the claimant may appeal again to the Plan Manager. Urgent care claims and concurrent care decisions are subject to a single level appeal process only, with the Plan Manager making the determination. A first level and second level appeal must be made by a claimant by means of written application, in person, or by mail (postage prepaid), addressed to: Humana Grievance and Appeals P.O. Box 14546 Lexington, KY 40512-4546 Appeals of denied claims will be conducted promptly, will not defer to the initial determination, and will not be made by the person who made the initial adverse claim determination. or a subordinate of that person. The determination will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim. A claimant may review relevant documents and may submit issues and comments in writing. A claimant on appeal may, upon request, discover the identity of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the adverse determination being appealed, as permitted under applicable law. 82 r ~ ~ CLAIM PROCEDURES (continued) If the claims denial being appealed is based in whole, or in part, upon a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or for research purposes, or not medically necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person. Time Periods for Decisions on Appeal -- First Level Appeals of claims denials will be decided and notice of the decision provided as follows: Urgent Care Claims As soon as possible, but not later than 72 hours after the Plan Manager receives the appeal request. (If oral notification is given, written notification will follow in hard copy or electronic format within the next 3 days). Pre-Service Claims Within a reasonable period, but not later than 15 days after the Plan Manager receives the appeal request. Post-Service Claims Within a reasonable period, but no later than 30 days after the Plan Manager receives the appeal request. Concurrent Care Decisions Within the time periods specified above, depending upon the type of claim involved. Time Periods for Decisions on Appeal -- Second Level Appeals of claims denials will be decided and notice of the decision provided as follows: Pre-Service Claims Within a reasonable period, but not later than 15 days after the Plan Manager receives the appeal request. Post-Service Claims Within a reasonable period, but no later than 30 days after the Plan Manager receives the appeal request. 83 ~ ~ ~ CLAIM PROCEDURES (continued) APPEAL DENIAL NOTICES Notice of a benefit determination on appeal will be provided to claimants by mail, postage prepaid, or by e-mail, as appropriate, within the time frames noted above. A notice that a claim appeal has been denied will convey the specific reason or reasons for the adverse determination and the specific Plan provisions on which the determination is based. The notice will also disclose any internal Plan rule, protocol or similar criterion that was relied on to deny the claim. A copy of the rule, protocol or similar criterion relied upon will be provided to a claimant free of charge upon request. If the adverse determination is based on medical necessity, experimental, investigational, or for research purposes or similar exclusion or limit, the notice will provide either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request. In the event of a denial of an appealed claim, the claimant on appeal will be entitled to receive, upon request and without charge, reasonable access to and copies of any document, record or other information: Relied on in making the determination; 2. Submitted, considered or generated in the course of making the benefit determination; That demonstrates compliance with the administrative processes and safeguards required with respect to such determinations; 4. That constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment, without regard to whether the statement was relied on. RIGHT TO REQUIRE MEDICAL EXAMINATIONS (Applies only to medical Plans) The Plan has the right to require that a medical examination be performed on any claimant for whom a claim is pending as often as may be reasonably required. If the Plan requires a medical examination, it will be performed at the Plan's expense. The Plan also has a right to request an autopsy in the case of death, if state law so allows. EXHAUSTION Upon completion of the appeals process under this section, a claimant will have exhausted his or her administrative remedies under the Plan. If the Plan Manager fails to complete a claim determination or appeal within the time limits set forth above, the claimant may treat the claim or appeal as having been denied, and the claimant may proceed to the next level in the review process. After exhaustion, a claimant may pursue any other legal remedies available to him or her which may include bringing a civil action. Additional information may be available from a local U.S. Department of Labor Office. 84 ~ F CLAIM PROCEDURES (continued) LEGAL ACTIONS AND LIMITATIONS No action at law or inequity may be brought with respect to Plan benefits until all remedies under the Plan have been exhausted and then prior to the expiration of the applicable limitations period under applicable law. 85 l ~ 1 PRESCRIPTION DRUG BENEFIT DEFINITIONS Brand name medication means a medication that is manufactured and distributed by only one pharmaceutical manufacturer, or as defined by the national pricing standard used by the Plan Manager. Copay»rent (prescription drug) means the amount to be paid by yogi toward the cost of each separate prescription or refill of a covered prescription drug when dispensed by a pharmacy. Dispensing limit means the monthly drug dosage limit and/or the number of months the drug usage is needed to treat a particular condition. Generic medication means a drug that is manufactured, distributed and available from several pharmaceutical manufacturers and identified by the chemical name; or as defined by the national pricing standard used by the Plan Manager. Legend drug means any medicinal substance the label of which, under the Federal Food, Drug and Cosmetic Act, is required to bear the legend: Caution: Federal Law Prohibits dispensing without prescription. Mail order plearmacy means a pharmaceutical vendor designated by the Plan Manager who is properly licensed to dispense and deliver covered prescriptions through the mail. Non participating plearmacy means a pha~°macy, which has not entered into an agreement with the Plan Manager or has not been designated by the Plan Manager to provide services to covered persons. Orphan drug means a drug or biological used for the diagnosis, treatment, or prevention of rare diseases or conditions, which: 1. Affects less than 200,000 persons in the United States; or 2. Affects more than 200,000 persons in the United States, however, there is no reasonable expectation that the cost of developing the drug and making it available in the United States will be recovered from the sales of that drug in the United States. Participating pharmacy means a pharmacy which has entered into an agreement with or has been designated by the Plan Manager to provide services to covered persons. P/zarmacist means a person who is licensed to prepare, compound and dispense medication and who is practicing within the scope of his or her license. Pharmacy means a licensed establishment where prescription medications are dispensed by a pharmacist. 86 ~ ~ F PRESCRIPTION DRUG BENEFIT (continued) Prescription means a direct order for the preparation and use of a drug, medicine or medication. The drug, medicine or medication must be obtainable only by prescription. The prescription must be given verbally, electronically or in writing by a garalified practitioner to a pharmacist for the benefit of and use by a covered person. The prescription must include: 1. The name and address of the covered person for whom the prescription is intended; 2. The type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. The date the prescription was prescribed; and 4. The name, address and DEA number of the prescribing gz~alified practitioner. Prior authorization means the required prior approval from the Plan Manager for the coverage of prescription drugs, medicines, medications, including the dosage, quantity and duration, as appropriate for the covered person's age and sex. Self-administered injectable drug means an FDA approved medication which a person may administer to himself/herself by means of intramuscular, intravenous, or subcutaneous injection, and intended for use by you. SCHEDULE OF PRESCRIPTION DRUG BENEFITS NOTE: Additional drug information can be obtained by accessing the Plan Manager's website at www.humana.com. Yoa~ are required to pay the applicable copayment per prescription as follows: 87 ~ ~ , PRESCRIPTION DRUG BENEFIT (continued) RETAIL PHARMACY PARTICIPATING NON-PARTICIPATING PIARMACY PIARMACY Generic Medication $10 copayment per prescription $10 copayment plus 25% per copayment prescription Brand Name Medication $20 copayment per prescription $20 copayment plus 25% per copayment prescription Retail Prescription Drug 30 days 30 days Maximum Supply Fora 90-day maximum Two (2) times the applicable copayment as outlined under the Retail supply of a maintenance Pharmacy copayment Structure above. medication received from a retail pharmacy MAIL ORDER PHARMACY For up to a 90-day supply of a medication Two (2) times the applicable copayment as received from a mail order pharmacy outlined under the Retail Pharmacy copayment Structure above. Mail Order Pharmacy Drug Maximum Supply 90 days 88 ( ~ l PRESCRIPTION DRUG BENEFIT (continued) SPECIALTY OFFICE MEDICATION AND INJECTABLE DRUGS PER PRESCRIPTION* For up to a 30 day supply I $0 copayment *Specialty office medication and injectable drugs do not include self-administered injectable drugs. ADDITIONAL PRESCRIPTION DRUG BENEFIT INFORMATION If an employee/eligible dependent purchases a brand name medication, and an equivalent generic medication is available, the employee/eligible dependent must pay the difference between the brand name medication and the generic medication plus any applicable generic medication copayment. If the physician indicates on the prescription "dispense as written", the drug will be dispensed as such, the employee/eligible dependent will only be responsible for the brand name medication copayment. Participating Pharmacy When a participating pharmacy is used and you do not present your I.D. card at the time of purchase, you must pay the pharmacy the full retail price and submit the pharmacy receipt to Humana at the address listed below. You will be reimbursed at 100% of billed charges after the charge has been reduced by the applicable copayment and 20%. Non-participating Pharmacy When a non participating pharmacy is used, you must pay the pharmacy the full price of the drug and submit the pharmacy receipt to Humana at the address listed below. You will be responsible for 25% of the actual charge made by the dispensing pharmacy after this charge has been reduced by the applicable copayment. Mail pharmacy receipts to: Humana Claims Office Attention: Pharmacy Department P.O. Box 14610 Lexington, KY 40512-4610 PRIOR AUTHORIZATION Some p~°escription drugs may be subject to prior aa~thorization. To verify if a prescription drug requires prior authorization, call the toll free customer service phone number on the back of yoz~r ID card or visit the Plan Manager's website at wtivw.humana.com. DISPENSING LIMITS Some prescription drugs may be subject to dispensing limits. To verify if a prescription drug has dispensing limits, call the toll free customer service phone number on the back of yoatr ID card or visit the Plan Manager's website at www.humana.com. 89 3 ~ i rx~~CK1YTION DRUG BENEFIT (continued) RETAIL PHARMACY Your Plan provisions include a retail prescription drug benefit. You will receive an identification (ID) card, which includes yozzr name, group number and yozzr effective date. Present yozzr ID card at a participating pharmacy when purchasing a prescription. Prescriptions dispensed at a retail pharmacy are limited to a 30 day supply per prescription or refill. MAIL ORDER PHARMACY Yozcr prescription drug coverage also includes mail order pharmacy benefits, allowing participants an easy and convenient way to obtain prescription drugs. Mail order pharmacy prescriptions will only be filled with the quantity prescribed by your physician and are limited to a maximum of a: 90 day supply per prescription or refill for a drug received from a mail order pharmacy; or 30 day supply per prescription or refill for self-administered injectable medications or specialty office medications and injectables. Additional mail order pharmacy information can be obtained through your Human Resources Department or by calling the toll free customer service phone number on the back of your ID card or visit the Plan Manager's website at www.humana.com. SPECIALTY OFFICE MEDICATIONS AND INJECTABLES Your qualified practitioner has access to specialty office medications and injectables used to treat chronic conditions. These medications can be ordered specifically for you for administration in his/her office setting. This allows yoz~r physician a cost effective and convenient way to obtain high cost, high tech specialty medications and injectables. Additional information can be obtained through your Human Resources Department or by calling the toll-free customer service phone number on the back of your ID card. PRESCRIPTION DRUG COST SHARING Prescription drug benefits are payable for covered prescription expenses incurred by you and your covered dependents. Benefits for expenses made by a pharmacy are payable as shown on the Schedule of Prescription Drug Benefits. You are responsible for payment o£ • The drug deductible, if any; • The copayment; • The cost of medication not covered under the prescription drug benefit; • The cost of any quantity of medication dispensed in excess of the day supply noted on the Schedule of Prescription Drug Benefits. 90 r ~ {. PRESCRIPTION DRUG BENEFIT (continued) If the dispensing pharmacy's charge is less than the copayment, you will be responsible for the lesser amount. The amount paid by the Plan Manager to the dispensing pharmacy may not reflect the ultimate cost to the Plan Manager for the drug. Your copayment is made on a per prescription or refill basis and will not be adjusted if the Plan Manager or yoa~r employer receives any retrospective volume discounts or prescription drug rebates. PRESCRIPTION DRUG COVERAGE Because Humana's drz~g list is continually updated with prescription drugs approved or not approved for coverage, you must call the toll free customer service phone number on the back of your ID card to verify whether a prescription drug is covered or not covered under the Plan. Please follow the directions below when accessing Humana's website: Go to Humana's website (www.humana.com) and log-in as a Registered Member; 2. Click on the "Doctors & RX" drop down box located at the top of the page; 3. Click "Pharmacy Tools"; 4. Click "Prescription Benefits" to get details about the prescription drug benefits under your Plan, including specific out-of-pocket costs; OR Click "Printable Drug Lists and Forms" to view or download your drug list; OR 6. Click "Drug Pricing" and search for a drug by name, health condition or alphabetically to receive an estimated retail or mail order pharmacy drug price. Covered prescription drugs, medicine or medications must: Be prescribed by a gacalified practitioner for the treatment of a sickness or bodily injury; and 2. Be dispensed by a pharmacist. Prescription drug expenses covered under the Prescription Drug Benefit are not covered under any other provisions of the Plan. Any amount in excess of the maximum amount provided under the Prescription Drug Benefit is not covered under any other provision of the Plan. Any expenses incurred under provisions of the Prescription Drug Benefit section do not apply toward your medical deductible, out-of-pocket limits or lifetime maximum. Any expenses incurred under the medical benefits do not apply toward your prescription drug deductible or out-of-pocket limits. The Plan Manager may decline coverage of a specific medication until the conclusion of a review period not to exceed six (6) months following FDA approval for the use and release of the drug, medicine or medication into the market. 91 ~ ~ . PRESCRIPTION DRUG BENEFIT (continued) PRESCRIPTION DRUG LIMITATIONS Expense incatrred will not be payable for the following: Any drug, medicine, medication or supply not approved for coverage under the Plan (call the toll free customer service phone number on the back of your ID card or visit the Plan Manager's website at www.humana.com to verify whether a prescription drug is covered or not covered under the Plan); Legend drugs which are not recommended and not deemed necessary by a qualified practitioner; 3. More than two fills for the same drug or therapeutic equivalent medication prescribed by one or more qualified practitioners and dispensed by one or more retail pharmacies; Charges for the administration or injection of any drug; Drug delivery implants; 6. Any drug, medicine or medication labeled "Caution-Limited by Federal Law to Investigational Use," or experimental drug, medicine or medication, even though a charge is made to you, 7. Any drug, medicine or medication that is consumed or injected at the place where the prescription is given, or dispensed by the qualified practitioner; Prescriptions that are to be taken by or administered to the covered person, in whole or in part, while he or she is a patient in a facility where drugs are ordinarily provided by the facility on an inpatient basis. Inpatient facilities include, but are not limited to: a. Hospital; b. Skilled nursing facility; or c. Hospice facility. 9. Any drug prescribed for intended use other than for: a. Indications approved by the FDA; or b. Recognized off-label indications through peer-reviewed medical literature. 10. Prescription refills: a. In excess of the number specified by the qualified practitioner; or b. Dispensed more than one year from the date of the original order. 1 1. Any drug for which a charge is customarily not made; 12. Therapeutic devices or appliances, including: hypodermic needles and syringes (except needles and syringes for use with insulin, and covered self-administered injectable drugs); support garments; test reagents; mechanical pumps for delivery of medication; and other non-medical substances, unless otherwise specified by the Plan; 92 r ~ ~; PRESCRIPTION DRUG BENEFIT (continued) 13. Dietary supplements, nutritional products, fluoride supplements, minerals, herbs and vitamins (except pre-natal vitamins, including greater than one milligram of folic acid, and pediatric multi- vitamins with fluoride), unless otherwise specified by the Plan; 14. Injectable drugs, including but not limited to: immunizing agents; biological sera; blood; blood plasma; orself-administered injectable drugs not covered under the Plan; 15. Any drug prescribed for a sickness or bodily injury not covered under this Plan; 16. Any portion of a prescription or refill that exceeds a 30-day supply (or a 90-day supply for a prescription or refill that is received from a mail order pharmacy); 17. Any portion of a prescription refill that exceeds the drug specific dispensing limit, is dispensed to a covered person whose age is outside the drug specific age limits, or exceeds the duration- specific dispensing limit, if applicable; 18. Any drug, medicine or medication received by the covered person: a. Before becoming covered under the Plan; or b. After the date the covered person's coverage under the Plan has ended. 19. Any costs related to the mailing, sending, or delivery of prescription drugs; 20. Any fraudulent misuse of this benefit including prescriptions purchased for consumption by someone other than the covered person, 21. Prescription or refill for drugs, medicines, or medications that are lost, stolen, spilled, spoiled, or damaged; 22. Repackaged drugs; 23. Any drug or medicine that is: a. Lawfully obtainable without a prescription (over the counter drugs), except insulin; or b. Available in prescription strength without a prescription, 24. Any drug or biological that has received an "orphan drug" designation, unless approved by the Plan Administrator; 25. Any amount yozc paid for a prescription that has been filled, regardless of whether the prescription is revoked or changed due to adverse reaction or change in dosage or prescription; 26. More than one prescription within a 23-day period for the same drug or therapeutic equivalent medication prescribed by one or more qualified practitioners and dispensed by one or more pharmacies, unless received from a mail order pharmacy. For drugs received from a mail order pharmacy, more than one prescription within a 20-day period fora 1-30 day supply; or a 60-day period fora 61-90 day supply. (Based on the dosage schedule prescribed by the qualified practitioner). 93 ~ ~ , Administered by: Ll ~~_ Cytcic~cxtrLC:~ whcn }^au n~:ed it mast Humana Insurance Company 500 West Main Street Louisville, KY 40202 Copyright 2009