How To Get A Health Insurance Plan

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1 Document title: AUTHORIZED COPY Progress Energy Health Benefit Plans Document number: HRI-SUBS Applies to: Keywords: Eligible non-bargaining unit employees of Progress Energy, Inc., Progress Energy Carolinas, Inc.; Progress Energy Florida, Inc.; Progress Energy Service Company, LLC human resources information; benefits booklets Summary Plan Description Progress Energy, Inc. Employer Identification No Plan No. 526 Effective January 1, 2012 (unless otherwise noted) This document is a Summary Plan Description (SPD) for the Progress Energy health benefit plans, component plans under the Progress Energy, Inc. Welfare Benefit Plan (the Plan ), sponsored by Progress Energy, Inc. (Progress Energy or the company). The plans are composed of the: Progress Energy (the medical plan ) Progress Energy Employee Assistance and Mental Health & Substance Abuse Services Plan (the EAP and MHSA Services Plan ) (each a plan and together the plans ) Progress Energy Dental Plan (the dental plan ) Progress Energy Vision Plan (the vision plan ) An SPD is a summary of the official plan documents that govern the terms, conditions and administrative operations of a benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (ERISA). It does not describe every plan provision in full detail, and it does not alter any plan or any legal instrument related to the plans creation, operations, funding or benefit payment obligations. Every effort has been made to ensure that this document reflects relevant plan provisions in effect as of January 1, However, if there are any inconsistencies between this document and the official plan documents (including any insurance contracts), the terms and conditions of the applicable official plan documents (including any insurance contracts) will govern. In no case does this document imply or guarantee any right of future employment. Non-bargaining regular, full-time employees, long-term disability (LTD) recipients and retired employees and their eligible dependents of Progress Energy as well as Progress Energy Carolinas, Inc., Progress Energy Florida, Inc., and Progress Energy Service Company, LLC (participating subsidiaries of Progress Energy) are eligible to participate in: The Progress Energy (enrollment in the medical plan also provides access to coverage for prescription drugs, as well as mental health & substance abuse services under the EAP and MHSA Services Plan) The Progress Energy Employee Assistance and Mental Health & Substance Abuse Services Plan The Progress Energy Dental Plan* (see note below) The Progress Energy Vision Plan* (see note below) *Note: Former Florida Power Corporation (non-bargaining employees), Progress Fuels Corporation (corporate employees) and Progress Telecom Corporation employees who were eligible for benefits under the FlexPower program and who retired on or before January 1, 2002 and their surviving dependents are not eligible for the Progress Energy Dental Plan or the Progress Energy Vision Plan. HRI-SUBS Rev. 23 Page 1 of 205

2 Non-bargaining part-time and temporary employees and their eligible dependents of Progress Energy participating subsidiaries of Progress Energy are eligible to participate in: The employee assistance program (EAP) portion of the EAP and MHSA Services Plan Progress Energy reserves the right to amend or terminate the plans or any plans benefits at any time based on the cost of the benefits or other considerations without prior approval of or notification to any party. Links to Reference Documents and Forms FRM-SUBS-00011, Choice Benefits Change Form FRM-SUBS-01117, Catalyst Rx Reimbursement Form FRM-SUBS-20112, Walgreens Mail Service Registration and Prescription Order Form HRI-SUBS-30003, Your Guide to the HDHP and HSA Option HRI-SUBS-30004, Guide to Benefits for Domestic Partners FRM-SUBS-01062, UHC Health Claim Transmittal Form FRM-SUBS-00877, Group Dental Claim Form FRM-SUBS-00091, VSP (Vision Service Plan) Information FRM-SUBS-01112, ValueOptions Claim Form FRM-SUBS-00879, BCBSNC Member Claim Form HRI-SUBS Rev. 23 Page 2 of 205

3 Eligibility Pgs 4-11 Newly Eligible Employees 4 Dependents 4 QMCSO 5 Employment of Both You & Your Dependent by 6 Progress Energy Leaves of Absence 6 Former Employees 6 Retired Employees 6 Age and Service Requirements for Retirees 7 Retiree Medical Caps 10 Enrollment and Changes Pgs Enrollment for Newly Eligible Employees 12 Levels of Coverage 12 Enrolling Dependents 13 Enrollment for Newly Eligible Retirees 13 Changing Your Elections 13 Annual/Biennial Benefits Enrollment 14 Qualifying Events 14 Pgs Section Contents 16 Important Information 17 BCBSNC HDHP 22 BCBSNC Standard and Choice Plans 45 BCBSF Standard and Choice Plans 71 UHC Standard and Choice Plus Plans 94 AvMed and BlueCare HMO Plans 117 AUTHORIZED COPY Table of Contents When Coverage Ends Pgs When Eligibility Ends 186 When Eligibility Ends for Dependents 186 When Coverage Ends 186 HIPAA Certificates of Coverage 187 COBRA Coverage Pgs Eligibility for COBRA 188 Plans Covered Under COBRA 188 Responsibility of Employer to Provide Notice 189 Your Responsibility to Notify Your Employer 189 Cost of COBRA Coverage 189 Maximum Period of Coverage 190 Termination of COBRA Coverage 190 Other COBRA Information 191 Other Important Information Pgs Section Contents 193 Plan Information 194 Plan Administration 196 Your Rights Under ERISA 200 Contact Information Pgs Employee Service Center 202 Benefits Administrators 202 EAP & MHSA Services Plan Pgs Section Contents 124 EAP-ValueOptions 125 MHSA Services ValueOptions 128 MHSA Services BCBSNC/Magellan 136 Dental Plan Pgs Section Contents 141 Important Dental Plan Information 142 Dental Premium Plan 144 Vision Plan Pgs Section Contents 151 Vision Service Plan 152 Claims and Appeals Pgs Section Contents 155 HRI-SUBS Rev. 23 Page 3 of 205

4 Eligibility AUTHORIZED COPY Eligibility The plans cover employees and their dependents who meet the eligibility requirements specified herein and who are employed by a participating subsidiary. The plans provide benefits to eligible retirees and LTD recipients and their dependents as described herein. A subsidiary is a participating subsidiary if it is within Progress Energy's controlled group and if it, with the approval of Progress Energy, has elected by action of its Board of Directors to participate in these plans. The term "controlled group" means the group of companies as defined in Section 1563(a) of the Internal Revenue Code (the "Code"). A participating subsidiary may only participate in the plans for so long as it is a member of Progress Energy's controlled group. A participating subsidiary may elect to withdraw from participation in the plans at any time. Leased employees as defined in Section 414(n) of the Code and independent contractors are not eligible to participate in the plans. Newly Eligible Employees Choice Benefits is the benefits program Progress Energy offers to certain non-bargaining employees to provide them with the flexibility to choose from a variety of benefit options and coverage levels. Medical, Dental and Vision Non-bargaining regular, full-time employees are eligible to enroll in one of the Progress Energy-sponsored medical plan options (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Services Plan), dental and vision plans on the first day of employment or reclassification with a participating subsidiary. You and your employer share the cost of medical, dental and optional vision coverage. If you choose basic vision coverage, your employer pays the full cost for that option. Payroll deductions are taken on a before-tax basis. For newly eligible employees, payroll deductions begin with the paycheck following processing of your enrollment. Mental Health and Substance Abuse (MHSA) Non-bargaining regular, full-time employees who are enrolled in one of the Progress Energy-sponsored medical plan options are eligible for mental health and substance abuse services on the first day of employment or reclassification with a participating subsidiary. Employee Assistance Program (EAP) Non-bargaining full-time, part-time, and temporary employees and all members of their household are eligible to receive EAP services on the first day of employment or reclassification with a participating subsidiary. Progress Energy pays the full cost of coverage for EAP services. Dependents If you are eligible for and you elect medical, dental or vision coverage for yourself, you may also elect to cover your eligible dependents. Dependent eligibility for prescription drug coverage and mental health and substance abuse services requires participant and dependent enrollment in one of the Progress Energy-sponsored medical plan options. Each eligible dependent must be listed by name, Social Security number, relationship and date of birth in order to be covered. HRI-SUBS Rev. 23 Page 4 of 205

5 Eligibility Eligible dependents under the medical plan (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Services Plan), dental and vision plans are: Your spouse or domestic partner 1 Children under age 26 who: Are your biological children; or Have been placed with you for legal adoption, whether or not the adoption has become final; or Are your stepchildren or domestic partner s children; or Are your foster children; or Are your ward under a legal guardianship appointment or for whom you have legal custody under a valid court decree. Your unmarried children age 26 or older 2 : Who are incapable of self-support because of mental or physical disability, provided they became disabled before age 26, and Who either live with you or live in a long-term care facility and are mainly dependent upon you or your spouse or domestic partner for support and care 3, and For whom you can provide proof of their incapacity, residency, and dependency continuously since age Your domestic partner is eligible only if you both satisfy the criteria described in the Declaration of Domestic Partner Relationship and have submitted a Declaration of Domestic Partner Relationship form to the Employee Service Center. The Guide to Benefits for Domestic Partners (HRI-SUBS-30004) and forms are available through ProgressNet or from the Employee Service Center at or [email protected]. Such documents are hereby incorporated by reference and made a part of this SPD. Your former spouse (by divorce, legal separation or annulment) and former stepchildren may not be covered under these plans unless the two of you remarry; likewise, your former domestic partner and domestic partner s children may not be covered unless you and your former domestic partner re-establish a domestic partner relationship or marry. 2 For children who are disabled, you must notify the Employee Service Center within 30 days of the child reaching age 26 and provide the necessary documentation. 3 To determine if you provide more than half of a child s support, you must first determine the total support provided for that child. Total support includes amounts spent to provide food, lodging, clothing, education, medical and dental care, recreation, transportation and similar necessities. Note: Employees who cover or attempt to enroll ineligible dependents are in violation of the company s Code of Ethics and may be subject to disciplinary action up to and including termination of employment. They may also be required to pay damages and costs to the company, including reimbursement of any benefit payments made with respect to an ineligible dependent. Qualified Medical Child Support Order A qualified medical child support order (QMCSO) is an order issued by a court or through a state administrative process established under state law. In addition, national medical support notices must be treated as QMCSOs. A QMCSO directs the Plan Administrator to cover a child for benefits under the health care plan. Upon receipt of the order, the Plan Administrator will review the order to determine whether or not it is a QMCSO. During this review period, the Plan Administrator will instruct the applicable Benefits Administrator to hold all claims that may be payable for the children named in the order. The Plan Administrator will notify in writing all persons named in the order of the determination. If the Plan Administrator determines the order is a QMCSO, its terms must be followed to the extent required by law. If you are subject to a QMCSO, you must pay the appropriate cost of coverage as for any dependent coverage. If the Plan Administrator determines the order is not a QMCSO, a revised order may be prepared for submission and review. The Plan Administrator will instruct the applicable Benefits Administrator to discontinue holding claims at the time an order is determined not to be a QMCSO. If a revised order is submitted and determined to be a QMCSO, the Benefits Administrator will pay any claims on behalf of the child to the extent required by the revised order. HRI-SUBS Rev. 23 Page 5 of 205

6 Eligibility Employment of Both You and Your Dependent by Progress Energy If both you and your dependent are employed by a participating subsidiary of Progress Energy, each of you may elect to be covered under different Progress Energy-sponsored medical and dental plans. Or, one of you may elect the No Coverage option and be covered as a dependent by the other. You may not be covered both as an employee and as a dependent under the Progress Energy-sponsored medical and dental plans. Also, only one of you may cover your children, stepchildren or domestic partner children. These same restrictions apply if your dependent is a bargaining unit employee of Progress Energy Florida, Inc. The above restrictions don t apply for vision coverage. If both you and your dependent are employed by a participating subsidiary of Progress Energy, you may be covered both as an employee and as a dependent under your dependent s vision coverage. Also, if you and your spouse or domestic partner are employed by a participating subsidiary of Progress Energy, both of you may cover your children, stepchildren or domestic partner children. Leaves of Absence If you make the required contributions, you and your eligible dependents may continue medical (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Plan), EAP, dental and vision coverage for yourself and your eligible dependents while you are on a leave of absence as permitted in the Employee Handbook for: Newborn care Adoption/foster care Military service Long-Term Disability (see note below regarding dental and vision eligibility*) Any other absence that qualifies under the Family and Medical Leave Act *If you were an employee of the former Florida Power Corporation (non-bargaining employees), Progress Fuels Corporation (corporate employees), or Progress Telecom Corporation and were eligible for benefits under the FlexPower program, and you became disabled and were reclassified to disabled retiree status under the LTD Plan of Progress Energy Florida, Inc., prior to January 1, 2002, then you and your dependents are not eligible for Progress Energy-sponsored dental and vision coverage. Former Employees Terminated employees of a Progress Energy participating subsidiary who have entered into a binding written agreement that grants the terminated employee and any of his or her otherwise eligible dependents the right to continued participation in medical (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Services Plan), EAP, dental and vision coverage may continue coverage according to the terms of the agreement. Retired Employees Employees must meet specific eligibility requirements to continue Progress Energy-sponsored health benefits coverage after retirement. The age and service requirements differ depending upon the employer and the effective date of the employee's retirement. See below for more detailed information about the age and service requirements that apply to you and your employer group. Employees who terminated between June 1, 2005 and December 1, 2005 pursuant to the terms of the Voluntary Enhanced Retirement Program may continue to be eligible to be covered under the Plans, subject to the terms of that Program. HRI-SUBS Rev. 23 Page 6 of 205

7 Eligibility Age and Service Requirements for Retirees The table below describes how the age and service requirements relate to continuation and cost of medical (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Services Plan), dental, vision and EAP coverage upon retirement. Note that full-cost retirees are not eligible for EAP only coverage. The Retirement Age and Service Requirements reflect the minimum requirements for retirement. The Welfare Benefits Age and Service Access Requirements reflect the minimum requirements for access to unsubsidized (full cost) retiree health benefits. The Welfare Benefits Age and Service Subsidy Requirements reflect the minimum requirements for qualifying for subsidized retiree health benefits. To qualify for subsidized retiree health benefits, you must meet the Welfare Benefits Age and Service Subsidy Requirements, shown in the following table. If you do not meet the Welfare Benefits Age and Service Subsidy Requirements, you may be eligible for access to Progress Energy-sponsored health benefits coverage based on the Welfare Benefits Age and Service Access Requirements. In the event that you meet neither the Welfare Benefits Age and Service Access nor Subsidy Requirements upon retirement, you may still be eligible to retire under the Progress Energy Pension Plan according to that plan s benefit and vesting service requirements, but you will not be eligible to elect health benefits at retirement or in the future. In determining whether the specified Retirement Age and Service Requirements and the Welfare Benefits Age and Service Requirements have been met, "service" includes years of employment as an eligible employee (as previously defined in this SPD) with a Progress Energy participating subsidiary. Service as a temporary or part-time employee does not count towards satisfaction of Welfare Benefits Age and Service Requirements. Once you have met the minimum required age and years of service as described under the Welfare Benefits Age and Service Access and/or Subsidy Requirements, you will remain eligible for retiree health benefits (access only or subsidized) upon retirement, even if you are reclassified to temporary or part-time employment prior to retirement. Employees of a participating subsidiary may receive credit for prior service with a non-participating subsidiary only if that service was incurred during the time the non-participating subsidiary was within the controlled group of Progress Energy. (Note: Service with SRS will be included only during the time said employer was within the controlled group of Progress Energy. Service with Progress Telecom, LLC will be included only through December 31, 2004.) A non-participating subsidiary is an employer that is within Progress Energy s controlled group of companies (as defined in Internal Revenue Code Section 1563) but that does not offer a particular benefit to its employees. HRI-SUBS Rev. 23 Page 7 of 205

8 H I R E D A T E & C O M P A N Y A G E & S E R V I C E R E Q U I R E M E N T S Age and Service Requirements for Retirees - Must be attained by your retirement date New employees hired or rehired on or after 1/1/2002 Eligible employees 1 of Progress Energy Carolinas, Inc., Progress Energy Service Company, and Progress Energy Ventures, Inc. (regardless of hire date) Eligible employees hired by or transferred to NCNG on or after 1/1/ Eligible employees hired by or transferred 3 to Progress Energy Florida, Inc. (non-bargaining employees), Progress Fuels (corporate employees), and Progress Telecom Corporation (or Progress Telecom, LLC) on or after 1/1/2002 See additional Employer Group information on the following page. AUTHORIZED COPY Eligibility Employer Group Group 1 Group 2 Group 3 Eligible employees hired by NCNG on or before 12/31/1999 Retirement Age and Service Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 15 years of service; or 35 years of service regardless of age. The years of service, above, must be in a nonbargaining employment classification. Temporary and part-time service must comply with the benefit service definition as defined in the Progress Energy Pension Plan document in order to meet these requirements. Welfare Benefits Age and Service Access Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 15 years of service; or 35 years of service regardless of age. The total years of service worked must include regular, full-time service for the minimum required years of service shown above. Welfare Benefits Age and Service Subsidy Requirements (must meet the first and second bullets and either bullet three or four) Hired or rehired on or before 12/31/2001; and Attained age 40 or completed 5 years of eligible service on or before 12/31/2001; and Completion of 15 years of service after reaching age 40; or Completion of 35 or more years of service. The total years of service worked must include regular, full-time service for the minimum required years of service shown above. Note: Employees hired by NCNG on or before 12/31/1999 must meet the age and service requirements defined below to qualify for Progress Energy-sponsored retiree medical (includes prescription drug and MHSA coverage), EAP, dental and vision coverage. Employees hired on or after 1/1/2000 must meet the age and service requirements defined in Group 1. Retirement Age and Service Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 20 years of service. Welfare Benefits Age and Service Access Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 20 years of service. The total years of service worked must include regular, full-time service for the minimum required years of service shown above. Welfare Benefits Age and Service Subsidy Requirements Hired or rehired on or before 12/31/2001; and Attained age 40 or completed 5 years of eligible service on or before 12/31/2001; and Completion of 15 years of service after reaching age 40. The total years of service worked must include regular, full-time service for the minimum required years of service shown above. Eligible employees of Progress Energy Florida, Inc. (non-bargaining employees), Progress Fuels (corporate employees), and Progress Telecom Corporation (or Progress Telecom, LLC) hired on or before 12/31/2001 Note: Employees hired on or before 12/31/2001, who were receiving benefits under the FlexPower program prior to 1/1/2002, must meet the age and service requirements defined below to qualify for Progress Energysponsored retiree health benefits coverage. Employees hired on or after 1/1/2002, must meet the age and service requirements defined in Group 1. See additional Employer Group information on the following page. Retirement Age and Service Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 15 years of service. Welfare Benefits Age and Service Access Requirements Age 65 or older with at least 5 years of service; or Age 55 or older with at least 15 years of service. The total years of service worked must include regular, full-time service for the minimum required years of service shown above; exception: regular, parttime service on or before 12/31/2001 counts towards the Welfare Benefits Age and Service Requirements. Welfare Benefits Age and Service Subsidy Requirements Hired or rehired on or before 12/31/2001; and Attained age 40 or completed 5 years of eligible service on or before 12/31/2001; and Completion of 15 years of service after reaching age 40. The total years of service worked must include regular, full-time service for the minimum required years of service shown above; exception: regular, parttime service on or before 12/31/2001 counts towards the Welfare Benefits Age and Service Requirements. HRI-SUBS Rev. 23 Page 8 of 205

9 The notes below apply to the table on the previous page: AUTHORIZED COPY Eligibility 1 Applies to employees of Progress Energy Carolinas, Inc., Progress Energy Service Company, LLC and Progress Energy Ventures, Inc. (participating subsidiaries of Progress Energy) who were eligible for benefits under the Progress Energy-sponsored Choice Benefits program prior to 1/1/2002. Does not include any employees transferred or relocated to these subsidiaries who were eligible for benefits under the FlexPower program prior to the merger of the Choice Benefits and FlexPower benefit programs effective 1/1/2002, or employees who were hired by or transferred to NCNG prior to 1/1/ Applies to employees of NCNG who were eligible for benefits under the Progress Energy-sponsored Choice Benefits program prior to 1/1/ Applies to former employees of Progress Energy Carolinas, Inc., Progress Energy Service Company, LLC, and Progress Energy Ventures, Inc. (participating subsidiaries of Progress Energy) who were eligible for benefits under the Progress Energysponsored Choice Benefits program prior to 1/1/2002. Does not include any employees transferred or relocated to these subsidiaries who were eligible for benefits under the FlexPower program prior to the merger of the Choice Benefits and FlexPower benefit programs effective 1/1/2002, or employees who were hired by or transferred to NCNG prior to 1/1/2000 Additional Employer Group information regarding the table on the previous page: Group 1 former CP&L employees: For retirement from the former CP&L after 1/1/1993 (last day of active employment was on or after 1/1/1993) but on or before 1/1/2002 (last day of active employment was on or before 12/31/2001) retirees who met both the Retirement Age and Service Requirements AND the Welfare Benefits Age and Service Subsidy Requirements are eligible to continue Progress Energy-sponsored retiree medical, EAP, dental and vision coverage at company-subsidized retiree rates. Retirees who met the Retirement Age and Service Requirements AND the Welfare Benefits Age and Service Access Requirements are eligible to continue retiree medical, dental and vision coverage at full cost rates. For retirement from the former CP&L on or before 1/1/1993 (last day of active employment was on or before 12/31/1992) employees who met the Retirement Age and Service Requirements at the time they terminated employment with CP&L are eligible to continue Progress Energy-sponsored retiree medical, EAP, dental and vision coverage for themselves and their eligible dependents at company-subsidized retiree rates. Group 3 former Florida Progress employees: For employees hired on or before 12/31/2001 Retirement effective after 1/1/2002 (last day of active employment is on or after 1/1/2002) retirees who meet the Retirement Age and Service Requirements AND the Welfare Benefits Age and Service Access Requirements defined in Group 3 on the previous page are eligible for Progress Energy-sponsored retiree medical, dental and vision coverage for themselves and their eligible dependents at full cost rates. To qualify for medical, EAP, dental and vision coverage for themselves and their eligible dependents at company-subsidized retiree rates (reduced from full-cost rates), both the Retirement Age and Service Requirements AND the Welfare Benefits Age and Service Subsidy Requirements defined in Group 3 on the previous page must be met. For retirement effective on or before 1/1/2002 (last day of active employment was on or before 12/31/2001) - non-bargaining employees who retired from the former Florida Power Corporation, Florida Progress Corporation, or any participating subsidiary of the Progress Energy Florida, Inc.-sponsored FlexPower program on or before 1/1/2002, are eligible for Progress Energy-sponsored retiree medical and EAP coverage for themselves and their eligible dependents but are not eligible for Progress Energy-sponsored dental and vision coverage for themselves and their eligible dependents. The retiree and spouse contribution is based on the age/service matrix percentage at retirement if retirement is on or after 1/1/1993. Retirements prior to 1/1/1993 require no retiree or spouse contribution. Dependent child coverage is paid 100% by the retiree. HRI-SUBS Rev. 23 Page 9 of 205

10 Eligibility Retiree Medical Caps Effective January 1, 2002, Progress Energy implemented retiree medical funding caps that will affect the cost of medical benefits for some retired employees who have company-subsidized medical coverage. Medical caps are limits on the annual dollar amount of future company contributions to retiree medical benefits and are based on the average cost per participant and the expected rate of medical inflation. When the applicable limits are reached, company contributions will be "capped" and future premium increases will be paid by plan participants. However, the retiree medical caps will not affect the availability or cost of any other retiree benefits. How the retiree medical caps will apply to you depends on your age, service and employer group. See Age and Service Requirements for Retirees on the previous pages for more detailed information. How the caps will work: There are separate pre-65 and post-65 caps, with the post-65 cap taking effect when the covered retiree reaches age 65. The annual total cost caps are: Pre-65 $7,000 Post-65 1 $4,000 1 Retirees and dependents that are Medicare-eligible due to disability prior to age 65 are subject to the post-65 cap. The premiums (and funding cap) for post-65 retiree medical coverage are lower than the pre-65 premiums (and funding cap) because Medicare becomes the primary coverage (and the Progress Energy plan provides secondary coverage) when an individual reaches age 65 or becomes Medicare eligible due to disability. Retirees and their covered dependents are required to move from pre-65 coverage to post-65 coverage in the year when either they or their covered dependents reach age 65 or become Medicare eligible due to disability. This is necessary because Medicare will become primary to (or pay benefits before) the retiree medical coverage for either the retiree or his or her covered dependents. However, the determination of whether the total cost for a retiree and his or her covered dependents counts toward the pre- or post-65 cap calculation is based on the retiree s age. For example, the total cost for a retiree age 65 or older whose spouse or domestic partner is not yet age 65 will count toward the post-65 cap calculation. Likewise, the total cost for a retiree under age 65 whose spouse or domestic partner is age 65 or older will count toward the pre-65 cap calculation. Calculating the caps To determine when each cap is reached, the total cost of pre- and post-65 retiree coverage (claims plus administrative costs) is divided by the total number of participants (both retirees and dependents) in each group. This calculation produces an average cost per participant for each group that will be monitored annually until the caps are met. When the caps are met, the employer-provided subsidy for affected retirees will be capped and continue at that level for the foreseeable future. Pre- and post-65 plan costs are combined for all retirees from participating subsidiaries so costs can be accurately monitored for comparison with the caps. Caps will affect premiums only The caps will not affect the benefits payable under the medical plan; they apply only to the funding of future premiums. For example, a post-65 retiree will not be limited to $4,000 of benefits. Likewise, a pre-65 retiree will not be limited to $7,000 of benefits. The caps will only impact the monthly premiums. It is possible that a pre-65 retiree will experience the impact of the pre-65 cap on his or her premiums and then transition to post-65 premiums that are not yet impacted by the post-65 cap. How the medical caps will be applied Retiree medical funding caps affect the cost of medical benefits for some retired employees who have subsidized medical coverage. See the following page for a detailed explanation of how retiree medical caps work. Refer to the table on page 8 for detailed information related to the Welfare Benefits Age and Service Subsidy Requirements that must be met to qualify for company-subsidized retiree medical rates. HRI-SUBS Rev. 23 Page 10 of 205

11 Eligibility Note: Medical caps do not apply to eligible employees who meet only the Welfare Benefits Age and Service Access Requirements. These individuals must pay the full cost of retiree medical coverage as explained below. Employees who are subject to the age and service requirements in Groups 1 & 2 on page 8 Active employees who were both under age 40 and had less than five years of service as of December 31, 2001, and all employees hired or rehired on or after January 1, 2002, are required to pay the full cost of retiree medical coverage and are not subject to the retiree medical funding caps. They will continue to remain eligible for retiree medical coverage when they meet the applicable age and service requirements. These individuals will have access to coverage at that time, but there will be no employer-provided subsidy of coverage. They will be required to pay the applicable premium rates that are subject to change each year. Active employees who were either age 40 or older or had five or more years of service as of December 31, 2001, who later qualify for company-subsidized retiree medical coverage, and who retire on or after January 1, 2002, are subject to the retiree medical funding caps. These individuals will continue to remain eligible for retiree medical coverage and will be required to pay the applicable premium rates that are subject to change each year. However, beginning in the year in which the applicable cap is met, the employer-provided subsidy for these retirees will be capped, and all future cost increases will be passed on to the affected retirees through increased premium rates. Active employees who were either age 40 or older or had five or more years of service as of December 31, 2001, who retire prior to qualifying for company-subsidized retiree medical coverage on or after January 1, 2002, and who meet the Welfare Benefits Age & Service Access Requirements are required to pay the full cost of retiree medical coverage and are not subject to the retiree medical funding caps. These individuals will continue to remain eligible for retiree medical coverage, but there will be no employer-provided subsidy of coverage. They will be required to pay the applicable premium rates that are subject to change each year. Active employees who were eligible for companysubsidized retiree medical coverage as of December 31, 2001 (regardless of their retirement date) are not subject to the retiree medical funding caps. These individuals will continue to remain eligible for retiree medical coverage and will be required to pay the applicable retiree premium rates that are subject to change each year. Retirees who retired prior to January 1, 2002 are not subject to the retiree medical caps. They will be required to pay the applicable premium rates that are subject to change each year. Employees who are subject to the age and service requirements in Group 3 on page 8 Active employees who were both under age 40 and had less than five years of service as of December 31, 2001, and all employees hired or rehired on or after January 1, 2002, are required to pay the full cost of retiree medical coverage and are not subject to the retiree medical funding caps. They will continue to remain eligible for retiree medical coverage when they meet the applicable age and service requirements. These individuals will have access to coverage at that time, but there will be no employer-provided subsidy of coverage. They will be required to pay the applicable premium rates that are subject to change each year. Active employees who were either age 40 or older or had five or more years of service as of December 31, 2001, who later qualify for company-subsidized retiree medical coverage, and who retire on or after January 1, 2002, are subject to the retiree medical funding caps. These individuals will continue to remain eligible for retiree medical coverage and will be required to pay the applicable premium rates that are subject to change each year. However, beginning in the year in which the applicable cap is met, the employer-provided subsidy for these retirees will be capped, and all future cost increases will be passed on to the affected retirees through increased premium rates. Active employees who were either age 40 or older or had five or more years of service as of December 31, 2001, who retire prior to qualifying for company-subsidized retiree medical coverage on or after January 1, 2002, and who meet the Welfare Benefits Age & Service Access Requirements are required to pay the full cost of retiree medical coverage and are not subject to the retiree medical funding caps. These individuals will continue to remain eligible for retiree medical coverage, but there will be no employer-provided subsidy of coverage. They will be required to pay the applicable premium rates that are subject to change each year. Retirees who retired on or after January 1, 1998 and on or before January 1, 2002 (those who were subject to the retiree medical funding caps of the former Florida Power) are subject to the Progress Energy retiree medical funding caps. These retirees will continue to be subject to the Florida retiree medical rate matrix and if applicable will be required to pay the retiree premiums that are subject to change each year. Retirees who retired prior to January 1, 1998 (those who were not subject to the retiree medical funding caps of the former Florida Power) are not subject to the Progress Energy medical caps. Individuals in this group who retired on or after January 1, 1993, will continue to be subject to the Florida retiree medical rate matrix and if applicable will be required to pay the retiree premiums that are subject to change each year. HRI-SUBS Rev. 23 Page 11 of 205

12 Enrollment and Changes Enrollment and Changes Enrollment for Newly Eligible Employees As a non-bargaining regular, full-time employee, you must enroll yourself and your eligible dependents in the medical, dental and vision plans within 30 days of your employment date or reclassification date. Also, you must enroll through Employee Self Service to elect the appropriate coverage and list each dependent by name, Social Security number, relationship and date of birth before any benefits may be paid. Coverage will be effective on your date of hire or reclassification if your elections are made within 30 days of such date. There are no pre-existing condition exclusions for you or your dependents for the medical plan (including EAP & mental health and substance abuse) or the vision plan. There are pre-existing condition exclusions under the dental plan. (See Expenses Not Covered in the Dental Plan section.) Levels of Coverage If you enroll in the medical, dental or vision plan, there are three levels of coverage available: Self (employee only) Self + 1 (employee plus one eligible dependent) Family (employee plus two or more eligible dependents) If you do not enroll within 30 days of your employment date or reclassification date, your benefits will default as described below: Plan Medical - includes mental health & substance abuse (MHSA) and prescription drug coverage Dental Vision Default Coverage Standard, self only (BCBSNC or BCBSF, depending on location) No Coverage Basic plan, self only Medical If you do not enroll in the medical plan option within 30 days of becoming eligible, you will be automatically enrolled with self only coverage under the BCBSNC or BCBSF Standard Plan. Your dependents will not be covered. The effective date of coverage will be your date of hire or reclassification. Note: You may elect the No Coverage option only if you are covered by another medical plan. If you elect the No Coverage option, you must provide evidence of other coverage within 30 days of your election. If you provide evidence of other coverage within 30 days, coverage will be waived retroactive to the date you requested No Coverage. If you present evidence after 30 days, the change will be effective the date the evidence is provided. MHSA and prescription drugs Your enrollment and the enrollment of your eligible dependents in one of the Progress Energy-sponsored medical plan options automatically enrolls you in the MHSA benefit under the EAP and MHSA Plan and gives you access to prescription drug coverage. An additional election is not required. Dental If you do not enroll in the dental plan within 30 days of becoming eligible, your dental election will automatically default to the No Coverage option. HRI-SUBS Rev. 23 Page 12 of 205

13 Enrollment and Changes Vision If you do not enroll in a vision plan option within 30 days of becoming eligible, you will be automatically enrolled with self only coverage under the Basic Plan at no cost to you. Your dependents will not be covered. The effective date of coverage will be your date of hire or reclassification. You may elect to cover your eligible dependents under the Basic Plan or you may elect coverage under the Optional Plan for yourself and your eligible dependents, the cost of which you and your employer will share. There is not a No Coverage option under the vision plan. Enrolling Dependents You must cover yourself under a plan option in order to enroll your eligible dependents. Each dependent must meet the eligible dependent definition (see Dependents in the Eligibility section). Also you must elect the plans, the appropriate level of coverage (self, self plus one or family) and list each dependent by name, Social Security number*, relationship and date of birth through Employee Self Service or on the enrollment form before benefits can be paid. Enrollment through Employee Self Service applies to new employees, reclassifications to regular, full-time status and annual/biennial benefits enrollment. Enrollment on the employer-provided enrollment form applies to all other qualifying events. Coverage will be effective on your date of hire or reclassification if you enroll within 30 days of such date. Please see the Guide to Benefits for Domestic Partners (HRI-SUBS-30004) for an explanation of the tax impact of paying premiums for your domestic partner on a before-tax basis. *Note: The Mandatory Insurer Reporting Law (Section 111 of Public Law ) requires group health plan insurers, third party administrators, and plan administrators of self-insured group health plans to report Social Security numbers for certain covered members. To comply with this legislation, Progress Energy needs Social Security numbers for dependents covered under any company-sponsored medical plan. If you do not have the dependent's Social Security number, you should complete the rest of the information and submit your enrollment. You must call the Employee Service Center and add the dependent's Social Security number as soon as you receive it. Note: Employees who cover ineligible dependents are in violation of the company s Code of Ethics and may be subject to disciplinary action up to and including termination of employment. They may also be required to pay damages and costs to the company, including any benefit payments made with respect to an ineligible dependent. Enrollment for Newly Eligible Retirees As a newly eligible retiree medical, dental and vision coverage will automatically continue. If you wish to waive some or all of the coverage, you must complete a retiree enrollment form within 30 days of your retirement date. Coverage will be effective on your retirement date. Deductions will begin with your second pension check. If there is not a monthly pension check, you will receive a bill for your benefits on a monthly basis. If you choose to waive coverage, you will not be able to enroll in benefits until the next annual/biennial enrollment period unless you have a qualifying event. Changing Your Elections After the 30-day newly eligible enrollment period has expired, you may not change your elections until the next annual enrollment period for medical coverage or biennial enrollment period for dental and vision coverage unless you experience a qualifying event. HRI-SUBS Rev. 23 Page 13 of 205

14 Enrollment and Changes Annual/Biennial Benefits Enrollment You may change your medical election each year during annual benefits enrollment. Elections made during annual benefits enrollment are effective January 1 through December 31 of the upcoming year (or through some earlier date if coverage ends as described under When Coverage Ends or if you make an election change upon a qualifying event). There are no pre-existing condition exclusions for you or your dependents under the medical plan. The dental and vision plans have biennial (every two years) enrollment periods, and changes to your dental and vision elections may only be made at those times unless you have a qualifying event that will allow you to make a change. Elections made during dental and vision enrollment periods are effective for two years beginning January 1 of the upcoming year unless coverage ends as described under When Coverage Ends or if you experience a qualifying event. Qualifying Events The Internal Revenue Service rules do not permit you to change your Choice Benefits elections during the plan year unless you experience a qualifying event. If you experience a qualifying event, a completed employer-provided Choice Benefits Change Form (FRM-SUBS-00011) must be received by the Employee Service Center within 30 days of the event to modify your coverage (or 60 days for certain events as noted below). Changes due to birth, adoption or placement for adoption (a subset of HIPAA special enrollment right events) may be effective retroactively back to the date of the birth, adoption or placement for adoption, as long as such date is no more than 30 days prior to the date of notification, subject to the provisions of the underlying group health plan. All other changes may only be effective on a prospective basis and no earlier than the first day of the pay period after the Choice Benefits Change Form is received by the Employee Service Center. Otherwise, you will have to wait until the next annual or biennial enrollment period to change your elections. All election changes must be consistent with the qualifying event and the following participant group guidelines. Regular, full-time non-bargaining employees and employees on a leave of absence may not make changes to their medical, dental or vision election until the next benefits enrollment period unless they experience a qualifying event. Enrollment occurs annually for medical and biennially for dental and vision. Retired employees, including full-cost retirees, may make changes to their coverage within 30 days of a qualifying event (or 60 days for certain events as noted below), consistent with the qualifying event. However, they may elect to drop coverage or dependents without a qualifying event at any time during the year. They may also make changes during annual benefits enrollment for medical or biennial benefits enrollment for dental and vision. LTD recipients and COBRA participants may not add dependents to their medical, dental or vision coverage until the next annual enrollment period for medical or the next biennial enrollment period for dental and vision unless they experience a qualifying event. However, they may elect to drop coverage or dependents without a qualifying event at any time during the year. Changes made as a result of a qualifying event must be requested within 30 days (or 60 days for certain events as noted below) of, and be consistent with, the qualifying event. Qualifying events do not allow you to change from one medical plan option to another unless you relocate and the new location is outside of the option s service area or unless you are making a change pursuant to a HIPAA special enrollment right event (i.e., adding a new dependent via marriage, birth, adoption or placement for adoption; losing other coverage; or the Medicaid/CHIP events listed in the last two bullets below). Also note that a physician/hospital leaving the network does not constitute a qualifying event. Qualifying events include: Your marriage or fulfillment of all Progress Energy domestic partner relationship requirements. Legal separation, annulment, divorce or termination of domestic partner relationship. Birth, adoption or placement for adoption, or change in custody of your child. HRI-SUBS Rev. 23 Page 14 of 205

15 Enrollment and Changes Death of your spouse, domestic partner or child. Loss of dependent status (e.g., child reaching age 26). You, your spouse, domestic partner or child takes or returns from an unpaid leave of absence. Your spouse s, domestic partner s, child s or your health care coverage changes significantly (attributable to your spouse s, domestic partner s or child s employment or change in student status or to a significant cost change or coverage curtailment). Your spouse s, domestic partner s or child s employer conducts an annual enrollment and your spouse, domestic partner or child changes his or her benefit elections. You, your spouse, domestic partner or child changes from part-time to full-time or from full-time to part-time employment and that change impacts eligibility for coverage. Your spouse, domestic partner or child becomes employed or unemployed. You, your spouse, domestic partner or child changes place of work or permanent residence (and the new location is outside of the option s service area) (only applicable for medical). You, your spouse, domestic partner or child loses eligibility for Medicaid or Children s Health Insurance Program (CHIP) coverage 1 (only applicable for medical). You, your spouse, domestic partner or child becomes eligible to participate in a premium assistance program under Medicaid or CHIP. 1 1 Employee must notify the Employee Service Center within 60 days of loss of Medicaid/CHIP eligibility or of the premium assistance eligibility determination. All other qualifying events must be communicated to the Employee Service Center within 30 days of the event. In order to cover a new dependent due to a qualifying event, you must complete an employer-provided Choice Benefits Change Form (FRM-SUBS-00011) or a retiree change form even if you already have family coverage. The new dependent's name, Social Security number*, relationship and date of birth must be listed on the form. If the Employee Service Center does not receive the form within 30 days of the event (or 60 days for certain events as noted above), the dependent may not be added to your coverage until the next enrollment period. The dental and vision options have biennial enrollment periods. *Note: The Mandatory Insurer Reporting Law (Section 111 of Public Law ) requires group health plan insurers, third party administrators, and plan administrators of self-insured group health plans to report Social Security numbers for certain covered members. To comply with this legislation, Progress Energy needs Social Security numbers for dependents covered under any company-sponsored medical plan. If you do not have the dependent's Social Security number, you should complete the rest of the information and submit the form. You must call the Employee Service Center and add the dependent's Social Security number as soon as you receive it. When a dependent is no longer eligible for coverage, you must complete an employer-provided Choice Benefits Change Form (FRM-SUBS-00011) or a retiree change form within 30 days of the qualifying event to remove the dependent from coverage and reduce your premiums if applicable. Termination of coverage will be effective on the date your dependent ceases to be eligible for coverage. Premiums will not be refunded retroactively. If you do not remove the dependent from coverage, you will be covering an ineligible dependent. Note: Employees who cover ineligible dependents are in violation of the company s Code of Ethics and may be subject to disciplinary action up to and including termination of employment. They may also be required to pay damages and costs to the company, including any benefit payments made with respect to an ineligible dependent. HRI-SUBS Rev. 23 Page 15 of 205

16 Important Information Pgs Coverage Options 17 Primary and Secondary Coverage 18 Medicare Part D 19 Maintenance of Benefits 20 BCBSNC High Deductible Health Plan Pgs Enrollment Eligibility 22 Medical and Prescription Drug ID Card 22 BCBSNC HDHP Summary Chart 23 How the HDHP Works 25 Utilization Management (UM) Program 27 Care Management 30 Condition Management Program 30 Covered Expenses 31 Expenses Not Covered 40 AUTHORIZED COPY Section Contents UHC Choice Plus Plan Summary Chart 98 How the UHC Standard and Choice Plus 100 Plans Work Utilization Review Program 102 Case Management 104 Condition Management Program 104 Covered Expenses 105 Expenses Not Covered 113 HMO Plans Pgs Enrollment Eligibility 117 Medical and Prescription Drug ID Card 117 AvMed HMO Plan Summary Chart 118 BlueCare HMO Plan Summary Chart 120 How the HMO Plans Work 122 BCBSNC Standard and Choice Plans Pgs Enrollment Eligibility 45 Medical and Prescription Drug ID Cards 45 BCBSNC Standard Plan Summary Chart 46 BCBSNC Choice Plan Summary Chart 48 How the BCBSNC Standard and Choice 50 Plans Work Utilization Management (UM) Program 53 Care Management 55 Condition Management Program 55 Covered Expenses 56 Expenses Not Covered 66 BCBSF Standard and Choice Plans Pgs Enrollment Eligibility 71 Medical and Prescription Drug ID Cards 71 BCBSF Standard Plan Summary Chart 72 BCBSF Choice Plan Summary Chart 74 How the BCBSF Standard and Choice Plans 76 Work Utilization Review (UR) Program 78 Case Management 80 Condition Management Program 80 Covered Expenses 81 Expenses Not Covered 90 UHC Standard and Choice Plus Plans Pgs Enrollment Eligibility 94 Medical and Prescription Drug ID Cards 95 UHC Standard Plan Summary Chart 96 HRI-SUBS Rev. 23 Page 16 of 205

17 Important Information AUTHORIZED COPY Important Information Your eligibility and enrollment in one of the Progress Energy-sponsored medical plan options gives you access to coverage for prescription drugs, as well as mental health and substance abuse services under the EAP and MHSA Plan. Coverage Options Active employees and non-medicare eligible participants The medical plan coverage options listed below are available if you meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section), and if you are either (1) an active regular, full-time employee including eligible dependent (regardless of Medicare status); (2) a non-medicare eligible retiree including non-medicare eligible dependent of a retiree; or (3) a non-medicare eligible surviving dependent: High Deductible Health Plan (administered by BCBSNC) Standard Plan (administered by BCBSNC, BCBSF and UnitedHealthcare) Choice Plan (administered by BCBSNC and BCBSF) Choice Plus Plan (administered by UnitedHealthcare) AvMed HMO (administered by AvMed) BlueCare HMO (administered by BCBSF) No Coverage* *Note: If you are a regular, full-time employee, you may elect the No Coverage option only if you are covered by another medical plan. If you elect the No Coverage option, you must provide evidence of other coverage within 30 days of your election. If you provide evidence of other coverage within 30 days, coverage will be waived retroactive to the date you requested No Coverage. If you present evidence after 30 days, the change will be effective the date the evidence is provided. Medicare-eligible retirees and surviving dependents The medical plan coverage options listed below are available if you meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section), and if you are either (1) a retiree and you (or your covered dependents) are eligible for Medicare or (2) a surviving dependent and you (or your covered dependents) are eligible for Medicare: Standard Plan (administered by BCBSNC, BCBSF and UnitedHealthcare) Choice Plan (administered by BCBSNC and BCBSF) No Coverage You should apply for and purchase Medicare Part B when you or your dependent first become eligible for Medicare, and you should use providers who accept Medicare. The Benefits Administrator will assume you have purchased Medicare Part B and use providers who accept Medicare, and will coordinate benefits accordingly, whether or not you are actually covered under Part B or actually use providers who accept Medicare. This means that if you do not enroll in Medicare Part B when you become eligible or if you use providers who do not accept Medicare and then incur expenses that would be covered by Medicare Part B, you will be responsible for paying the full cost of those expenses. They will not be covered or paid by the Progress Energy plan. Long-term disability recipients If you are an LTD recipient and eligible for Progress Energy-sponsored medical coverage (see the Eligibility section), you and your eligible dependents may choose one of the following options 1 : HRI-SUBS Rev. 23 Page 17 of 205

18 Standard Plan (administered by BCBSNC, BCBSF and UnitedHealthcare) Choice Plan (administered by BCBSNC and BCBSF) Choice Plus Plan (administered by UnitedHealthcare) AvMed HMO until Medicare-eligible (administered by AvMed) BlueCare HMO until Medicare-eligible (administered by BCBSF) Primary and Secondary Coverage AUTHORIZED COPY Important Information 1 LTD recipients and their eligible dependents can continue enrollment in an HMO until they become eligible for Medicare, at which time they must change plans (or they can change plans effective January 1 prior to becoming Medicare-eligible if they do not want to change plans mid-year). Progress Energy and another employer-sponsored plan If you and your eligible dependents are covered under a Progress Energy-sponsored plan and another employersponsored plan, one plan is considered the primary plan and the other is the secondary plan. The primary plan pays claims first and the secondary plan pays claims after the primary plan has paid. Primary and secondary responsibility for a claim under these plans is usually determined as follows: The plan without a claims coordination provision will be primary and the plan with a claims coordination provision will be secondary. When both plans have coordination provisions, the plan covering the patient as an active employee will be primary. A plan that covers an active employee or a dependent of an active employee will be primary to a plan that covers the patient as an inactive (retired or terminated) employee or as a dependent of an inactive employee. If a determination of responsibility cannot be made using the above guidelines, the plan that has covered the patient the longest will be the primary plan. Dependent children If a dependent child is covered by two or more employer-sponsored plans, the "birthday rule" will apply unless there has been a divorce. Under the birthday rule, the plan of the parent whose birthday occurs first in the year is primary regardless of the year of birth. For example, the plan of the parent with a February birthday is primary to the parent with a May birthday. The father s plan will be primary if a plan does not contain the birthday rule. If there has been a divorce and the courts have assigned financial responsibility for a child s health care to one parent, that parent s plan is primary. Otherwise, in the case of divorce: The plan of the parent with custody pays first, and the plan of the stepparent pays second. The plan of the parent without custody pays third (second if there is no stepparent or the stepparent does not participate in an employer-sponsored plan). Medicare eligible participants Active employees If you are actively employed, the Progress Energy-sponsored medical plan will be primary and Medicare will be secondary in accordance with the following principles: For you, if you are covered by both the Progress Energy-sponsored medical plan and Medicare. For your dependent, if you have a Medicare-eligible dependent covered under a Progress Energy-sponsored medical plan. For you or your dependent, during the first 30-months of eligibility or entitlement to Medicare based solely on end stage renal disease (ESRD). After 30 months, Medicare will be primary. HRI-SUBS Rev. 23 Page 18 of 205

19 Important Information Retirees, surviving dependents or long-term disability recipients If you are a retiree, surviving dependent or LTD recipient, Medicare will be primary and the Progress Energysponsored medical plan will be secondary in accordance with the following principles*: For you, if you are retired or a surviving dependent and are age 65 or over. For you, if you are disabled when you retire or are a surviving dependent and are eligible for Medicare (regardless of your age). For you, if you are eligible for LTD benefits and have received Social Security benefits for 24 months (regardless of your age). For your dependent, if you have a Medicare-eligible dependent covered under a Progress Energy-sponsored plan and you are retired or eligible for LTD benefits (regardless of your age) or a surviving dependent. Pre age 65 - For you or your dependent, after the first 30 months of eligibility or entitlement to Medicare based solely on end stage renal disease (ESRD). Post age 65 - Medicare will remain primary for you or your dependent even if you become eligible for Medicare based on end stage renal disease (ESRD). *You should send the Employee Service Center a copy of the Medicare card within 30 days of becoming eligible for Medicare so your coverage and premium may be changed appropriately. You should apply for and purchase Medicare Part B when you or your dependent first become eligible for Medicare, and you should use providers who accept Medicare. The Progress Energy-sponsored plan will assume you have purchased Medicare Part B and use providers who accept Medicare, and will coordinate benefits accordingly, regardless of whether or not you are actually covered under Part B or actually use providers who accept Medicare. This means that if you do not enroll in Medicare Part B when you become eligible or if you use providers who do not accept Medicare and then incur expenses that would be covered by Medicare Part B, you will be responsible for paying the full cost of those expenses. They will not be covered or paid by the Progress Energy plan. If you are a retiree or a surviving dependent when you or a dependent becomes eligible for Medicare, your participation in the HDHP, Choice Plus Plan, AvMed HMO Plan or BlueCare HMO Plan will end and you will need to elect coverage under the Standard or Choice Plans by the month in which Medicare becomes effective. If you are an LTD recipient when you or a dependent becomes eligible for Medicare, your participation in the AvMed HMO Plan or BlueCare HMO Plan will end and you will need to elect coverage under the Standard, Choice or Choice Plus Plans by the month in which Medicare becomes effective. Note: If you notify the Employee Service Center that you or your spouse became Medicare-eligible and are covered under the UHC Choice Plus Plan, you will become covered under the UHC Standard Plan (except LTD recipients) unless you elect to be covered under the BCBS Choice or Standard Plan. If your spouse or domestic partner is not Medicare-eligible at that time and becomes covered under the UHC Standard Plan, copays will no longer apply. Additionally, if you notify the Employee Service Center when you or your spouse becomes Medicare-eligible and you are covered under AvMed HMO or BlueCare HMO, you will become covered under the BCBS Choice Plan unless you elect to be covered under the BCBS or UHC Standard Plans (or UHC Choice Plus Plan if you are an LTD recipient). Medicare Part D If you participate in a Progress Energy medical plan option, you may continue receiving your prescription drugs through the Progress Energy medical plan and not elect a separate Medicare Part D plan. The company will provide a certificate of creditable coverage you can use to avoid any Medicare Part D plan premium increase that would otherwise be required if you choose to enroll in a Medicare Part D plan at a later date. HRI-SUBS Rev. 23 Page 19 of 205

20 Maintenance of Benefits AUTHORIZED COPY Important Information When you or a dependent is covered under the Progress Energy-sponsored medical plan and another employersponsored medical plan (or Medicare) and the Progress Energy-sponsored plan is secondary, benefits are coordinated through maintenance of benefits. Under maintenance of benefits, the Progress Energy-sponsored plan provides benefits only to make up the difference (if any) between what the other primary plan paid and what the Progress Energy-sponsored medical plan would have paid if it had been primary, using the lesser of the primary or secondary plan s allowed amount, subject to provider contract agreements. This means that 100% coverage between the two plans is not provided. You are responsible for any charges not paid by either plan, including any amounts in excess of the allowed (usual and customary) amount. Maintenance of benefits does not apply to the HMOs. See the HMO s Certificate of Coverage for coordination of benefit rules. Examples: The following examples show how a claim would be paid under maintenance of benefits. The assumptions in these examples are: (i) the primary plan paid the claim at 80% and 70%, respectively, after a $300 deductible; (ii) the Progress Energy BCBS or UHC Standard Plan was secondary; and (iii) the claim was for authorized outpatient services. Note: Deductible is the amount you pay in a calendar year for covered expenses before benefits are provided under the Progress Energy-sponsored medical plan on covered services that require you to pay a percentage of the charge (coinsurance). Maintenance of benefits when Medicare is primary Total bill $ 2,000 Allowed amount $ 1,500 Primary plan (Medicare) Assume deductible has been met - $1,500 x 80% $ 1,200 Participant liability $ 300 Secondary plan (Progress Energy BCBS or UHC Standard Plan) Assume deductible has been met - $1,500 x 80% $ 1,200 Participant liability $ 300 Since the secondary plan s (Progress Energy) maximum liability is $1,200 (the same as Medicare, the primary plan), the Progress Energy plan will pay $0, leaving a balance of $300 to be paid by the participant. In general, Medicare participants would reach the out-of-pocket limit and have 100% coverage between the primary and secondary plans for covered expenses when their total medical expenses (not including prescription drugs, charges over the allowed amount, services not precertified and non-covered services) exceed the following: Choice Plan $12,000 ($3,000 out of pocket consisting of Progress Energy plan deductible and coinsurance) Standard Plan $14,000 ($4,000 out of pocket consisting of Progress Energy plan deductible and coinsurance) Prior to reaching the out-of-pocket limit the Progress Energy plan would pay $0, except for wellness exams, prescription drugs and expenses covered under the Progress Energy plan that are not covered by Medicare. Note: The Progress Energy 150-day skilled nursing benefit includes 100 days that are allowed by Medicare. If Medicare pays for 100 days of skilled nursing care, the Progress Energy benefit is 50 days ( ). HRI-SUBS Rev. 23 Page 20 of 205

21 Important Information Maintenance of benefits when other employer-sponsored group coverage is primary (e.g., spouse s or domestic partner s plan) Total bill $10,000 Allowed amount $ 8,000 Primary plan (other employer-sponsored group coverage) Assume deductible has been met - $8,000 x 70% $ 5,600 Participant liability if only primary plan paid - $8,000 - $5,600 $ 2,400 Secondary plan (Progress Energy BCBS or UHC Standard Plan) Assume deductible has been met - $8,000 x 80% $ 6,400 Participant liability if only Progress Energy plan paid - $8,000 - $6,400 $ 1,600 Progress Energy plan pays its normal liability less the primary plan s payment $6,400 - $5,600 $ 800 Participant liability $8,000 - $5,600 - $800 $ 1,600 Note: Florida Power Corporation employees who retired prior to January 1, 1993, are not subject to maintenance of benefits ("carve out") but are eligible for full coordination of benefits, which means that 100% coverage between the two plans is possible. HRI-SUBS Rev. 23 Page 21 of 205

22 BCBSNC High Deductible Health Plan BCBSNC High Deductible Health Plan (HDHP) The HDHP is a comprehensive plan that reimburses you for covered hospital and medical expenses on a fee-forservice basis. With the exception of preventive care services, all eligible services (including prescription drugs, as well as mental health and substance abuse services under the EAP and MHSA Plan) are subject to the HDHP deductible before benefit payments begin. Each time you need medical care, you decide if you want to use a provider who participates in BCBSNC s network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. If you use an in-network provider, you will be eligible for the highest level of benefits under the HDHP. Enrollment Eligibility To participate in the HDHP, you must meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section), and be either (1) an active regular, full-time employee including eligible dependent (regardless of Medicare status); (2) a non-medicare eligible retiree including non-medicare eligible dependent; or (3) a non- Medicare eligible surviving dependent. Participation in the HDHP also permits you to establish a Health Savings Account (HSA) as long as you are not: Covered under any medical plan that is not a high-deductible health plan. Claimed as a dependent on anyone else s tax return. Participating in or eligible for benefits from a general purpose health care reimbursement account (including that of your spouse). Receiving any Veterans Administration medical benefits. Receiving benefits from the company-sponsored LTD plan. Enrolled in Medicare. For additional information about HSAs, see Your Guide to the HDHP/HSA Option, which is incorporated by reference into this document and constitutes part of the SPD for the HDHP. Medical and Prescription Drug ID Card If you enroll in the HDHP, you will receive a medical ID card but will not receive a separate prescription drug ID card. To purchase covered drugs at participating pharmacies, present your medical ID card to the pharmacist. The medical ID card should be presented to your physician and all other health care providers whenever services are received. HRI-SUBS Rev. 23 Page 22 of 205

23 BCBSNC High Deductible Health Plan 2012 BCBSNC HIGH DEDUCTIBLE HEALTH PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses (60% for out-of-network preventive care). For other covered expenses, after satisfying the annual deductible, the HDHP pays 100% for in-network and 100% of the allowed amount for out-of-network. Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Note: Deductible and out-of-network (OON) preventive amounts shown are paid by participant Annual deductible 1 $2,500 self only/$5,000 self plus one or family in-network or OON Out-of-pocket limit 2 Maximum lifetime plan benefit The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) The annual deductible applies to the following: $2,500 self only/$5,000 self plus one or family in- network or OON Unlimited Covered at 100% of allowed amount Covered at 100% in-network 40% OON 3 In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, non-surgical injections) Physician (includes family practice, OB/GYN, and Covered at 100% 4 Covered at 100% 4 internal medicine unless practicing in a specialty area) Specialist Office/surgical procedures (including MRI, PET, CT Covered at 100% 4 Covered at 100% 4 scans and nuclear medicine) Urgent care center 5 Covered at 100% Covered at 100% Emergency room 6 Covered at 100% Covered at 100% Hospital inpatient services 7 Covered at 100% 4 Covered at 100% 4, 8 Inpatient services (room, lab, x-ray) Providers (physician, surgeon, radiologist, anesthesiologist, pathologist, ER physician) Outpatient services Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, surgeon, radiologist, anesthesiologist, pathologist, ER physician) Covered at 100% 4 Covered at 100% 4 Covered at 100% 4 Occupational/physical/speech therapy; spinal Covered at 100% 4 manipulation 9 Durable medical equipment Covered at 100% 4 Covered at 100% 4 Mental health/substance abuse services 10 (deductible See the Mental Health & Substance Abuse Summary Chart. applies) Prescription drugs at participating BCBS Prime Therapeutics pharmacies 11, 12 (deductible applies) Retail (up to 30 days) Mail order (up to 90 days) Covered at 100% of allowed amount Specialty Deductible is the amount you must pay each calendar year before the plan pays a benefit. The deductible does not apply to preventive care. See Deductible section below for additional information. HRI-SUBS Rev. 23 Page 23 of 205

24 BCBSNC High Deductible Health Plan 2. Includes the deductible, but does not include charges in excess of the allowed amount, services not pre-certified, out-of-network (OON) hospital copays or non-covered services. The plan pays 100% of the allowed amount once the out-of-pocket limit is met. See Out-ofpocket limit section below for additional information. 3. OON charges are subject to the allowed amount. 4. Prior plan approval (PPA) (precertification before services occur) required for certain health care services from providers outside of North Carolina or any out-of-network providers. If not precertified, benefits may be denied or paid at 50% of the allowed amount. 5. Treatment must meet urgent care criteria. 6. Must meet emergency care criteria. 7. If not pre-certified in- or out-of-network, benefits reduced to 50% of the allowed amount. 8. $400 out-of-network hospital copay required in addition to deductible. 9. Limited to 60 visits/year for all therapies combined. 10. Inpatient and outpatient facility services must be pre-certified through Magellan Behavioral Health. 11. Prescription drugs are provided through BCBSNC. Prior review or certification is required for some drugs. 12. Medications classified by BCBS as those that generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies. 13. Specialty medications must be purchased through CuraScript Specialty Pharmacy in order to be eligible for coverage. HRI-SUBS Rev. 23 Page 24 of 205

25 BCBSNC High Deductible Health Plan How the HDHP Works This option includes a network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. Benefits under the HDHP are administered based on whether or not the covered services were received from an in-network provider or an out-of-network provider. Benefits for covered services provided by in-network and out-of-network providers are reimbursed as follows: In-network - The "in-network" benefit levels are used to process your claims when you receive covered medical services from a provider who is participating in the BCBSNC BlueCard network. Benefits are based on the lesser of the allowed amount or the provider's charge. In-network providers agree to limit charges for covered services to the allowed amount. However, members are responsible for any deductibles and charges not covered by the HDHP, such as amounts above benefit maximums. Members are responsible for the full cost of non-covered services. In-network providers agree to bill BCBSNC directly for any covered services provided to members so the member is not responsible for submitting claims to BCBSNC. In some situations, an out-of-network provider may be designated by BCBSNC to serve as an in-network provider for a specific covered service. In this situation, the member may be billed by the provider. If you are billed, you will be responsible for paying the bill and filing a claim with BCBSNC. Whether the claim is filed by the provider or by the member, benefits will be at the higher in-network benefit level. Out-of-network - If you do not use a BCBSNC BlueCard provider, your claims are processed using the "out-ofnetwork" benefit levels. Benefits are paid based on the allowed amount. Members are responsible for any amounts over the allowed amount, deductibles and charges not covered by the HDHP, such as amounts above benefit maximums. Members are responsible for the full cost of non-covered services. Some out-of-network providers have other agreements with BCBSNC that affect their reimbursement for covered services provided to the HDHP members. These providers agree not to bill members for any charges higher than their agreed upon, contracted amount. In these situations, members will be responsible for the difference between the HDHP allowed amount and the contracted amount. Out-of-network providers may bill you directly. If you are billed, you will be responsible for paying the bill and filing a claim with BCBSNC. Services received outside of North Carolina Your ID card gives you access to participating providers outside the state of North Carolina through the BlueCard Program. Your ID card tells participating providers that you are a member of BCBSNC. You may receive discounts from out-of-state providers who participate in the BlueCard Program. When you obtain covered health care services through the BlueCard Program outside the area in which the BCBSNC network operates, the amount you pay toward such covered services, such as deductibles, are usually based on the lesser of: The billed charges for your covered services. The negotiated price that the out-of-state Blue Cross and/or Blue Shield licensee ( Host Blue ) passes on to BCBSNC. If you receive covered services from an out-of-network provider, you will be eligible for a lower level of benefits and you may have to file a claim for reimbursement. Also, since the cost of medical procedures may vary widely among out-of-network providers, you may wish to discuss the cost of the specific procedure with the provider before receiving the covered services so you can determine your out-of-pocket costs. If you are traveling If you are traveling out of the service area or to a foreign country and require non-routine medical treatment, you may see a local physician, or if the situation meets the criteria for urgent care or medical emergency, you may go to an urgent care center or hospital emergency room. You may be required to pay the bill at the time of the services. Call BlueCard at BLUE to locate network providers. HRI-SUBS Rev. 23 Page 25 of 205

26 BCBSNC High Deductible Health Plan If your child attends school out of state If your child attends a school out of state, the child will have access to covered healthcare from any provider in the state where he or she lives. Your ID card provides access to participating providers outside the state of North Carolina through the BlueCard Program, and covered benefits are provided at the in-network level. If your child is in an area that has participating providers and chooses a provider outside the network, the lower out-of-network benefit will apply. The list of in-network providers may change from time to time. In-network providers are listed on the BCBSNC website at Questions For questions regarding BCBSNC HDHP medical claims, benefits and pre-certification call BCBSNC at Allowed amount limits Covered expenses are paid based on the allowed amount, the charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC. In the case of providers that have not entered into an agreement with BCBSNC, the allowed amount will be the lesser of the provider's actual charge or a reasonable charge established by BCBSNC using a methodology that is applied to comparable providers for similar services under a similar health benefit plan. BCBSNC's methodology is based on several factors including BCBSNC's medical, payment and administrative guidelines. Under the guidelines, some procedures charged separately by the provider may be combined into one procedure for reimbursement purposes. Charges for covered services received from BCBSNC BlueCard network providers generally are within the allowed amount limit. If covered services are received from a non-participating provider and the charges are above the allowed amount, you are responsible for paying the additional amount. The amount in excess of the allowed amount limit does not apply to the deductible or out-of-pocket limit. Deductible A deductible is the dollar amount you must pay in a calendar year before benefits are payable under the plan for covered services. There is a combined individual and family deductible for in-network and out-of-network covered expenses. If you have self + one or family coverage, the family deductible applies. In meeting your family deductible, all covered family members expenses can be combined to meet the deductible (with self + one or family coverage). The family deductible must be met before any covered expenses are paid. Charges for covered prescription drugs are subject to the HDHP deductible. Refer to the Benefit Summary Chart for specific deductible amounts. The following amounts do not apply toward the annual deductible and thus are not counted when determining whether the annual deductible has been met: Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Out-of-network hospital copayments If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. HRI-SUBS Rev. 23 Page 26 of 205

27 BCBSNC High Deductible Health Plan Coinsurance Coinsurance is the percentage of the cost of a covered expense that you pay. There is no coinsurance under the HDHP (except for out-of-network preventive care). After you have met the applicable deductible, the plan pays at 100% for covered in-network expenses or 100% of the allowed amount for covered out-of-network expenses. Some out-ofnetwork providers may require that you pay the entire bill at the time of service and file a claim with BCBSNC. Out-of-pocket limit The deductible you pay applies to your out-of-pocket limit. Once you reach the annual out-of-pocket limit, BCBSNC will pay 100% of most allowed charges for any additional covered charges incurred for the rest of the year. The following expenses do not apply toward the out-of-pocket limit and thus are not counted when determining whether the out-of-pocket limit has been met: Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Out-of-network hospital copayments If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Utilization Management (UM) Program To make sure you have access to high quality, cost-effective health care, the plan has a UM program. The UM program requires that certain covered health care services you receive be certified by BCBSNC in order to receive benefit coverage. As part of this process, BCBSNC looks at whether health care services are medically necessary, provided in the proper setting and for a reasonable length of time. The plan will honor a certification to cover medical services or supplies under the plan unless the certification was based on a material misrepresentation about your health condition or you were not eligible for these services under the plan due to termination of coverage or nonpayment of premiums. Prospective review/prior plan approval As part of receiving coverage under the UM process, BCBSNC requires that certain covered health care services be reviewed and precertified before you receive them. This process of review is called prior plan approval (PPA). Most inpatient admissions, skilled nursing facility admissions, all private duty nursing services, MRI, PET, CT scans and certain other outpatient services, such as durable medical equipment and home health care services, require PPA or precertification by BCBSNC. The list of services that must be approved in advance may change from time to time. Please visit the BCBSNC website at or call BCBSNC Customer Service at the number listed on the back of your member ID card for a detailed list of services that must be certified in advance. If your services are in-network and from a North Carolina provider, the provider will obtain certification for you. If your services are out-of-network or you receive services from a provider outside of North Carolina (even if the provider participates in the BlueCard network), you are responsible for requesting or having your provider request PPA: Provider approval request line (toll free) Member approval request line (toll free) HRI-SUBS Rev. 23 Page 27 of 205

28 BCBSNC High Deductible Health Plan BCBSNC will make a decision on your request within a reasonable amount of time taking into account the medical circumstances. The decision will be made and communicated to you and your provider within three business days after BCBSNC receives all necessary information but no later than 15 days (24 hours for urgent care claims) from the date BCBSNC received the request. If your request is incomplete, then within five days (24 hours for urgent care claims) from the date BCBSNC received your request, BCBSNC will notify you and your provider of how to properly complete your request. For non-urgent care claims, BCBSNC may also take an extension of up to 15 days if additional information is needed. BCBSNC will notify you and your provider before the end of the initial 15-day period of the information needed and the date by which BCBSNC expects to make a decision. You will have 45 days to provide the requested information. As soon as BCBSNC receives the requested information, or at the end of the 45 days, whichever is earlier, BCBSNC will make a decision within three business days (24 hours for urgent care claims). If BCBSNC does not approve benefit coverage of a health care service, BCBSNC will notify you and the provider by written or electronic confirmation. If pre-admission review is not followed If you or your provider fail to obtain PPA for services received out-of-network or outside of North Carolina and the services are not medically necessary, your claim will be denied for noncertification. If through the appeal process the services are found to be medically necessary, benefits will be reduced to 50% of the allowed amount due to failure to obtain PPA. Any costs incurred because of the denial will not apply to your annual out-of-pocket limit. If you do not agree with the denial, follow the appeals process. Claim review appeal procedures In the event that precertification is not granted for a service, the patient or the provider may appeal the noncertification decision. The noncertification appeals process does not apply to a decision that is based on the fact that the requested service is not covered or disputes regarding the dollar amount or number of covered visits that are limited under the plan. A written appeal must be made to BCBSNC and a decision will be made within a reasonable time but no later than 30 days from the date BCBSNC received the request. For additional information regarding appeals, refer to the BCBSNC medical appeals process under Claims and Appeals. Expedited review You have the right to a more rapid or expedited review of a denial of coverage if a delay: (i) would reasonably appear to seriously jeopardize you or your dependent s life, health or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that may not be adequately managed without the requested care or treatment. An expedited first or second level review may be requested by you, either orally or in writing. In such instance, you and BCBSNC can transmit information via telephone, fax machine or other similar method even if you did not request that the initial claim or first level review be expedited. BCBSNC will communicate the decision by phone to you and your provider no later than 72 hours after receiving the request. A written decision will be communicated within four days after receiving the request for the expedited appeal. After requesting an expedited review, the plan will remain responsible for covered health care services you are receiving until you have been notified of the review decision. HRI-SUBS Rev. 23 Page 28 of 205

29 BCBSNC High Deductible Health Plan If BCBSNC needs additional information to process your expedited review, BCBSNC will notify you and your provider of the information needed as soon as possible but no later than 24 hours following the receipt of your request. You will then be given a reasonable amount of time, but not less than 48 hours, to provide the requested information. As soon as BCBSNC receives the requested information, or at the end of the time period specified for you to provide the information, whichever is earlier, BCBSNC will make a decision on your request within a reasonable time but no later than 48 hours. An expedited review may be requested by calling BCBSNC Customer Service at Concurrent reviews BCBSNC will also review health care services at the time you receive them. These types of reviews are called concurrent reviews. BCBSNC will communicate concurrent review decisions to the hospital or other facility within one business day after BCBSNC makes a decision. If BCBSNC does not certify benefit coverage of a health care service, BCBSNC will notify you, your hospital s or other facility s Utilization Management department and your provider. Written confirmation of the decision will also be sent to your home by U.S. mail. For concurrent reviews, the plan will remain responsible for covered services you are receiving until you or your representatives have been notified of the denial of benefit coverage. Expedited concurrent review You have a right to an expedited concurrent review when the regular time frames for a decision: (i) could seriously jeopardize you or your dependent s life, health, or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that cannot be adequately managed without the requested care or treatment. If you request an extension of treatment that BCBSNC has already approved at least 24 hours before the current approved treatment ends, BCBSNC will notify you and your provider of its decision as soon as possible, taking into account the medical circumstances, but no later than 24 hours after receiving the request. Retrospective reviews BCBSNC also reviews the coverage of health care services after you receive them (called retrospective reviews). A retrospective review may include a review to determine if services received in an emergency setting qualify as an emergency. BCBSNC will make all retrospective review decisions and notify you of its decision within a reasonable time but no later than 30 days from the date BCBSNC received the retrospective review of certification request from you or the provider. When the decision is to deny benefit coverage, BCBSNC will notify you and your provider in writing within five business days of the decision. All decisions will be based on medical necessity and whether the service received was a benefit under the HDHP. BCBSNC may take an extension of up to 15 days if additional information is needed. BCBSNC will notify you before the end of the initial 30-day period of the information needed and the date by which BCBSNC expects to make a decision. You will have 90 days to provide the requested information. As soon as BCBSNC receives the requested information, or at the end of the 90 days, whichever is earlier, BCBSNC will make a decision within 15 days. Services that were certified in advance by BCBSNC will not be subject to denial for medical necessity once the claim is received, unless the certification was based on a material misrepresentation about your health condition or you were not eligible for these services under the HDHP due to termination of coverage or non-payment of premiums. All other services may be subject to retrospective review and could be denied for medical necessity or for a benefit limitation or exclusion. HRI-SUBS Rev. 23 Page 29 of 205

30 Care Management AUTHORIZED COPY BCBSNC High Deductible Health Plan Care management, also known as case management, encourages members with complicated or chronic medical needs, their providers, and the plan to work together to identify the appropriate services to meet the individual s health needs and promote quality outcomes. To accomplish this, members enrolled in or eligible for care management programs may be contacted by BCBSNC or by a representative of BCBSNC. Care management services are provided solely at the option of the plan, and the plan is not obligated to provide the same benefits or services to a member at a later date or to any other member. BCBSNC retains the right to review the patient s medical status while treatment is in process. Benefits may be discontinued for previously approved medical treatment if the: Attending physician does not provide the medical records or physician reports needed to determine the effectiveness of the alternative medical treatment. Goal of the alternative medical treatment has been met. Alternative medical treatment is no longer beneficial to the patient. Maximum allowable benefit under the plan has been paid. Condition Management Program The condition management program, administered by Blue Cross Blue Shield, is available to all active and retired employees and their covered dependents who participate in the High Deductible Health Plan. The program is designed to provide you with tools and resources to gain a better understanding of certain chronic conditions. The condition management program provides access to a 24-hour, 365 days per year information and support line that is staffed with medical professionals familiar with symptoms and issues associated with targeted chronic conditions. Condition specific interventions The condition management program offers health management services for conditions such as: Asthma Diabetes Fibromyalgia Heart Disease High Blood Pressure and High Cholesterol Migraine Pregnancy Tobacco Cessation Weight Management The services offered are intended to supplement but not replace the existing physician-patient relationship. Confidentiality The condition management program maintains the confidentiality of all patient-specific clinical information received from patients, their family members and their health care providers. Confidential information will not be disclosed to Progress Energy or others without your express written consent except when required by law, or (subject to applicable law) to a third party (e.g., an auditor contracted by the plan to review the program practices, including its clinical records, to evaluate the performance of the program administrator). HRI-SUBS Rev. 23 Page 30 of 205

31 BCBSNC High Deductible Health Plan Covered Expenses Medical expenses covered under the HDHP are summarized on the following pages; however this list may not be allinclusive. To be an eligible expense, the expense must be incurred for services that are medically necessary as determined by BCBSNC or qualify as preventive care. If you have questions about the eligibility of a covered medical expense, contact BCBSNC for verification. (See the HDHP Summary Chart for additional information on benefit levels.) Acupuncture Must be performed by a licensed physician or a licensed acupuncturist. Allergy testing and treatment Ambulance service To nearest facility where treatment can be obtained; must meet emergency services criteria or be part of a monitored authorized care plan. Ambulatory surgical centers Anesthesia charges In connection with a covered surgical procedure. Bariatric surgery Morbid obesity/severe obesity, with qualifying co-morbidities, provided that medical necessity is established based on BCBSNC medical policy. Coverage includes office visits/consultations and surgery as deemed appropriate provided the patient has not previously undergone the same or similar procedure while covered under a Progress Energy-sponsored medical plan or a predecessor plan. This coverage could include gastric bypass, laparoscopic (LAP) banding, etc. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Psychological consultation/testing may be considered under the MHSA benefit plan. Blood and blood products and their administration Breast reconstructive surgery and implanted prostheses Incident to mastectomy. Chemotherapy and radiation therapy Chiropractic care (see Therapy) Contraceptive devices and implants Coverage includes the insertion or removal of and any medically necessary examination associated with the use of a covered contraceptive device or implant. Covered contraceptives are intrauterine devices, diaphragms, and implanted hormonal contraceptives. Dental treatment Covered as follows (dentist's and oral surgeon's charges payable as in-network): Removal of tumors and lesions of the mouth. Surgical treatment of diseases when medical criteria are met as determined by BCBSNC, unless covered under the Progress Energy-sponsored dental plan. Accidental injury to sound natural teeth, gums, or jaw occurring from an external source while the patient is covered under a Progress Energy-sponsored medical plan (treatment for accidental injury must begin within 72 hours of the accident and coverage is limited to 12 months). HRI-SUBS Rev. 23 Page 31 of 205

32 BCBSNC High Deductible Health Plan Covered Expenses Anesthesia and hospital or facility charges in connection with dental procedures when hospitalization or general anesthesia is required for children age nine or younger, patients with serious mental or physical conditions, patients with significant behavior problems, or other situations determined medically necessary by BCBSNC; the attending dentist must certify that the criteria have been met. (Coverage does not include any professional fees, except for the anesthesiologist.) PPA must be obtained prior to receiving services. Diabetic treatment Covered as follows: self-management training and education, equipment, supplies and laboratory procedures that are medically necessary; outpatient self-management programs and equipment require referring physician s prescription. Diagnostic services Such as x-rays, metabolism tests, radioisotope tests, and lab tests. Dialysis treatment For renal disease. Durable medical equipment (Physician's prescription is required) Durable medical equipment (DME) is equipment that can be repeatedly used, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. An approved list of DME items is available from BCBSNC and includes, but is not limited to, ostomy supplies, oxygen/rental of oxygen equipment, prosthetic appliances, and orthopedic braces. Expenses are covered for rental (not to exceed the purchase price), purchase (if more economical), or repair or replacement (except due to misuse or loss). Benefits will end when it is determined that the equipment is no longer medically necessary. Certain durable medical equipment requires prior review and certification or services will not be covered. (See Durable medical equipment in the Expenses Not Covered list for exclusions.) Emergency room Foot orthotics If custom molded from a mold of the patient's foot and prescribed by a qualified provider. Hearing exams If performed as part of a wellness/preventive exam. Home health care By an accredited agency in accordance with plan established by your physician; does not include meals, custodial care, or housekeeping services. Prior plan approval must be obtained prior to receiving services. Hospice care Must be precertified payable as in-network. Hospital services Outpatient services Benefits are provided for outpatient services received in a hospital facility. The following are covered services: Diagnostic services Drugs administered by the facility HRI-SUBS Rev. 23 Page 32 of 205

33 BCBSNC High Deductible Health Plan Covered Expenses General nursing care Medical care provided by a doctor or other professional provider Medical supplies Observation Operating, recovery room and related services (outpatient surgery) Other therapy services Short-term rehabilitative therapies Use of appliances and equipment ordinarily provided by the facility for the care and treatment of outpatients Inpatient services (must be pre-certified; refer to Utilization Management) The plan provides coverage when you are admitted to a hospital as an inpatient. The following are covered services: Administration of blood Critical care Diagnostic services and medical supplies Drugs administered by the hospital General nursing care Intensive care Medical care provided by a doctor or other professional provider Neo-natal unit Other therapies Semi-private room; or a private room if medically necessary or the hospital has only private rooms Short-term rehabilitative therapies Use of appliances and equipment ordinarily provided by the hospital Use of the operating, delivery, recovery rooms, nursery and related services Intensive care Emergency and maternity admissions If you or your dependent is admitted to the hospital for emergency treatment or maternity, you or someone acting on your behalf must notify BCBSNC within two working days of the admission. Mammograms (see Preventive care) Mastectomy services Reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the nondiseased breast to produce a symmetrical appearance without regard to the lapse of time between the mastectomy and the reconstructive surgery; and prostheses and physical complications of all stages of the mastectomy, including lymphedemas. Mental health and substance abuse Mental health and substance abuse services are administered by BCBSNC and Magellan Behavioral Health. Your coverage for in-network inpatient and outpatient facility mental health and substance abuse services is coordinated through Magellan Behavioral Health. The plan provides benefits under the EAP and MHSA Plan for the treatment of mental illness and substance abuse by a hospital, doctor or other provider. Covered services are subject to the deductible and apply toward the total out-of-pocket maximum. (See the Employee Assistance and Mental Health & Substance Abuse Services Plan section for information.) HRI-SUBS Rev. 23 Page 33 of 205

34 Covered Expenses Nutritional counseling Up to 12 visits per calendar year if medically necessary. AUTHORIZED COPY BCBSNC High Deductible Health Plan Occupational therapy (see Therapy) Ostomy supplies Members can purchase these supplies through Edgepark at (see Durable medical equipment). Oxygen and rental equipment for oxygen administration (see Durable medical equipment) Physical therapy (see Therapy) Physician fees For medical care to diagnose or treat an illness or injury. Prescription drugs If you are participating in the HDHP, you must use your BCBSNC medical ID card when you have prescriptions filled at your local pharmacy. You may receive your prescription drugs and diabetic supplies from an in-network or out-of-network pharmacy. Your cost may be less if you use an in-network pharmacy. When you visit an innetwork pharmacy, always present your ID card along with your prescription. You will pay the applicable deductible amount. If you visit an out-of-network pharmacy or an in-network pharmacy and do not show your ID card, you will pay for all covered prescriptions and diabetic supplies at the time of purchase and be required to file a claim. You will be responsible for the applicable deductible amount, plus any charges that exceed the allowed amount. When choosing a prescription drug, you and your doctor should discuss whether a lower cost prescription drug, such as a generic, could provide the same results as a more expensive prescription drug. Note: Specialty medications must be purchased through CuraScript. Specialty medications are generally used to treat chronic conditions such as multiple sclerosis, rheumatoid arthritis and cancer. If you attempt to fill a specialty medication at any other pharmacy, that pharmacy will receive an error message stating the medication cannot be filled at their pharmacy. Periodically the list of medications dispensed by CuraScript will be updated. Impacted member s will be notified by BCBSNC and will be given 30 days to transition their prescriptions to CuraScript. CuraScript can be contacted at Eligible drugs Drugs that are covered: Legend drugs or controlled substances that bear the statement "Caution: Federal Law prohibits dispensing without prescription" (except those listed under exclusions). Diabetic syringes, glucose test strips, and supplies. Oral contraceptives. Injectables, such as insulin, Imitrex and Depo-Provera (prior authorization or quantity limit may apply). Compound drugs. Hypnotic drugs (sleep aids) - will be limited to 20 pills per 30-day supply. Impotency drugs (such as Viagra, Caverject, and Muse) if medically necessary due to an organic dysfunction; the attending physician must provide BCBSNC with written documentation certifying the medical necessity of the prescription; a benefit limit of 6 units per 30-day supply may apply. Growth hormones if the attending physician provides BCBSNC with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (only for morbid obesity, member must be enrolled in the Member Health Partnerships). HRI-SUBS Rev. 23 Page 34 of 205

35 Covered Expenses AUTHORIZED COPY BCBSNC High Deductible Health Plan To determine if a specific drug is covered, you should contact BCBSNC. For questions regarding having a prescription filled, call: BCBSNC (retail) Prime Therapeutics (mail order) CuraScript (specialty) Formulary BCBSNC determines the tier placement of prescription drugs in the formulary. The list of prescription drugs in the formulary or the tier placement may change from time to time. If you would like a free, updated copy of the formulary, a list of restricted access drugs and devices, or you want to check the tier placement of a specific drug, please visit the BCBSNC website at or call BCBSNC Customer Service at BCBSNC formularies may change during the year. If you are affected by a change in which your drugs are removed from the formulary (no longer covered), or in which your drugs are moved to a tier requiring a higher member liability, BCBSNC will mail you a notification. This notification will be sent at least 60 days before the formulary change will take effect. BCBSNC will tell you why they are making the change and will list alternative drugs with expected costs. You are encouraged to use this 60-day time frame to have your drug switched to an appropriate alternative medication. Notification about drugs that are removed from the market due to safety reasons will not be sent within 60 days of removal from the market. Mail order drug service Prim , the mail order drug service, may be used for maintenance medications that are taken on a continuing basis. To use Prim , the prescription should be written for a 90-day supply when appropriate and the number of refills indicated on the prescription. You can fill the prescription online, by mail, or by phone. Providers have the option to fax prescriptions. For online orders or to access a mail order form, visit Phone orders are placed by calling Prim at (TTY users can dial 711) 24 hours a day, seven days a week. Note: If the prescription is written for less than a 90-day supply (e.g., for a 30-day supply with 3 refills) it may only be filled with a 30-day supply. You should allow at least 10 business days for new prescriptions to be processed and returned to you. Refills can be delivered in three to five business days. Pre-certification Some prescription drugs may require certification, also known as prior approval, in order to be covered. It is very important to make sure that prior approval is received before you go to the pharmacy. If you need a prescription drug that requires prior approval, your in-network provider should call BCBSNC to request prior approval. If you see an out-of-network provider or a provider outside of NC (even if the provider participates in the BlueCard network), make sure your provider has requested prior approval or you may request prior approval by calling BCBSNC Customer Service. If you receive your prescription drugs from an out-of-north Carolina pharmacy, you need to ensure that prior plan approval, if required, is obtained. For more information on specific drugs that require prior plan approval, contact BCBSNC Customer Service or visit the BCBSNC website at HRI-SUBS Rev. 23 Page 35 of 205

36 BCBSNC High Deductible Health Plan Covered Expenses Purchasing drugs from participating pharmacies To purchase covered drugs at participating pharmacies, present your BCBSNC medical ID card to the pharmacist at the time you submit the prescription. Call BCBSNC for a listing of participating pharmacies. If you live in an area where there are no participating pharmacies or you have a prescription filled on an emergency basis, you may be reimbursed by Prime Therapeutics for the charges. Requests for reimbursement must be filed within 12 months of the date the prescription was filled. Retain copies for your records in case you need to refer to them. Quantity limits Additionally, some prescription drugs may be subject to quantity limits based on criteria developed by BCBSNC. Prior approval is required before excess quantities of these drugs will be covered. If you need quantities in excess of the limit for a drug that is subject to quantity limits, it is important to make sure that your provider has received prior approval before you go to the pharmacy. Refills You cannot refill a prescription until three fourths of the supply has been used. If you would like to receive an extended supply of prescription drugs through the mail, please have your provider write a new prescription for up to 90 days, and call BCBSNC Customer Service to ask for a mail service order form. See Prescription drugs in the Expenses Not Covered list for excluded items. Preventive care Preventive care benefits are available in- and out-of-network. Preventive care can help you stay safe and healthy. The plan covers preventive care services and includes: Colorectal screening - colorectal cancer examinations and laboratory tests for cancer are covered once per calendar year for any symptomatic or nonsymptomatic member who is at least 50 years of age, or is less than 50 years of age and at high risk for colorectal cancer. Increased/high risk individuals are those who have a higher potential of developing colon cancer because of a personal or family history of certain intestinal disorders. In-network Routine/wellness/screening colorectal procedures (i.e., colonoscopy) will be paid at 100% with no deductible if performed in a physician s office, outpatient facility or ambulatory surgical center. Out-of-network Routine/wellness/screening colorectal procedures (i.e., colonoscopy) will be paid at 60% of the allowed amount with no deductible if performed in a physician s office, outpatient facility or ambulatory surgical center. Gynecological exam, including Pap smear - one routine gynecological examination is covered at 100% in-network per female member per calendar year in addition to your calendar year routine physical. This benefit includes the examination, Pap smear, laboratory fee and doctor s interpretation of the lab results. Additional Pap smears will be covered if recommended by a doctor. Mammogram (beginning at any age) one screening mammogram will be covered in- or out-of-network per female member per calendar year, along with a doctor s interpretation of the results. More frequent mammograms will be covered as recommended by a doctor when a female member is considered at risk for breast cancer. A female member is at risk if she: Has a personal history of breast cancer. Has a personal history of biopsy-proven benign breast disease. HRI-SUBS Rev. 23 Page 36 of 205

37 Covered Expenses Has a mother, sister, or daughter who has or has had breast cancer. Has not given birth prior to the age of 30. AUTHORIZED COPY BCBSNC High Deductible Health Plan Prostate screening - one Prostate Specific Antigen (PSA) test or an equivalent serological test will be covered per male member per calendar year. Additional PSA tests will be covered if recommended by a doctor. Routine physical examinations - one routine physical examination and related diagnostic services per calendar year will be covered for each member age two and older in-network. Well-baby and well-child care - these services are covered for each member up to 18 years of age including periodic assessments and immunizations. Benefits are limited to six well-baby visits for members through 12 months old and three well-child visits for members 13 months up to 23 months old. Benefits are limited to one exam per year for members ages 2-18 in network. For claims to be processed as wellness, the exam and related laboratory and/or screenings must be coded with a primary diagnosis coding of screening. If a medical condition is diagnosed and treated during an initial or followup visit for a wellness exam or preventive care, the treating physician may apply the appropriate diagnostic or treatment code. The charges for this diagnosis or treatment may require you to pay the deductible. Prosthetic appliances and orthopedic braces (see Durable medical equipment) Second surgical opinions Sexual dysfunction Treatment to restore sexual function including penile implants when medically necessary (benefits limited to $5,000 per lifetime). Skilled nursing facility Charges for up to 150 days per calendar year if the patient s condition requires the level of nursing care available in a skilled nursing facility; prior plan approval must be obtained prior to receiving services. Speech therapy (see Therapy) Sterilization procedures for either sex (including elective sterilization) Surgery Performed on an inpatient or outpatient basis for treatment of an illness or injury and surgical procedures required to correct birth defects. Coverage includes post-operative care normally provided as part of the surgical procedure. These benefits include the services of the surgeon or medical specialist, assistant, and anesthetist or anesthesiologist, together with pre-operative and post-operative care. Temporomandibular joint syndrome (TMJ) Coverage includes office visits, consultations, physical therapy, and surgical procedures as deemed medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. Hospital charges (including anesthesia and other ancillary charges) are covered when incurred due to an accidental injury or disease in the temporomandibular joint. HRI-SUBS Rev. 23 Page 37 of 205

38 Covered Expenses Therapy Limited to 60 visits per year for the following therapies combined: AUTHORIZED COPY BCBSNC High Deductible Health Plan Chiropractic care including spinal manipulation services by physicians for manipulations of the spine to correct dislocation of a bone or joint. Occupational therapy services provided by a physician or occupational therapist for the purpose of aiding in the restoration of a previously impaired function. Physical therapy services provided by a physician or physical therapist to restore normal physical function. Speech therapy services of a physician, speech therapist or licensed audiologist to aid in the restoration of speech loss or an impairment of speech as a result of sickness, disease, injury or congenital anomaly. A patient may be allowed to go beyond the current 60 visit limit only if a request is made by or on behalf of the patient, a treatment plan is submitted and prior approval is obtained from BCBSNC based on medical necessity. Other therapies: Cardiac rehabilitation therapy. Chemotherapy, including intravenous chemotherapy (this does not include high dose chemotherapy done with bone marrow or peripheral blood stem cell transplants). Pulmonary therapy. Radiation therapy including accelerated partial breast brachytherapy. Breast brachytherapy is investigational but will be covered upon prior review and certification, based on meeting the American Society of Breast Surgeons (ASBS) criteria. Respiratory therapy. Transplants The plan provides benefits for transplant services including hospital and professional services for the transplant procedures listed below. As a BCBSNC member, you have access to the Blue Quality Centers for Transplants, a group of facilities that provide organ transplant services. Facilities chosen are nationally recognized for their delivery of these highly specialized procedures. If a transplant is being considered, you should call BCBSNC Customer Service to speak with a transplant case manager. You must obtain certification from BCBSNC in advance for all transplant-related services in order to assure maximum coverage of these services. Eligible transplant procedures include: Heart Lung, single and bilateral Combined heart and lung Pancreas Kidney Simultaneous pancreas and kidney Liver Cornea Small bowel Simultaneous small bowel and liver High dose chemotherapy with bone marrow or peripheral blood stem cell rescue, including autologous (self-donor) and allogeneic (other donor) bone marrow transplant Allogeneic (other donor) bone marrow transplant HRI-SUBS Rev. 23 Page 38 of 205

39 BCBSNC High Deductible Health Plan Covered Expenses If a transplant is provided from a living donor to the recipient member who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant unless a higher amount is authorized by the transplant case manager in special and unique situations. Both the recipient and the donor are entitled to transplant benefits when the recipient is a member. Benefits provided to the live donor will be charged against the recipient s coverage. Benefits are payable only for covered services provided to the actual donor selected, and not for services provided to other prospective donors. Based on BCBSNC travel and lodging guidelines, benefits may be paid for transportation, lodging, and necessary living expense for the patient and one companion if the patient is referred by a case manager to an out-of-area facility for an organ or tissue transplant. The companion must either be a spouse or domestic partner, family member, or guardian of the patient. Necessary living expenses include expenses such as hotel and car rental, but do not include items such as meals, child care, house sitting charges, kennel boarding, or reimbursement of any wages lost by the companion during the patient s stay in a referred facility. Reimbursement amounts over $50 per person (you may include lodging for one companion of the patient) per day for lodging expenses are considered by the IRS to be excess benefits and would be reported as taxable to the recipient. Some transplant services are investigational for some or all conditions or illnesses. (See Transplants in the Expenses Not Covered list for exclusions.) Weight management If enrolled in BCBSNC Member Health Partnerships, up to four doctor s office visits to assess and monitor weight, up to six annual nutrition counseling visits with a registered dietitian and weight management tools. Contact BCBSNC for details. HRI-SUBS Rev. 23 Page 39 of 205

40 BCBSNC High Deductible Health Plan Expenses Not Covered The following goods and services are not covered. This list may not be all-inclusive. For questions regarding coverage, contact BCBSNC. General exclusions include, but are not limited to: Acupuncture treatments except when performed by a licensed physician or a licensed acupuncturist. Air conditioners, furnaces, humidifiers, dehumidifiers, vacuum cleaners, electronic air filters and similar equipment. Air purification systems. Allowed amount for services usually provided by one doctor, when those services are provided by multiple doctors. Amounts in excess of the allowed amount limits as determined by BCBSNC. Any health care services not specifically listed in the Covered Expenses list, unless such services are specifically required to be covered by applicable law. Any health care services or supplies that are not medically necessary according to accepted standards of medical practice or that are not related to the diagnosis or treatment of a given illness or injury as determined by BCBSNC; the ordering of a service by a health care provider does not in itself make such service medically necessary or a covered service. Any health care services provided to a dependent deemed ineligible (see Dependents in the Eligibility section). Any health care services received: That are covered by any other benefit plan or insurance program that is sponsored by Progress Energy. By a patient who resides permanently outside of the United States or Canada. As a result of an illness or injury caused by war, rebellion, or riot. From a member of your or your spouse s or domestic partner s immediate family (spouse, domestic partner, children or parents) or from a person who normally resides in your home. As a result of illness or injury incurred while committing or attempting to commit a crime. Any health care services received prior to an employee's or dependent s effective date or after the date an employee's or dependent s coverage terminates. Any health care services rendered at no charge. Any health care services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group. Any health care services to treat a work-related condition to the extent the employee is covered or required to be covered by Workers Compensation law. Any service or supply to diagnose or treat any condition resulting from or in connection with an employee's job or employment will not be covered, except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers Compensation and that lack of coverage did not result from any intentional action or omission by that individual. Bunion treatment except by capsular or bone surgery. Care that the provider may not legally provide or legally charge or is outside the scope of license or certification. HRI-SUBS Rev. 23 Page 40 of 205

41 Expenses Not Covered Charges for letters or other documents regarding treatment. AUTHORIZED COPY BCBSNC High Deductible Health Plan Charges incurred after termination of coverage. Chiropractic maintenance treatments. Conditions that federal, state, or local law requires to be treated in a public facility or for any treatment covered by any governmental body or agency unless payment is required by law. Cosmetic surgery and related services and supplies; surgery is covered if the surgery is to correct the effects of birth defects, accidental injury, or reconstructive procedures to replace diseased tissue. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Counseling. (See the Employee Assistance and Mental Health & Substance Abuse Services section.) Court ordered services that are otherwise excluded from benefits under this plan. Custodial care, respite care and domiciliary care or rest cures, care provided and billed for by a hotel, health resort, convalescent home, rest home, nursing home or other extended care facility, home for the aged, infirmary, school infirmary, institution providing education in special environments or any similar facility or institution. Dental care, dentures, dental implants, oral orthotic devices, palatal expanders and orthodontics except as specifically covered by the plan. Dental services provided in a hospital, except when a hazardous condition exists at the same time or covered oral surgery services are required at the same time as a result of a bodily injury. (See Dental treatment in the Covered Expenses list.) Dependent child pregnancy - expenses for the newborn child are not covered unless the newborn is legally adopted by the employee or the employee obtains legal guardianship within 30 days of date of birth. (Maternity expenses for the eligible dependent daughter are covered.) Durable medical equipment exclusions: Durable medical equipment that is primarily for convenience and/or comfort; modifications to motor vehicles and/or homes such as wheelchair lifts or ramps; water therapy devices such as jacuzzis, hot tubs, swimming pools or whirlpools; exercise and massage equipment; electric scooters; hearing aids; air conditioners; humidifiers; water purifiers; pillows, mattresses or waterbeds; escalators, elevators or stair glides; emergency alert equipment; handrails; heat appliances; and dehumidifiers. Educational treatment and services including reading clinics and special schools for mentally retarded or behaviorally impaired individuals; services primarily for education purposes include but are not limited to books, tapes, pamphlets, seminars, classroom, Internet or computer programs, individual or group instruction and counseling. Elective abortion procedures. Expenses provided and billed by a licensed health care professional who is in training. HRI-SUBS Rev. 23 Page 41 of 205

42 BCBSNC High Deductible Health Plan Expenses Not Covered Experimental and/or investigational services or supplies and any related expenses as determined by BCBSNC, except as otherwise covered under the bone marrow transplant provision of the transplant services. (See Transplants in the Covered Expenses list.) Eyeglasses or contact lenses and examinations except following cataract surgery or to treat keratoconus. Fertility treatments including drugs and charges for artificial insemination and in-vitro fertilization. Genetic testing, except for high risk patients when the therapeutic or diagnostic course would be determined by the outcome of the testing. Health check-ups, premarital examinations, and immunizations except those specifically covered as preventive care expenses. Hearing aids. Hearing examinations, except those included as part of a wellness/preventive exam. Heating pads, hot water bottles, ice packs and personal hygiene and convenience items such as, but not limited to, devices and equipment used for environmental control or to enhance the environmental setting. Holistic medicine services. Injectable prescription drugs which may be self-administered that are administered by a health care professional, unless medical supervision is required. Inpatient admissions primarily for the purpose of receiving diagnostic services or a physical examination; inpatient admissions primarily for the purpose of receiving therapy services are excluded except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy. Maintenance therapy, including therapy services that are provided over a long period of time in order to keep the patient s condition stable. Massage therapy services. Music therapy, remedial reading, recreational or activity therapy, all forms of special education and supplies or equipment used similarly. Outpatient pre-operative and post-operative care in excess of that normally provided for surgery. Physical fitness equipment, hot tubs, jacuzzis, heated spas, pool or memberships to health clubs. Prescription drugs that are excluded: Drugs that may be purchased without a prescription (over-the-counter drugs). Fertility medications, injections, and treatments. Ostomy supplies (members can purchase these supplies through Edgepark at ); claims may be filed with BCBSNC for reimbursement; subject to deductible. Therapeutic appliances or devices, support garments, or other non-medical items. Nicorette or other tobacco cessation products. HRI-SUBS Rev. 23 Page 42 of 205

43 BCBSNC High Deductible Health Plan Expenses Not Covered Impotency drugs (such as Viagra, Caverject, and Muse) unless medically necessary due to an organic dysfunction; the attending physician must provide BCBSNC with written documentation certifying the medical necessity of the prescription; a benefit limit of 6 units per 30-day supply may apply. Growth hormones unless the attending physician provides BCBSNC with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (unless for morbid obesity, member must be enrolled in the Member Health Partnerships). Refills beyond one year of original prescription date (six months for controlled drugs). Experimental or investigational drugs. Drugs used for cosmetic purposes. Drugs covered under Workers Compensation or any other federal or state program. Private duty nurses for inpatient hospital care. Refractory procedures, including charges for any procedure performed for the purpose of correcting myopia, hyperopia, or astigmatism, and expenses related to such procedures. Reversal of sterilization procedures. Routine foot care or podiatry, including treatment of toenails, bunions, corns, calluses, fallen arches, flat feet, weak feet, chronic foot strain or over-the-counter shoe inserts. Self-care unit, apartment or similar facility care operated by or connected with a hospital. Services incurred more than 18 months prior to submission of a claim to BCBSNC, except in the absence of legal capacity of the member. Services not prescribed or performed by or upon the direction of a doctor or other provider. Services that are investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment, as well as services whose efficacy has not been established by controlled clinical trials, or are not recommended as a preventive service by the U.S. Public Health Service. Services that would not be necessary if a noncovered service had not been received, except for emergency services in the case of an emergency. Sex change or modification treatments or studies leading to or in connection with sex changes or modifications and related care. Sexual dysfunction unrelated to organic disease. Side effects and complications of noncovered services, except for emergency services in the case of an emergency. Speech therapy for problems not caused by illness, injury or congenital anomaly. Surgery for psychological or emotional reasons. Telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records, and late payment charges. HRI-SUBS Rev. 23 Page 43 of 205

44 Expenses Not Covered AUTHORIZED COPY BCBSNC High Deductible Health Plan Temporomandibular joint syndrome (TMJ) treatment; except those charges specifically listed under covered expenses. Other TMJ charges may be eligible for coverage under the Progress Energy-sponsored dental plan. Charges for oral surgery and appliances may be eligible for coverage under the Progress Energy-sponsored dental plan. After individual consideration and review of the patient s history, expenses may not be covered if treatment is deemed not medically necessary or when diagnostic tests and procedures proposed do not meet the medical criteria. Transplant exclusions: Purchase price of the organ or tissue if any organ or tissue is sold rather than donated to the recipient member. Procurement of organs, tissue, bone marrow or peripheral blood stem cells or any other donor services if the recipient is not a member. Transplants that are considered experimental or investigational (including high dose chemotherapy). Services, drugs and supplies for or related to transplants, except those transplants specifically listed as covered services. Services for or related to the transplantation of animal or artificial organs or tissues. Transportation except for medically necessary road or air ambulance service. Treatment or regimen, medical or surgical, for the purpose of reducing or controlling the weight of a member or for treatment of obesity, except for surgical treatment of morbid obesity when medically necessary and medical criteria are met. (See Bariatric surgery in the Covered Expenses list.) Vitamins, food supplements or replacements, nutritional or dietary supplements, formulas or special foods of any kind. Weight reduction procedures designed to restrict the patient s ability to assimilate food (such as gastric bypass, gastric balloons, jaw wiring, and stomach stapling) unless medically necessary. (See Bariatric surgery in the Covered Expenses list.) Wigs and/or cranial prostheses. HRI-SUBS Rev. 23 Page 44 of 205

45 BCBSNC Standard and Choice Plans AUTHORIZED COPY BCBSNC Standard and Choice Plans The Blue Cross Blue Shield of North Carolina (BCBSNC) Standard and Choice medical plans are comprehensive plans that reimburse you for covered hospital and medical expenses on a fee-for-service basis. Each time you need medical care, you decide if you want to use a provider who participates in BCBSNC s BlueCard network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. If you use an in-network provider, you will be eligible for the highest level of benefits from the Standard or Choice medical plan in which you are enrolled. Enrollment Eligibility To participate in the BCBSNC Standard or Choice medical plan, you and your dependents must (1) meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section) and (2) be either: An active regular, full-time employee residing or working outside of Florida including eligible dependent (regardless of residence). An LTD recipient residing outside of Florida including eligible dependent (regardless of residence). A retiree residing outside of Florida including eligible dependent (regardless of residence). A surviving dependent residing outside of Florida including eligible dependent (regardless of residence). Progress Energy Carolinas retirees that relocate to Florida may continue to participate in the BCBSNC Standard or Choice medical plan. Medicare-eligible participants LTD recipients, retirees and surviving dependents should apply for and purchase Medicare Part B when you or your dependent first becomes eligible for Medicare, and you should use providers who accept Medicare. BCBSNC will assume you have purchased Medicare Part B and use providers who accept Medicare, and will coordinate benefits accordingly, regardless of whether or not you are actually covered under Part B or actually use providers who accept Medicare. This means that if you do not enroll in Medicare Part B when you become eligible or if you use providers who do not accept Medicare and then incur expenses that would be covered by Medicare Part B, you will be responsible for paying the full cost of those expenses. They will not be covered or paid by the BCBSNC Standard or Choice medical plan. The benefit levels for in-network office visits and urgent care centers for the Choice medical plan will be coinsurance amounts, rather than copayments, when Medicare is primary. For active regular, full-time employees, you and your covered dependents are not required to apply for and purchase Medicare Part B as long as you remain an active regular, full-time employee. Medical and Prescription Drug ID Cards If you enroll in either the BCBSNC Standard or Choice option, you will receive: BCBSNC Standard or Choice medical ID cards. The medical ID card should be presented to your physician and all other health care providers (except pharmacies) whenever services are received. If you have questions about your ID card or need additional cards, you should call BCBSNC. A prescription drug ID card from Catalyst Rx. You must use your Catalyst Rx card (and not your BCBSNC Standard or Choice medical ID card) when you have prescriptions filled at your local pharmacy. Your Catalyst Rx ID card will contain your name, member ID number, and the prescription drug program group number. The pharmacist uses this information to verify eligibility and copayment/coinsurance amounts. The card will also list your covered dependents' names. HRI-SUBS Rev. 23 Page 45 of 205

46 BCBSNC Standard and Choice Plans 2012 BCBSNC STANDARD PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses. For covered prescription drugs, copays or coinsurance applies. For most other covered expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Note: Copays, coinsurance, and deductibles shown below are amounts paid by participant. Annual deductible 1 $1,500 individual/$3,000 family in- or out-of-network (coinsurance applies thereafter) Out-of-pocket limit 2 $4,000 individual/$8,000 family in- or out-of-network Maximum lifetime plan benefit Unlimited The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse services 4 Prescription drugs at participating pharmacies 5 Generic Preferred Brand Name Non-Preferred Brand Name Covered at 100% of allowed amount Covered at 100% in-network 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Walgreen s Retail (up to 30 days) Mail Order (up to 90 days) $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Speciality 7 Once the deductible is met, the following charges are subject to coinsurance: In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, non-surgical injections) Physician (includes family practice, OB/GYN, and internal medicine unless practicing in a specialty area) Specialist 20% 8 40% 8 20% 8 40% 8 20% 8 40% 8 Office/surgical procedures (including MRI, PET, CT scans and nuclear medicine) Urgent care center 9 20% 20% Emergency room 10 20% 20% Hospital inpatient services 11 Inpatient services (room, lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) Outpatient services Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) 20% 8 20% 8 8, 13 20% 20% 8 20% 8 20% 8 8, 13 20% 8, 12 40% 40% 8 8, 13 40% 40% 8 40% 8 40% 8 8, 13 40% HRI-SUBS Rev. 23 Page 46 of 205

47 BCBSNC Standard and Choice Plans 20% 8 Occupational/physical/speech therapy; spinal 40% 8 manipulation 14 Durable medical equipment 20% 8 40% 8 1. Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the allowed amount, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include prescription drug coinsurance or copays, charges in excess of the allowed amount, services not pre-certified, or noncovered services. The out-of-pocket limit is maximum amount of deductible and coinsurance combined that you must pay during a plan year. 3. Out-of-network charges are subject to the allowed amount. 4. Services are provided through ValueOptions and must be pre-certified; annual deductible does not apply. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. The Formulary Advantage and Maximum Dollar Amount Programs apply. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Prior plan approval (PPA) precertification before services occur required for certain health care services from providers outside of North Carolina or any out-of-network providers. If not precertified, benefits may be denied or paid at 50% of the allowed amount. 9. Treatment must meet urgent care criteria. 10. $50 copay required in addition to deductible and coinsurance; waived if admitted or if Medicare is primary; must meet emergency care criteria. 11. If not pre-certified in- or out-of-network, benefits reduced to 50% of the allowed amount. 12. $400 out-of-network hospital copay required in addition to deductible and coinsurance % coinsurance if performed at an in-network facility or on the same day as an in-network provider visit; 40% coinsurance if performed at an out-of-network facility. 14. Limited to 60 visits per year for all therapies combined. HRI-SUBS Rev. 23 Page 47 of 205

48 BCBSNC Standard and Choice Plans 2012 BCBSNC CHOICE PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses. Copays apply to some prescription drugs, innetwork office visits for physician and specialist, in-network outpatient mental health/substance abuse services office visits, and urgent care. For most other covered expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Annual deductible 1 Out-of-pocket limit 2 Maximum lifetime plan benefit Note: Copays, coinsurance, and deductibles shown below are amounts paid by participant. $750 individual/$1,500 family in- or out-of-network (coinsurance applies thereafter) $3,000 individual/$6,000 family in- or out-of-network The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse services 4 Prescription drugs at participating pharmacies 5 Unlimited Covered at 100% of allowed amount Covered at 100% innetwork 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Walgreen s Retail (up to 30 days) Mail Order (up to 90 days) Generic Preferred Brand Name Non-Preferred Brand Name $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Speciality 7 Once the deductible is met, the following charges are subject to coinsurance. Copays, not coinsurance and deductible, apply to in-network office and any urgent care visits if member is not eligible for Medicare, or if Medicare or other insurance is secondary. In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, non-surgical injections) Physician (includes family practice, OB/GYN, and internal $25/20% 8, 9 40% 8 medicine unless practicing in a specialty area) Specialist $35/20% 8, 9 40% 8 Office/surgical procedures (including MRI, PET, CT scans 20% 8 40% 8 and nuclear medicine) Urgent care center 10 $35/20% 9 $35/20% 9 Emergency room 11 20% 20% Hospital inpatient services 12 Inpatient services (room, lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) 20% 8 20% 8 8, 14 20% 8, 13 40% 40% 8 8, 14 40% HRI-SUBS Rev. 23 Page 48 of 205

49 Outpatient services Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) AUTHORIZED COPY BCBSNC Standard and Choice Plans 20% 8 20% 8 20% 8 8, 14 20% 40% 8 40% 8 40% 8 8, 14 40% Occupational/physical/speech therapy; spinal manipulation 15 $35/20% 8, 9 40% 8 Durable medical equipment 20% 8 40% 8 1. Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the allowed amount, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include office or urgent care visit copays, prescription drug copays and coinsurance, charges in excess of the allowed amount, services not pre-certified, or non-covered services. Out-of-pocket limit is maximum amount of deductible and coinsurance you must pay during a plan year. 3. Out-of-network charges are subject to the allowed amount. 4. Services are provided through ValueOptions and must be pre-certified; annual deductible does not apply. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Prior plan approval (PPA) (precertification before services occur) required for certain health care services from providers outside of North Carolina or any out-of-network providers. If not precertified, benefits may be denied or paid at 50% of the allowed amount. 9. Copays, not coinsurance and deductible, apply to office or urgent care visits if member is not eligible for Medicare or if Medicare or other insurance is secondary. 10. Treatment must meet urgent care criteria. 11. $50 copay required in addition to deductible and coinsurance; waived if admitted or if Medicare is primary. Must meet emergency care criteria. 12. If not pre-certified in- or out-of-network, benefits reduced to 50% of the allowed amount. 13. $250 out-of-network hospital copay required in addition to deductible and coinsurance % coinsurance if performed at an in-network facility or on the same day as an in-network provider visit; 40% coinsurance if performed at an out-of-network facility. 15. Limited to 60 visits per year for all therapies combined. HRI-SUBS Rev. 23 Page 49 of 205

50 BCBSNC Standard and Choice Plans How the BCBSNC Standard and Choice Plans Work These plans include a network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. Benefits under the BCBSNC Standard and Choice Plans are administered based on whether or not the covered services were received from an in-network provider or an out-ofnetwork provider. Benefits for covered services provided by in-network and out-of-network providers are reimbursed as follows: In-network - The "in-network" benefit levels are used to process your claims when you receive covered medical services from a provider who is participating in the BCBSNC BlueCard network. Benefits are based on the lesser of the allowed amount or the provider's charge. In-network providers agree to limit charges for covered services to the allowed amount. However, members are responsible for any deductibles, coinsurance and charges not covered by BCBSNC Standard and Choice Plans, such as amounts above benefit maximums. Members are responsible for the full cost of noncovered services. In-network providers agree to bill BCBSNC directly for any covered services provided to members so the member is not responsible for submitting claims to BCBSNC. In some situations, an out-of-network provider may be designated by BCBSNC to serve as an in-network provider for a specific covered service. In this situation, the member may be billed by the provider. If you are billed, you will be responsible for paying the bill and filing a claim with BCBSNC. Whether the claim is filed by the provider or by the member, benefits will be at the higher innetwork benefit level. Out-of-network - If you do not use a BCBSNC BlueCard provider, your claims are processed using the "outof-network" benefit levels. Note: The out-of-network benefit levels do not apply if Medicare is primary. Benefits are paid based on the allowed amount. Members are responsible for any amounts over the allowed amount, deductibles, coinsurance and charges not covered by BCBSNC Standard and Choice Plans, such as amounts above benefit maximums. Members are responsible for the full cost of noncovered services. Some out-of-network providers have other agreements with BCBSNC that affect their reimbursement for covered services provided to BCBSNC Standard and Choice Plans members. These providers agree not to bill members for any charges higher than their agreed upon, contracted amount. In these situations, members will be responsible for the difference between the BCBSNC Standard and Choice Plans allowed amount and the contracted amount. Out-of-network providers may bill you directly. If you are billed, you will be responsible for paying the bill and filing a claim with BCBSNC. Services received outside of North Carolina Your ID card gives you access to participating providers outside the state of North Carolina through the BlueCard Program. Your ID card tells participating providers that you are a member of BCBSNC. By taking part in this program, you may receive discounts from out-of-state providers who participate in the BlueCard Program. When you obtain covered health care services through the BlueCard Program outside the area in which the BCBSNC network operates, the amount you pay toward covered services, such as deductibles, copayments or coinsurance is usually based on the lesser of: The billed charges for your covered services. The negotiated price that the out-of-state Blue Cross and/or Blue Shield licensee ( Host Blue ) passes on to BCBSNC. If you receive covered services from an out-of-network provider, you will pay a deductible and a higher coinsurance and you may have to file a claim for reimbursement. Also, since the cost of medical procedures may vary widely among out-of-network providers, you may wish to discuss the cost of the specific procedure with the provider before receiving the covered services so you can determine your out-of-pocket costs. HRI-SUBS Rev. 23 Page 50 of 205

51 BCBSNC Standard and Choice Plans If you are traveling If you are traveling out of the service area or to a foreign country and require non-routine medical treatment, you may see a local physician, or if the situation meets the criteria for urgent care or medical emergency, you may go to an urgent care center or hospital emergency room. You may be required to pay the bill at the time of the services. Call BlueCard at BLUE to locate network providers. If your child attends school out of state If your child attends a school out of state, the child will have access to covered healthcare from any provider in the state where he or she lives. Your ID card provides access to participating providers outside the state of North Carolina through the BlueCard Program, and covered benefits are provided at the in-network level. If your child is in an area that has participating providers and chooses a provider outside the network, the lower out-of-network benefit will apply. The list of in-network providers may change from time to time. In-network providers are listed on the BCBSNC website at Questions For questions regarding BCBSNC Standard and Choice Plans medical claims, benefits and pre-certification call BCBSNC at Allowed amount limits Covered expenses are paid based on the allowed amount, the charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC. In the case of providers that have not entered into an agreement with BCBSNC, the allowed amount will be the lesser of the provider's actual charge or a reasonable charge established by BCBSNC using a methodology that is applied to comparable providers for similar services under a similar health benefit plan. BCBSNC's methodology is based on several factors including BCBSNC's medical, payment and administrative guidelines. Under the guidelines, some procedures charged separately by the provider may be combined into one procedure for reimbursement purposes. Charges for covered services received from BCBSNC BlueCard network providers generally are within the allowed amount limit. If covered services are received from a non-participating provider and the charges are above the allowed amount, you are responsible for paying the additional amount. The amount in excess of the allowed amount limit does not apply to the deductible or out-of-pocket limit. Deductible A deductible is the dollar amount you must pay each calendar year before benefits are payable for covered services that require you to pay a percentage of the charge (coinsurance). The deductible is combined for in- and out-ofnetwork services. The BCBSNC Standard and Choice Plans have an individual deductible for each person you cover (including dependents) up to a combined family deductible. When a covered individual meets his or her individual deductible or when several covered family members expenses combine to satisfy the family deductible, the option will begin paying benefits for covered expenses that require coinsurance. Refer to the Summary Charts for specific deductible amounts. The following amounts do not apply toward the annual deductible and thus are not counted when determining whether the annual deductible has been met: Copayments Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) HRI-SUBS Rev. 23 Page 51 of 205

52 Expenses that are not covered Prescription copays and coinsurance AUTHORIZED COPY BCBSNC Standard and Choice Plans If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Coinsurance and copayments under the Standard Plan For charges from in-network providers (including doctor s office visits, surgery, outpatient procedures and inpatient expenses), after you have met your annual deductible, you pay a percentage of the cost of the covered expenses (called coinsurance). The plan pays the remainder of the covered charges. Deductibles and coinsurance do not apply to in-network preventive care. When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the allowed amount. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require that you pay the entire bill at the time of service and file a claim with BCBSNC. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Standard Plan as described in the Summary Chart. Coinsurance and copayments under the Choice Plan When you have an office visit with an in-network physician or specialist, you pay a flat amount called a copayment. You do not have to meet a deductible for services that require a copayment. Office visit copayments include exams, diagnosis, lab tests, and non-surgical injections. If lab or other tests are conducted in a doctor s office in preparation for an office visit or in a follow-up visit and you do not see the physician, the tests are not subject to an additional copayment. If services in connection with an office visit are performed at a hospital-owned or operated facility, they are subject to deductible and coinsurance. For allergy shots, you must pay a copayment or the actual cost of the injection, whichever is less. If an office visit includes a surgical procedure, deductible and coinsurance amounts apply. If an office visit is billed separately from the surgical procedure, a copayment will apply to the office visit. Note: When Medicare or other insurance is primary, copayment amounts do not apply; deductible and coinsurance amounts do apply. Copayments, deductibles and coinsurance do not apply to in-network preventive care. For most other covered in-network expenses (such as outpatient procedures, hospital charges and surgery), you pay a percentage of the cost of the covered expense (called coinsurance) after you have met your deductible. BCBSNC pays the remainder of the covered charges. When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the allowed amount. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require you to pay the entire bill at the time of service and file a claim with BCBSNC. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Choice Plan as described in the Summary Chart. Copayments do not apply towards the out-of-pocket limit or the deductible. HRI-SUBS Rev. 23 Page 52 of 205

53 BCBSNC Standard and Choice Plans Out-of-pocket limit The deductible and coinsurance amounts you pay apply to your out-of-pocket limit. If you reach the annual out-ofpocket limit, BCBSNC will pay 100% of allowed charges for any additional covered charges incurred for the rest of the year if the charges are subject to deductible and coinsurance. The out-of-pocket limit is combined for in- and outof-network charges. If the annual family out-of-pocket limit has been met, no additional coinsurance amounts or deductibles will apply for that year. The following expenses do not apply toward the out-of-pocket limit and thus are not counted when determining whether the out-of-pocket limit has been met: Copayments Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Prescription drug copays and coinsurance If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Utilization Management (UM) Program To make sure you have access to high quality, cost-effective health care, the plan has a UM program. The UM program requires that certain covered health care services you receive be certified by BCBSNC in order to receive benefit coverage. As part of this process, BCBSNC looks at whether health care services are medically necessary, provided in the proper setting, and for a reasonable length of time. The plan will honor a certification to cover medical services or supplies under the plan unless the certification was based on a material misrepresentation about your health condition or you were not eligible for these services under the plan due to termination of coverage or nonpayment of premiums. Prospective review/prior plan approval As part of receiving coverage under the UM process, BCBSNC requires that certain covered health care services be reviewed and precertified before you receive them. This process of review is called prior plan approval (PPA). Most inpatient admissions, skilled nursing facility admissions, all private duty nursing services, MRI, PET, CT scans and certain other outpatient services, such as durable medical equipment and home health care services, require PPA, or precertification, by BCBSNC. The list of services that must be approved in advance may change from time to time. Please visit the BCBSNC website at or call BCBSNC Customer Service at the number listed on the back of your member ID card for a detailed list of services that must be certified in advance. If your services are in-network and from a North Carolina provider, the provider will obtain certification for you. If your services are out-of-network or you receive services from a provider outside of North Carolina (even if the provider participates in the BlueCard network), you are responsible for requesting or having your provider request prior plan approval: Provider approval request line (toll free) Member approval request line (toll free) HRI-SUBS Rev. 23 Page 53 of 205

54 BCBSNC Standard and Choice Plans BCBSNC will make a decision on your request within a reasonable amount of time taking into account the medical circumstances. The decision will be made and communicated to you and your provider within three business days after BCBSNC receives all necessary information but no later than 15 days (24 hours for urgent care claims) from the date BCBSNC received the request. If your request is incomplete, then within five days (24 hours for urgent care claims) from the date BCBSNC received your request, BCBSNC will notify you and your provider of how to properly complete your request. For non-urgent claims, BCBSNC may also take an extension of up to 15 days if additional information is needed. BCBSNC will notify you and your provider before the end of the initial 15-day period of the information needed and the date by which BCBSNC expects to make a decision. You will have 45 days to provide the requested information. As soon as BCBSNC receives the requested information, or at the end of the 45 days, whichever is earlier, BCBSNC will make a decision within three business days (24 hours for urgent care claims). If BCBSNC does not approve benefit coverage of a health care service, BCBSNC will notify you and the provider by written or electronic confirmation. If pre-admission review is not followed If you or your provider fails to obtain PPA for services received out-of-network or outside of North Carolina and the services are not medically necessary, your claim will be denied for noncertification. If through the appeal process the services are found to be medically necessary, benefits will be reduced to 50% of the allowed amount due to failure to obtain PPA. Any costs incurred because of the denial will not apply to your annual out-of-pocket limit. If you do not agree with the denial, follow the appeal process. Claim review appeal procedures In the event that precertification is not granted for a service, the patient or the provider may appeal the noncertification decision. The noncertification appeals process does not apply to a decision that is based on the fact that the requested service is not covered or disputes regarding the dollar amount or number of covered visits that are limited under the plan. A written appeal must be made to BCBSNC and a decision will be made within a reasonable time but no later than 30 days from the date BCBSNC received the request. For additional information regarding filing an appeal, refer to the BCBSNC medical appeals process under Claims and Appeals. Expedited review You have the right to a more rapid or expedited review of a denial of coverage if a delay: (i) would reasonably appear to seriously jeopardize you or your dependent s life, health or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that may not be adequately managed without the requested care or treatment. An expedited first or second level review may be requested by you, either orally or in writing. In such instance, you and BCBSNC can transmit information via telephone, fax machine or other similar method even if you did not request that the initial claim or first level review be expedited. BCBSNC will communicate the decision by phone to you and your provider no later than 72 hours after receiving the request. A written decision will be communicated within four days after receiving the request for the expedited appeal. After requesting an expedited review, the plan will remain responsible for covered health care services you are receiving until you have been notified of the review decision. If BCBSNC needs additional information to process your expedited review, BCBSNC will notify you and your provider of the information needed as soon as possible but no later than 24 hours following the receipt of your request. You will then be given a reasonable amount of time, but not less than 48 hours, to provide the requested information. As soon as BCBSNC receives the requested information, or at the end of the time period specified for you to provide the information, whichever is earlier, BCBSNC will make a decision on your request within a reasonable time but no later than 48 hours. An expedited review may be requested by calling BCBSNC Customer Service at HRI-SUBS Rev. 23 Page 54 of 205

55 BCBSNC Standard and Choice Plans Concurrent reviews BCBSNC will also review health care services at the time you receive them. These types of reviews are called concurrent reviews. BCBSNC will communicate concurrent review decisions to the hospital or other facility within one business day after BCBSNC makes a decision. If BCBSNC does not certify benefit coverage of a health care service, BCBSNC will notify you, your hospital s or other facility s Utilization Management department and your provider. Written confirmation of the decision will also be sent to your home by U.S. mail. For concurrent reviews, the plan will remain responsible for covered services you are receiving until you or your representatives have been notified of the denial of benefit coverage. Expedited concurrent review You have a right to an expedited concurrent review when the regular time frames for a decision: (i) could seriously jeopardize you or your dependents life, health, or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that cannot be adequately managed without the requested care or treatment. If you request an extension of treatment that BCBSNC has already approved at least 24 hours before the current approved treatment ends, BCBSNC will notify you and your provider of its decision as soon as possible taking into account the medical circumstances, but no later than 24 hours after receiving the request. Care Management Care management, also known as case management, encourages members with complicated or chronic medical needs, their providers, and the plan to work together to identify the appropriate services to meet the individual s health needs and promote quality outcomes. To accomplish this, members enrolled in or eligible for care management programs may be contacted by BCBSNC or by a representative of BCBSNC. Care management services are provided solely at the option of the plan, and the plan is not obligated to provide the same benefits or services to a member at a later date or to any other member. BCBSNC retains the right to review the patient s medical status while treatment is in process. Benefits may be discontinued for previously approved medical treatment if the: Attending physician does not provide the medical records or physician reports needed to determine the effectiveness of the alternative medical treatment. Goal of the alternative medical treatment has been met. Alternative medical treatment is no longer beneficial to the patient. Maximum allowable benefit under the plan has been paid. Condition Management Program The condition management program, administered by Blue Cross Blue Shield, is available to all active and retired employees and their covered dependents who participate in the Standard or Choice Plan. The program is designed to provide you with tools and resources to gain a better understanding of certain chronic conditions. The condition management program provides access to a 24-hour, 365 days per year information and support line that is staffed with medical professionals familiar with symptoms and issues associated with targeted chronic conditions. Condition specific interventions The condition management program offers health management services for conditions such as: Asthma HRI-SUBS Rev. 23 Page 55 of 205

56 Diabetes Fibromyalgia Heart Disease High Blood Pressure and High Cholesterol Migraine Pregnancy Tobacco Cessation Weight Management AUTHORIZED COPY BCBSNC Standard and Choice Plans The services offered are intended to supplement but not replace the existing physician-patient relationship. Confidentiality The condition management program maintains the confidentiality of all patient-specific clinical information received from patients, their family members and their health care providers. Confidential information will not be disclosed to Progress Energy or others without your express written consent except when required by law, or (subject to applicable law) to a third party (e.g., an auditor contracted by the plan to review the program practices, including its clinical records, to evaluate the performance of the program administrator). Covered Expenses Medical expenses covered under the BCBSNC Standard and Choice medical plan options are summarized on the following pages; however this list may not be all-inclusive. To be an eligible expense, the expense must be incurred for services that are medically necessary as determined by BCBSNC or qualify as preventive care. If you have questions about the eligibility of a covered medical expense, contact BCBSNC for verification (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). (See the BCBSNC Standard or Choice Plan Summary Charts for additional information on benefit levels.) Acupuncture Must be performed by a licensed physician or a licensed acupuncturist. Allergy testing and treatment Ambulance service To nearest facility where treatment can be obtained; must meet emergency services criteria or be part of a monitored authorized care plan; payable as in-network. Ambulatory surgical centers Anesthesia charges In connection with a covered surgical procedure. Bariatric surgery Morbid obesity/severe obesity, with qualifying co-morbidities, provided that medical necessity is established based on BCBS medical policy. Coverage includes office visits/consultations and surgery as deemed appropriate provided the patient has not previously undergone the same or similar procedure while covered under a Progress Energy-sponsored medical plan or a predecessor plan. This coverage could include gastric bypass, laparoscopic (LAP) banding, etc. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Psychological consultation/testing may be considered under the MHSA benefit plan. Blood and blood products and their administration Breast reconstructive surgery and implanted prostheses Incident to mastectomy. HRI-SUBS Rev. 23 Page 56 of 205

57 Covered Expenses Chemotherapy and radiation therapy AUTHORIZED COPY BCBSNC Standard and Choice Plans Chiropractic care (see Therapy) Contraceptive devices and implants Coverage includes the insertion or removal of and any medically necessary examination associated with the use of a covered contraceptive device or implant. Covered contraceptives are intrauterine devices, diaphragms, and implanted hormonal contraceptives. Dental treatment Covered as follows (dentist's and oral surgeon's charges payable as in-network): Removal of tumors and lesions of the mouth. Surgical treatment of diseases when medical criteria are met as determined by BCBSNC, unless covered under the Progress Energy-sponsored dental plan. Accidental injury to sound natural teeth, gums, or jaw occurring from an external source while the patient is covered under a Progress Energy-sponsored medical plan (treatment for accidental injury must begin within 72 hours of the accident and coverage is limited to 12 months). Anesthesia and hospital or facility charges in connection with dental procedures when hospitalization or general anesthesia is required for children age nine or younger, patients with serious mental or physical conditions, patients with significant behavior problems, or other situations determined medically necessary by BCBSNC; the attending dentist must certify that the criteria have been met. (Coverage does not include any professional fees, except for the anesthesiologist.) PPA must be obtained prior to receiving services. Diabetic treatment Covered as follows: self-management training and education, equipment, supplies (unless covered under prescription drugs), and laboratory procedures that are medically necessary; outpatient self-management programs and equipment require referring physician s prescription. Diagnostic services Such as x-rays, metabolism tests, radioisotope tests, and lab tests; diagnostic mammograms (paid based on the place of service). Dialysis treatment For renal disease. Durable medical equipment (Physician's prescription is required) - Durable medical equipment (DME) is equipment that can be repeatedly used, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. An approved list of DME items is available from BCBSNC and includes, but is not limited to, ostomy supplies, oxygen/rental of oxygen equipment, prosthetic appliances, and orthopedic braces. Expenses are covered for rental (not to exceed the purchase price), purchase (if more economical), or repair or replacement (except due to misuse or loss). Benefits will end when it is determined that the equipment is no longer medically necessary. Certain durable medical equipment requires prior review and certification or services will not be covered. (See Durable medical equipment in the Expenses Not Covered list for exclusions.) Emergency room $50 copayment will apply in addition to deductible and coinsurance; copayment waived if admitted or if Medicare is primary. HRI-SUBS Rev. 23 Page 57 of 205

58 Covered Expenses AUTHORIZED COPY BCBSNC Standard and Choice Plans Foot orthotics If custom molded from a mold of the patient's foot and prescribed by a qualified provider. Hearing exams If performed as part of a wellness/preventive exam. Home health care By an accredited agency in accordance with plan established by your physician; does not include meals, custodial care, or housekeeping services. PPA must be obtained prior to receiving services. Hospice care Must be precertified payable as in-network. Hospital services Emergency and maternity admissions If you or your dependent is admitted to the hospital for emergency treatment or maternity, you or someone acting on your behalf must notify BCBSNC within two working days of the admission. Inpatient services The plan provides coverage when you are admitted to a hospital as an inpatient. The following are covered services: Administration of blood Critical care Diagnostic services and medical supplies Drugs administered by the hospital General nursing care Intensive care Medical care provided by a doctor or other professional provider Neo-natal unit Other therapies Semi-private room; or a private room if medically necessary or the hospital has only private rooms Short-term rehabilitative therapies Use of appliances and equipment ordinarily provided by the hospital Use of the operating, delivery, recovery rooms, nursery and related services Outpatient services Benefits are provided for outpatient services received in a hospital facility. The following are covered services: Diagnostic services Drugs administered by the facility General nursing care Medical care provided by a doctor or other professional provider Medical supplies Observation Operating, recovery room and related services (outpatient surgery) Other therapy services Short-term rehabilitative therapies HRI-SUBS Rev. 23 Page 58 of 205

59 BCBSNC Standard and Choice Plans Covered Expenses Use of appliances and equipment ordinarily provided by the facility for the care and treatment of outpatients Mammograms (see Preventive care) Mastectomy services Reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the nondiseased breast to produce a symmetrical appearance without regard to the lapse of time between the mastectomy and the reconstructive surgery; and prostheses and physical complications of all stages of the mastectomy, including lymphedemas. Mental health and substance abuse Mental health and substance abuse services are administered by ValueOptions. (See the Employee Assistance and Mental Health & Substance Abuse Services Plan section for benefit information.) Nutritional counseling Up to 12 visits per calendar year if medically necessary. Occupational therapy (see Therapy) Ostomy supplies (see Durable medical equipment) Oxygen and rental equipment for oxygen administration (see Durable medical equipment) Physical therapy (see Therapy) Physician fees For medical care to diagnose or treat an illness or injury. Prescription drugs You may purchase prescriptions that are covered under the three-tiered Prescription Drug Program through Catalyst Rx at participating retail pharmacies or through Walgreens, the mail order drug service. The three-tiered Prescription Drug Program requires separate copays/coinsurance depending on whether you elect generic, preferred brand name, or non-preferred brand name drugs. Eligible drugs Drugs that are covered under the Prescription Drug Program offered by Catalyst Rx (or Walgreens for mail order): Legend drugs or controlled substances that bear the statement "Caution: Federal Law prohibits dispensing without prescription" (except those listed under exclusions). Diabetic syringes, glucose test strips, and supplies. Oral contraceptives. Injectables, such as insulin, Imitrex and Depo-Provera. Compound drugs. Over-the-counter (OTC) Prilosec if you have a prescription, you are eligible to purchase Prilosec OTC at the generic copay. Your prescription will need to be presented to the pharmacist for confirmation so the copay can be applied. Sleep aids - will be limited to 10 pills per prescription as recommended by the manufacturer. HRI-SUBS Rev. 23 Page 59 of 205

60 BCBSNC Standard and Choice Plans Covered Expenses Impotency drugs (such as Viagra, Caverject, and Muse) if medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones if the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (only for morbid obesity). Prenatal vitamins with a prescription. (See Prescription drugs in the Expenses Not Covered list for excluded items.) To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: Catalyst Rx Customer Service Walgreens (mail order) Customer Service Refills Prescription drug claims cannot be filed with BCBSNC and the copayments and coinsurance do not apply to the deductible or out-of-pocket limits. Formulary Generic - Generic drugs have the same active chemical composition as brand name drugs but are generally available at a lower cost. Generic drugs become available when the patent on the original brand name drug expires, enabling pharmaceutical companies to replicate the chemical formula of the brand name drug. Preferred Brand Name - Preferred brand name drugs are brand name drugs that are on a preferred list. Preferred brand name drugs generally are more cost effective than most other brand name drugs. A formulary listing of preferred brand name drugs may be obtained from the Employee Service Center or at Formulary preferred brand name options are designed to deliver the highest quality prescription drugs at the best possible price without impacting the effectiveness of the patient's therapy. The formulary listing includes many of the most effective and highly utilized drugs. The formulary copays/ coinsurance and specific drugs within the formulary are subject to change as new drugs and generic alternatives become available. Non-preferred Brand Name - Non-preferred brand name drugs are brand name drugs not on the preferred list. They are generally the most expensive and will require the highest copay/coinsurance. Specialty drugs - Specialty medications must be purchased through the Walgreens Specialty Pharmacy only and members will need to contact Walgreens Specialty Pharmacy by calling to participate. Specialty medications are limited to a 30-day supply whether they are picked up at a retail location or delivered via mail service. Formulary Advantage Program The Formulary Advantage Program encourages the safe and cost-effective use of prescription drugs by taking a step approach to the coverage of certain high-cost medications. This means that you may need to first try a proven, lower-cost alternative saving both you and the plan money before you progress to a more costly treatment, if necessary. Drug classes subject to this program include certain brand name antidepressants and sleep aids, as well as select brand name medications used to treat hypertension, migraines, nasal allergies, osteoporosis HRI-SUBS Rev. 23 Page 60 of 205

61 BCBSNC Standard and Choice Plans Covered Expenses and stomach ulcers/heartburn. If you have previously tried a lower-cost generic or recommended brand name alternative and it did not work for you, your healthcare provider can contact Catalyst Rx directly to request a prior authorization. If you have not received prior approval from Catalyst Rx, prescriptions written for higher-cost brand name medications will not be covered by the plan and you will be responsible for 100% of the medication s cost at the pharmacy. This program is not required for members under age 18 and other exceptions may apply. Please call the Catalyst Rx Member Services Department at for more information. Mail order drug service Walgreens, the mail order drug service, may be used for maintenance medications that are taken on a continuing basis. To use Walgreens, the prescription should be written for a 90-day supply when appropriate and the number of refills indicated on the prescription. You should also complete and submit Walgreens Mail Service Registration and Prescription Order Form (FRM-SUBS-20112). Note: If the prescription is written for less than a 90-day supply (e.g., for a 30-day supply with 3 refills) it may only be filled with a 30-day supply but the copayment will be the same as for a 90-day supply. You should allow at least 14 days for the prescription to be processed and returned to you. Allow an additional week for a new prescription. Pill splitting Many medications come in various strengths or doses. However, you may not be aware that in many cases, the cost of each pill does not vary much (if at all) based on the dosage. Progress Energy offers voluntary pillsplitting for eligible medications. You will pay the 30-day copay/coinsurance (or 90-day copay for mail order) and use a pill splitting device. For example, if you take 25mg Zocor, you may purchase a 30-day supply (or 90- day supply for mail order) of 50mg Zocor and use a pill splitting device to cut the medication into two 25mg doses. In this example, you will double your supply. Only certain medications are eligible for pill-splitting. If you take an eligible medication, the Catalyst Rx claims system will prompt your pharmacist to ask you if you are interested in taking advantage of this program. This program will be voluntary; you will not be required to use it. For mail order, the physician must write the prescription for a 180-day supply and note that you want to participate in the pill splitting program. Prescription drug copayment/coinsurance The drug copayment/coinsurance amount is based on the number of days supply (up to 30 days at participating retail pharmacies and up to 90 days for mail order) and whether the prescription is filled with generic, preferred brand name, or non-preferred brand name drugs. If the patient elects to have the prescription filled with a brand name drug when the prescription was written to allow generic substitution, an elective copayment amount will apply. The elective copayment will equal $10 plus the difference in the cost between the brand name and generic drug. Prior authorization Note: Any single prescription fill (not cumulative fills) that costs the plan greater than $750 retail or $2,250 mail order will require prior authorization by Catalyst Rx. When your pharmacist enters the claim in the Catalyst Rx system, he/she will receive a system prompt from Catalyst Rx indicating the need for prior authorization and inform you to contact Catalyst Rx customer service to start the process. You should call Catalyst Rx customer service at to initiate the prior authorization and provide customer service with your physician s contact information (physician s name/phone number). The turnaround time once Catalyst Rx has received the information from your physician is generally hours. HRI-SUBS Rev. 23 Page 61 of 205

62 BCBSNC Standard and Choice Plans Covered Expenses Purchasing drugs from participating pharmacies To purchase covered drugs at participating pharmacies, present your Catalyst Rx card to the pharmacist at the time you submit the prescription. Call Catalyst Rx or search for a listing of participating pharmacies. If you live in an area where there are no participating pharmacies or you have a prescription filled on an emergency basis, you may be reimbursed by Catalyst Rx for the charges, less the appropriate copayment/coinsurance, using Catalyst Rx Reimbursement Form (FRM-SUBS-01117). Requests for reimbursement must be filed within 12 months of the date the prescription was filled. Retain copies for your records in case you need to refer to them. Preventive care Benefits are available in- and out-of-network. Preventive care can help you stay safe and healthy. The plan covers preventive care services and includes: Colorectal screening - colorectal cancer examinations and laboratory tests for cancer are covered for any symptomatic or nonsymptomatic member who is at least 50 years of age, or is less than 50 years of age and at high risk for colorectal cancer. Increased/high risk individuals are those who have a higher potential of developing colon cancer because of a personal or family history of certain intestinal disorders. Frequency and type of tests performed will be determined based on generally accepted guidelines and approved by the Benefits Administrator. In-network Routine/wellness/screening and diagnostic colorectal procedures (i.e., colonoscopy) will be paid at 100% with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Out-of-network Routine/wellness/screening and diagnostic colorectal procedures (i.e., colonoscopy) will be paid at 60% of the allowed amount with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Gynecological exam, including Pap smear - one routine gynecological examination is covered at 100% innetwork per female member per calendar year in addition to your calendar year routine physical. This benefit includes the examination, Pap smear, laboratory fee and doctor s interpretation of the lab results. Additional Pap smears will be covered if recommended by a doctor. The claim must be filed with a primary diagnosis of screening. Mammogram - beginning at age 35, one screening mammogram will be covered in- or out-of-network per female member per calendar year, along with a doctor s interpretation of the results. More frequent or earlier mammograms will be covered as recommended by a doctor when a female member is considered at risk for breast cancer. A female member is at risk if she: Has a personal history of breast cancer. Has a personal history of biopsy-proven benign breast disease. Has a mother, sister, or daughter who has or has had breast cancer. Has not given birth prior to the age of 30. Prostate screening - one Prostate Specific Antigen (PSA) test or an equivalent serological test will be covered per male member per calendar year. Additional PSA tests will be covered if recommended by a doctor. Routine physical examinations - one routine physical examination and related diagnostic service per calendar year will be covered for each member age two and older; however, the claim must be filed with a primary diagnosis of screening. HRI-SUBS Rev. 23 Page 62 of 205

63 Covered Expenses AUTHORIZED COPY BCBSNC Standard and Choice Plans Well-baby and well-child care - these services are covered for each member up to 18 years of age including periodic assessments and immunizations. Benefits are limited to six well-baby visits for members through 12 months old and three well-child visits for members 13 months up to 23 months old. Benefits are limited to one exam per year for members ages The claim must be filed with a primary diagnosis of screening. For claims to be processed as wellness (with the exception of colorectal screening), the exam and related laboratory and/or screenings must be coded with a primary diagnosis coding of screening. If a medical condition is diagnosed and treated during an initial or follow-up visit for a wellness exam or preventive care, the treating physician may apply the appropriate diagnostic or treatment code. The charges for this diagnosis or treatment may require you to pay a copay, deductible and/or coinsurance. Prosthetic appliances and orthopedic braces (see Durable medical equipment) Second surgical opinions Sexual dysfunction Treatment to restore sexual function including penile implants when medically necessary (benefits limited to $5,000 per lifetime). Skilled nursing facility Charges for up to 150 days per calendar year if the patient s condition requires the level of nursing care available in a skilled nursing facility; prior plan approval must be obtained prior to receiving services. Speech therapy (see Therapy) Sterilization procedures for either sex (including elective sterilization) Surgery Performed on an inpatient or outpatient basis for treatment of an illness or injury and surgical procedures required to correct birth defects. Coverage includes post-operative care normally provided as part of the surgical procedure. These benefits include the services of the surgeon or medical specialist, assistant, and anesthetist or anesthesiologist, together with pre-operative and post-operative care. Temporomandibular joint syndrome (TMJ) Coverage includes office visits, consultations, physical therapy, and surgical procedures as deemed medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. Hospital charges (including anesthesia and other ancillary charges) are covered when incurred due to an accidental injury or disease in the temporomandibular joint. Therapy Limited to 60 visits per year for the following therapies combined: Chiropractic care including spinal manipulation services by physicians for manipulations of the spine to correct dislocation of a bone or joint. Occupational therapy services provided by a physician or occupational therapist for the purpose of aiding in the restoration of a previously impaired function. Physical therapy services provided by a physician or physical therapist to restore normal physical function. HRI-SUBS Rev. 23 Page 63 of 205

64 BCBSNC Standard and Choice Plans Covered Expenses Speech therapy services of a physician, speech therapist or licensed audiologist to aid in the restoration of speech loss or an impairment of speech as a result of sickness, disease, injury or congenital anomaly. A patient may be allowed to go beyond the current 60 visit limit only if a request is made by or on behalf of the patient, a treatment plan is submitted and prior approval is obtained from BCBSNC based on medical necessity. Other therapies: Cardiac rehabilitation therapy Chemotherapy, including intravenous chemotherapy (this does not include high dose chemotherapy done with bone marrow or peripheral blood stem cell transplants) Pulmonary therapy Radiation therapy Respiratory therapy Transplants The plan provides benefits for transplant services including hospital and professional services for the transplant procedures listed below. As a BCBSNC member, you have access to the Blue Quality Centers for Transplants, a group of facilities that provide organ transplant services. Facilities chosen are nationally recognized for their delivery of these highly specialized procedures. If a transplant is being considered, you should call BCBSNC customer service to speak with a transplant case manager. You must obtain certification from BCBSNC in advance for all transplant-related services in order to assure maximum coverage of these services. Eligible transplant procedures include: Heart Lung, single and bilateral Combined heart and lung Pancreas Kidney Simultaneous pancreas and kidney Liver Cornea Small bowel (pediatric only) Simultaneous small bowel and liver High dose chemotherapy with bone marrow or peripheral blood stem cell rescue, including autologous (self-donor) and allogeneic (other donor) bone marrow transplant Allogeneic (other donor) bone marrow transplant If a transplant is provided from a living donor to the recipient member who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant unless a higher amount is authorized by the transplant case manager in special and unique situations. Both the recipient and the donor are entitled to transplant benefits when the recipient is a member. Benefits provided to the live donor will be charged against the recipient s coverage. Benefits are payable only for covered services provided to the actual donor selected, and not for services provided to other prospective donors. HRI-SUBS Rev. 23 Page 64 of 205

65 Covered Expenses AUTHORIZED COPY BCBSNC Standard and Choice Plans Based on BCBSNC travel and lodging guidelines, benefits may be paid for transportation, lodging, and necessary living expense for the patient and one companion if the patient is referred by a case manager to an out-of-area facility for an organ or tissue transplant. The companion must either be a spouse or domestic partner, family member, or guardian of the patient. Necessary living expenses include expenses such as hotel and car rental, but do not include items such as meals, child care, house sitting charges, kennel boarding, or reimbursement of any wages lost by the companion during the patient s stay in a referred facility. Reimbursement amounts over $50 per person (you may include lodging for one companion of the patient) per day for lodging expenses are considered by the IRS to be excess benefits and would be reported as taxable to the recipient. Some transplant services are investigational for some or all conditions or illnesses. (See Transplants in the Expenses Not Covered list for exclusions.) Weight management If enrolled in BCBSNC Member Health Partnerships, up to four doctor s office visits to assess and monitor weight, up to six annual nutrition counseling visits with a registered dietitian and weight management tools. Contact BCBSNC for details. HRI-SUBS Rev. 23 Page 65 of 205

66 BCBSNC Standard and Choice Plans Expenses Not Covered The following goods and services are not covered. This list may not be all-inclusive. For questions regarding coverage, contact BCBSNC (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). General exclusions include, but are not limited to: Acupuncture treatments except when performed by a licensed physician or a licensed acupuncturist. Air conditioners, furnaces, humidifiers, dehumidifiers, vacuum cleaners, electronic air filters and similar equipment. Air purification systems. Allowed amount for services usually provided by one doctor, when those services are provided by multiple doctors. Amounts in excess of the allowed amount limits as determined by BCBSNC. Any health care services not specifically listed in the Covered Expenses list, unless such services are specifically required to be covered by applicable law. Any health care services or supplies that are not medically necessary according to accepted standards of medical practice or that are not related to the diagnosis or treatment of a given illness or injury as determined by BCBSNC; the ordering of a service by a health care provider does not in itself make such service medically necessary or a covered service. Any health care services provided to a dependent deemed ineligible. (See Dependents in the Eligibility section.) Any health care services received: That are covered by any other benefit plan or insurance program that is sponsored by Progress Energy. By a patient who resides permanently outside of the United States or Canada. As a result of an illness or injury caused by war, rebellion, or riot. From a member of your or your spouse s or domestic partner s immediate family (spouse, domestic partner, children or parents) or from a person who normally resides in your home. As a result of illness or injury incurred while committing or attempting to commit a crime. Any health care services received prior to an employee's or dependent s effective date or after the date an employee's or dependent s coverage terminates. Any health care services rendered at no charge. Any health care services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group. Any health care services to treat a work-related condition to the extent the employee is covered or required to be covered by Workers Compensation law. Any service or supply to diagnose or treat any condition resulting from or in connection with an employee's job or employment will not be covered, except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers Compensation and that lack of coverage did not result from any intentional action or omission by that individual. Bunion treatment except by capsular or bone surgery. Care that the provider may not legally provide or legally charge or is outside the scope of license or certification. Charges for letters or other documents regarding treatment. Charges incurred after termination of coverage. HRI-SUBS Rev. 23 Page 66 of 205

67 Expenses Not Covered Chiropractic maintenance treatments. AUTHORIZED COPY BCBSNC Standard and Choice Plans Conditions that federal, state, or local law requires to be treated in a public facility or for any treatment covered by any governmental body or agency unless payment is required by law. Cosmetic surgery and related services and supplies; surgery is covered if the surgery is to correct the effects of birth defects, accidental injury, or reconstructive procedures to replace diseased tissue. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Counseling. (See the Employee Assistance and Mental Health & Substance Abuse Services section.) Court ordered services that are otherwise excluded from benefits under this plan. Custodial care, respite care and domiciliary care or rest cures, care provided and billed for by a hotel, health resort, convalescent home, rest home, nursing home or other extended care facility, home for the aged, infirmary, school infirmary, institution providing education in special environments or any similar facility or institution. Dental care, dentures, dental implants, oral orthotic devices, palatal expanders and orthodontics except as specifically covered by the plan. Dental services provided in a hospital, except when a hazardous condition exists at the same time or covered oral surgery services are required at the same time as a result of a bodily injury. (See Dental treatment in the Covered Expenses list.) Dependent child pregnancy - expenses for the newborn child are not covered unless the newborn is legally adopted by the employee or the employee obtains legal guardianship within 30 days of date of birth. (Maternity expenses for the eligible dependent daughter are covered.) Durable medical equipment exclusions: Durable medical equipment that is primarily for convenience and/or comfort; modifications to motor vehicles and/or homes such as wheelchair lifts or ramps; water therapy devices such as jacuzzis, hot tubs, swimming pools or whirlpools; exercise and massage equipment; electric scooters; hearing aids; air conditioners; humidifiers; water purifiers; pillows, mattresses or waterbeds; escalators, elevators or stair glides; emergency alert equipment; handrails; heat appliances; and dehumidifiers. (See Durable medical equipment in the Covered Expenses list.) Educational treatment and services including reading clinics and special schools for mentally retarded or behaviorally impaired individuals; services primarily for education purposes include but are not limited to books, tapes, pamphlets, seminars, classroom, Internet or computer programs, individual or group instruction and counseling. Elective abortion procedures. Expenses provided and billed by a licensed health care professional who is in training. Experimental and/or investigational services or supplies and any related expenses as determined by BCBSNC, except as otherwise covered under the bone marrow transplant provision of the transplant services. (See Transplants in the Covered Expenses list.) Eyeglasses or contact lenses and examinations except following cataract surgery or to treat keratoconus. Fertility treatments including drugs and charges for artificial insemination and in-vitro fertilization. Genetic testing, except for high risk patients when the therapeutic or diagnostic course would be determined by the outcome of the testing. HRI-SUBS Rev. 23 Page 67 of 205

68 BCBSNC Standard and Choice Plans Expenses Not Covered Health check-ups, premarital examinations, and immunizations except those specifically covered as preventive care expenses. Hearing aids. Hearing examinations, except those included as part of a wellness/preventive exam. Heating pads, hot water bottles, ice packs and personal hygiene and convenience items such as, but not limited to, devices and equipment used for environmental control or to enhance the environmental setting. Holistic medicine services. Injectable prescription drugs which may be self-administered that are administered by a health care professional, unless medical supervision is required. Inpatient admissions primarily for the purpose of receiving diagnostic services or a physical examination; inpatient admissions primarily for the purpose of receiving therapy services are excluded except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy. Maintenance therapy, including therapy services that are provided over a long period of time in order to keep the patient s condition stable. Massage therapy services. Music therapy, remedial reading, recreational or activity therapy, all forms of special education and supplies or equipment used similarly. Outpatient pre-operative and post-operative care in excess of that normally provided for surgery. Physical fitness equipment, hot tubs, jacuzzis, heated spas, pool or memberships to health clubs. Prescription drugs that are not covered under the Prescription Drug Program offered by Catalyst Rx (or Walgreens for mail order): Drugs that may be purchased without a prescription (over-the-counter drugs). Fertility medications, injections, and treatments. Ostomy supplies (claims may be filed with BCBSNC for reimbursement; subject to deductible and coinsurance). Therapeutic appliances or devices, support garments, or other non-medical items. Drugs covered by BCBSNC, including those administered in an inpatient facility, physician s office or outpatient facility that are not usually self administered. Nicorette or other tobacco cessation products. Impotency drugs (such as Viagra, Caverject, and Muse) unless medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones unless the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (unless for morbid obesity). Refills beyond one year of original prescription date (six months for controlled drugs). Experimental or investigational drugs. Drugs used for cosmetic purposes. Drugs covered under Workers Compensation or any other federal or state program. HRI-SUBS Rev. 23 Page 68 of 205

69 BCBSNC Standard and Choice Plans Expenses Not Covered To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: Catalyst Rx Customer Service Walgreens (Mail order) Customer Service Refills Prescription drugs cannot be filed with BCBSNC. (See Prescription drugs in the Covered Expenses list.) Private duty nurses for inpatient hospital care. Refractory procedures including charges for any procedure performed for the purpose of correcting myopia, hyperopia, or astigmatism, and expenses related to such procedures. Reversal of sterilization procedures. Routine foot care or podiatry including treatment of toenails, bunions, corns, calluses, fallen arches, flat feet, weak feet, chronic foot strain or over-the-counter shoe inserts. Self-care unit, apartment or similar facility care operated by or connected with a hospital. Services incurred more than 18 months prior to submission of a claim to BCBSNC, except in the absence of legal capacity of the member. Services not prescribed or performed by or upon the direction of a doctor or other provider. Services that are investigational in nature or obsolete, including any service, drugs, procedure or treatment directly related to an investigational treatment, as well as services whose efficacy has not been established by controlled clinical trials, or are not recommended as a preventive service by the U.S. Public Health Service. Services that would not be necessary if a noncovered service had not been received, except for emergency services in the case of an emergency. Sex change or modification treatments or studies leading to or in connection with sex changes or modifications and related care. Sexual dysfunction unrelated to organic disease. Side effects and complications of non-covered services, except for emergency services in the case of an emergency. Speech therapy for problems not caused by illness, injury or congenital anomaly. Surgery for psychological or emotional reasons. Telephone consultations, charges for failure to keep a scheduled visit, charges for completion of a claim form, charges for obtaining medical records, and late payment charges. Temporomandibular joint syndrome (TMJ) treatment; except those charges specifically listed under covered expenses. Other TMJ charges may be eligible for coverage under the Progress Energy-sponsored dental plan. Charges for oral surgery and appliances may be eligible for coverage under the Progress Energy-sponsored dental plan. After individual consideration and review of the patient s history, expenses may not be covered if treatment is deemed not medically necessary or when diagnostic tests and procedures proposed do not meet the medical criteria. HRI-SUBS Rev. 23 Page 69 of 205

70 BCBSNC Standard and Choice Plans Expenses Not Covered Transplant exclusions: Purchase price of the organ or tissue if any organ or tissue is sold rather than donated to the recipient member. Procurement of organs, tissue, bone marrow or peripheral blood stem cells or any other donor services if the recipient is not a member. Transplants that are considered experimental or investigational (including high dose chemotherapy). Services, drugs and supplies for or related to transplants, except those transplants specifically listed as covered services. Services for or related to the transplantation of animal or artificial organs or tissues. Transportation except for medically necessary road or air ambulance service. Treatment or regimen, medical or surgical, for the purpose of reducing or controlling the weight of a member or for treatment of obesity, except for surgical treatment of morbid obesity when medically necessary and medical criteria are met. (See Bariatric surgery in the Covered Expenses list.) Vitamins, food supplements or replacements, nutritional or dietary supplements, formulas or special foods of any kind. Weight reduction procedures designed to restrict your ability to assimilate food (such as gastric bypass, gastric balloons, jaw wiring, and stomach stapling) unless medically necessary. (See Bariatric surgery in the Covered Expenses list.) Wigs and/or cranial prostheses. HRI-SUBS Rev. 23 Page 70 of 205

71 BCBSF Standard and Choice Plans AUTHORIZED COPY BCBSF Standard and Choice Plans The Blue Cross and Blue Shield of Florida (BCBSF) Standard and Choice medical plans are comprehensive plans that reimburse you for covered hospital and medical expenses on a fee-for-service basis. Each time you need medical care, you decide if you want to use a provider who participates in a network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. If you use an in-network provider, you will be eligible for the highest level of benefits from the BCBSF Standard or Choice medical plan in which you are enrolled. Enrollment Eligibility To participate in the BCBSF Standard or Choice medical plan, you and your dependents must (1) meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section) and (2) be either: An active regular, full-time employee residing or working in Florida including eligible dependent (regardless of residence). An LTD recipient residing in Florida including eligible dependent (regardless of residence). A retiree residing in Florida including eligible dependent (regardless of residence). A surviving dependent residing in Florida including eligible dependent (regardless of residence). Progress Energy Florida retirees that relocate outside of Florida may continue to participate in the BCBSF Standard or Choice medical plan. Medicare-eligible participants LTD recipients, retirees and surviving dependents should apply for and purchase Medicare Part B when you or your dependent first becomes eligible for Medicare and you should use providers who accept Medicare. BCBSF will assume you have purchased Medicare Part B and use providers who accept Medicare, and will coordinate benefits accordingly, regardless of whether or not you are actually covered under Part B or actually use providers who accept Medicare. This means that if you do not enroll in Medicare Part B when you become eligible or if you use providers who do not accept Medicare and then incur expenses that would be covered by Medicare Part B, you will be responsible for paying the full cost of those expenses. They will not be covered or paid by the BCBSF Standard or Choice medical plan. The benefit levels for in-network office visits and urgent care centers under the Choice Plan will be coinsurance amounts, rather than copayments, when Medicare is primary. For active regular, full-time employees, you and your covered dependents are not required to apply for and purchase Medicare Part B as long as you remain an active regular, full-time employee. Medical and Prescription Drug ID Cards If you enroll in either the BCBSF Standard or Choice option, you will receive: BCBSF Standard or Choice medical ID cards. The medical ID card should be presented to your physician and all other health care providers (except pharmacies) whenever services are received. If you have questions about your ID card or need additional ones, you should call BCBSF. A prescription drug ID card from Catalyst Rx. You must use your Catalyst Rx card (and not your BCBSF Standard or Choice medical ID card) when you have prescriptions filled at your local pharmacy. Your Catalyst Rx ID card will contain your name, member ID number, and the prescription drug program group number. The pharmacist uses this information to verify eligibility and copayment/coinsurance amounts. The card will also list your covered dependents' names. HRI-SUBS Rev. 23 Page 71 of 205

72 BCBSF Standard and Choice Plans 2012 BCBSF STANDARD PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses. For covered prescription drugs, copays or coinsurance applies. For most other expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Note: Copays, coinsurance, and deductibles shown are amounts paid by participant. Annual deductible 1 $1,500 individual/$3,000 family in- or out-of-network (coinsurance applies thereafter) Out-of-pocket limit 2 $4,000 individual/$8,000 family in- or out-of-network Maximum lifetime plan benefit Unlimited The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Covered at 100% of allowed amount Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse services 4 Prescription drugs at participating pharmacies 5 Generic Covered at 100% in-network 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Walgreen s Retail (up to 30 days) Mail Order (up to 90 days) $10 copay $25 copay Preferred Brand Name 20% coinsurance $75 copay ($25 minimum; $50 maximum) Non-Preferred Brand Name 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Speciality 7 Once the deductible is met, the following charges are subject to coinsurance: In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, radiology and surgery) Physician (includes family practice, OB/GYN, and internal medicine unless practicing in a specialty area) Specialist 20% 8 40% 8 Office/surgical procedures 20% 40% Urgent care center 20% 8 20% 8 Emergency room 9 20% 20% Hospital inpatient services 10 Inpatient services (room, lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) Outpatient services MRI, PET, CT scans and nuclear medicine Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) HRI-SUBS Rev. 23 Page 72 of % 8 20% 20% 20% 12 20% 20% 20% 8 20% 20% 12 40% 8 40% 11 40% 20% 12 Occupational/physical/speech/cardiac therapy; spinal 20% 40% manipulation 13 Durable medical equipment 20% 40% 40% 40% 40% 8 40% 20% 12

73 BCBSF Standard and Choice Plans 1. Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the allowed amount, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include prescription drug copays or coinsurance, charges in excess of the allowed amount, services not pre-certified or non-covered services. Out-of-pocket limit is maximum amount of deductible and coinsurance you must pay during a plan year. 3. Out-of-network charges are subject to the allowed amount. 4. Services are provided through ValueOptions and must be pre-certified; annual deductible does not apply. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Laboratory charges conducted by or sent to an independent lab, coinsurance applies with no deductible. 9. $50 copay required in addition to deductible and coinsurance; waived if admitted or if Medicare is primary. 10. If not pre-certified in- or out-of-network, benefits reduced to 50% of the allowed amount (not applicable if Medicare is primary). 11. $400 out-of-network hospital copay required in addition to deductible and coinsurance % coinsurance applies if the hospital-based provider (radiologist, anesthesiologist, pathologist, ER physician) is participating with BCBSF; 20% coinsurance applies to Maximum Allowable Payable (MAP) if the provider is not participating with BCBSF. 13. Calendar year maximum is 50 combined visits (physical, occupational, speech, cardiac, spinal manipulations, and massage therapy). Chiropractic (includes spinal manipulation) is limited to 26 per calendar year not to exceed 12 procedures per month. Reimbursement for physical medicine modalities/procedures is limited to four treatments per day not to exceed the benefit maximum. Cardiac therapy is limited to a maximum duration of 12-weeks per program. Reimbursement for physical therapy evaluation/re-evaluation (including physical performance testing) is limited to one initial evaluation and two re-evaluations within six months (180 days), same provider, same diagnosis/condition unless documented as to medical necessity for medical review. HRI-SUBS Rev. 23 Page 73 of 205

74 BCBSF Standard and Choice Plans 2012 BCBSF CHOICE PLAN SUMMARY CHART This option pays 100% for in-network adult or child wellness expenses. Copays apply to some prescription drugs, in-network office visits for physician and specialist, in-network outpatient mental health/substance abuse services office visits, and urgent care. For most other covered expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Note: Copays, coinsurance, and deductible shown are amounts paid by participant. Annual deductible 1 $750 individual/$1,500 family in- or out-of-network (coinsurance applies thereafter) Out-of-pocket limit 2 $3,000 individual/$6,000 family in- or out-of-network Maximum lifetime plan benefit Unlimited The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Covered at 100% of allowed amount Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse services 4 Prescription drugs at participating pharmacies 5 Covered at 100% in-network 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Walgreen s Retail (up to 30 days) Mail Order (up to 90 days) Generic Preferred Brand Name $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) Non-Preferred Brand Name 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Speciality 7 Once the deductible is met, the following charges are subject to coinsurance. Copays, not coinsurance and deductible, apply to in-network office and any urgent care visits if member is not eligible for Medicare, or if Medicare or other insurance is secondary. In-Network Out-of-Network 3 Physician office visits (includes exams, diagnosis, lab service, radiology and surgery) Physician (includes family practice, OB/GYN, and internal medicine unless practicing in a specialty area) Specialist $25/20% 8, 9 40% $35/20% 8, 9 40% 9 Office/surgical procedures Applicable physician or specialist copay/20% 8 Urgent care center $35/20% 8,9 $35/20% 8,9 Emergency room 10 20% 20% Hospital inpatient services 11 Inpatient services (room, lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) 20% 20% 20% 13 40% 9 40% 12 40% 20% 13 HRI-SUBS Rev. 23 Page 74 of 205

75 Outpatient services MRI, PET, CT scans and nuclear medicine Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, ER physician) 20% 20% 20% 9 20% 20% 13 AUTHORIZED COPY BCBSF Standard and Choice Plans Occupational/physical/speech/cardiac therapy; spinal $35/20% 8 40% manipulation 14 Durable medical equipment 20% 40% 40% 40% 40% 9 40% 20% Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the allowed amount, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include office or urgent care visit copays, prescription drug copays and coinsurance, charges in excess of the allowed amount, services not pre-certified, or non-covered services. Out-of-pocket limit is maximum amount of deductible and coinsurance you must pay in a plan year. 3. Out-of-network charges are subject to the allowed amount. 4. Services are provided through ValueOptions and must be pre-certified; annual deductible does not apply. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Copays, not coinsurance and deductible, apply to office visits if member is not eligible for Medicare, or if Medicare or other insurance is secondary. 9. Laboratory charges conducted by or sent to an independent lab, coinsurance applies with no deductible. 10. $50 copay required in addition to deductible and coinsurance; waived if admitted or if Medicare is primary. 11. If not pre-certified in- or out-of-network, benefits reduced to 50% of the allowed amount (not applicable if Medicare is primary). 12. $250 out-of-network hospital copay required in addition to deductible and coinsurance % coinsurance applies if the hospital-based provider (radiologist, anesthesiologist, pathologist, ER physician) is participating with BCBSF; 20% coinsurance applies to Maximum Allowable Payable (MAP) if the provider is not participating with BCBSF. 14. Calendar year maximum is 50 combined visits (physical, occupational, speech, cardiac, spinal manipulations, and massage therapy). Chiropractic (includes spinal manipulation) is limited to 26 per calendar year not to exceed 12 procedures per month. Reimbursement for physical medicine modalities/procedures is limited to four treatments per day not to exceed the benefit maximum. Cardiac therapy is limited to a maximum duration of 12-weeks per program. Reimbursement for physical therapy evaluation/re-evaluation (including physical performance testing) is limited to one initial evaluation and two re-evaluations within six months (180 days), same provider, same diagnosis/condition unless documented as to medical necessity for medical review. HRI-SUBS Rev. 23 Page 75 of 205

76 How the BCBSF Standard and Choice Plans Work AUTHORIZED COPY BCBSF Standard and Choice Plans These plans include a network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. Benefits under the BCBSF Standard and Choice Plans are administered based on whether or not the covered services were received from an in-network provider or an out-ofnetwork provider. Benefits for covered services provided by in-network and out-of-network providers are reimbursed as follows: In-network - The "in-network" benefit levels are used to process your claims when you receive covered medical services from a provider who is participating in the network. Out-of-network - If you choose not to use an in-network provider, your claims are processed using the "outof-network" benefit levels. Note: These benefit levels do not apply if Medicare is primary. OON providers may bill you directly. If you are billed, you will be responsible for paying the bill and filing a claim with BCBSF. Services received outside of Florida Your ID card gives you access to participating providers outside the state of Florida through the BlueCard Program. Your ID card tells participating providers that you are a member of BCBSF. By taking part in this program, you may receive discounts from out-of-state providers who participate in the BlueCard Program. When you obtain covered health care services through the BlueCard Program outside the area in which the BCBSF network operates, the amount you pay toward such covered services, such as deductibles, copayments or coinsurance is usually based on the lesser of: The billed charges for your covered services. The negotiated price that the out-of-state Blue Cross and/or Blue Shield licensee ( Host Blue ) passes on to BCBSF. If you receive covered services from an out-of-network provider, you will pay a deductible and a higher coinsurance and you may have to file a claim for reimbursement. Also, since the cost of medical procedures may vary widely among out-of-network providers, you may wish to discuss the cost of the specific procedure with the provider before receiving the covered services so you can determine your out-of-pocket costs. If you are traveling If you are traveling out of the service area or to a foreign country and require medical treatment, you may see a local physician, or if the situation meets the criteria for urgent care or medical emergency, you may go to an urgent care center or hospital emergency room. You may be required to pay the bill at the time of the services. Call BlueCard at BLUE to locate network providers. If your child attends school out of state If your child attends a school out of state, the child will have access to covered healthcare from any provider in the state where he or she lives. Your ID card provides access to participating providers outside the state of Florida through the BlueCard Program, and covered benefits are provided at the in-network level. If your child is in an area that has participating providers and chooses a provider outside the network, the lower out-of-network benefit will apply. The list of in-network providers may change from time to time. In-network providers are listed on the BCBSF website at Questions For questions regarding BCBSF Standard and Choice Plans medical claims and benefits, call BCBSF at For hospital pre-admission review, call HRI-SUBS Rev. 23 Page 76 of 205

77 BCBSF Standard and Choice Plans Allowed amount limits Covered expenses are paid based on the allowed amount (sometimes referred to as usual and customary or U&C limit), which is the prevailing rate charged for comparable services by providers located within the same geographical area. Charges for covered services received from BCBSF in-network providers generally are within the allowed amount limit. If covered services are received from a non-participating provider and the charges are above the allowed amount, you are responsible for paying the additional amount. The amount in excess of the allowed amount limit does not apply to the deductible or out-of-pocket limit. Deductible A deductible is the dollar amount you must pay each calendar year before benefits are payable for covered services that require you to pay a percentage of the charge (coinsurance). The deductible is combined for in- and out-ofnetwork services. The BCBSF Standard or Choice Plans have an individual deductible for each person you cover (including dependents) up to a combined family deductible. When a covered individual meets his or her individual deductible or when several covered family members expenses combine to satisfy the family deductible, the plan will begin paying benefits for covered expenses that require coinsurance. Refer to the Summary Charts for specific deductible amounts. The following amounts do not apply toward the annual deductible and thus are not counted when determining whether the annual deductible has been met: Copayments Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Inpatient newborn care services (well baby) Preventive care Prescription copays and coinsurance If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Coinsurance and copayments under the Standard Plan For charges from in-network providers (including doctor s office visits, surgery, outpatient procedures and inpatient expenses), after you have met your annual deductible, you pay a percentage of the cost of the covered expenses (called coinsurance). The plan pays the remainder of the covered charges. Deductibles and coinsurance do not apply to in-network preventive care or allergy injections. When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the allowed amount. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require that you pay the entire bill at the time of service and file a claim with BCBSF. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Standard Plan as described in the Summary Chart. HRI-SUBS Rev. 23 Page 77 of 205

78 BCBSF Standard and Choice Plans Coinsurance and copayments under the Choice Plan When you have an office visit with an in-network physician or specialist, you pay a flat amount called a copayment. You do not have to meet a deductible for services that require a copayment. Office visit copayments include exams, diagnosis, lab tests, and surgery. If lab or other tests are conducted in the doctor s office in preparation for an office visit or in a follow-up visit, the tests are subject to an additional copayment. If lab tests are conducted by or sent to an independent lab, only the coinsurance applies. Allergy shots are not subject to a copayment. When Medicare or other insurance is primary, copayment amounts do not apply; deductible and coinsurance amounts do apply. Copayments, deductibles and coinsurance do not apply to in-network preventive care. For most other covered in-network expenses (such as outpatient procedures and hospital charges), you pay a percentage of the cost of the covered expense (called coinsurance) after you have met your deductible. BCBSF pays the remainder of the covered charges When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the allowed amount. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require that you pay the entire bill at the time of service and file a claim with BCBSF. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Choice Plan as described in the Summary Chart. Copayments do not apply towards the out-of-pocket limit or deductible. Out-of-pocket limit The deductible and coinsurance amounts you pay apply to your out-of-pocket limit. If you reach the annual out-ofpocket limit, BCBSF will pay 100% of the allowed amount for any additional covered charges incurred for the rest of the year if the charges are subject to deductible and coinsurance. The out-of-pocket limit is combined for in- and outof-network charges. If the annual family out-of-pocket limit has been met, no additional coinsurance amounts or deductibles will apply for that year. The following expenses do not apply toward the out-of-pocket limit and thus are not counted when determining whether the out-of-pocket limit has been met: Copayments Charges over the allowed amount Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Prescription copays and coinsurance If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Utilization Review (UR) Program The UR program reviews the medical necessity of inpatient hospital care on both a pre-admission and a continued stay basis. The UR program also provides you with information about alternative treatment methods that may be more cost-effective than inpatient hospitalization. In addition, the UR program offers case management services for severe illnesses or injuries to assist the patient and physician in adopting a course of treatment. You must follow UR procedures to receive the highest level of benefit for inpatient hospitalization charges. HRI-SUBS Rev. 23 Page 78 of 205

79 BCBSF Standard and Choice Plans Pre-admission review When hospitalization is recommended for you or one of your dependents, you or your physician must call, as soon as possible but no later than five days prior to the admission date, to begin the pre-admission review process. Note: Pre-admission review is not required if Medicare is primary. The pre-admission review number is: Provider or member pre-admission review (toll free) During the pre-admission review process, a review nurse discusses the case with your physician and explains the purpose of the review. If your physician and the review nurse agree that your treatment should take place on an inpatient basis, the admission and an appropriate number of inpatient days will be authorized. If your physician and the review nurse agree instead that treatment can be performed on an outpatient basis, outpatient benefits will be provided. If your physician and the review nurse do not agree on the need for inpatient hospitalization, the case will be referred to a UR staff physician of the appropriate specialty. The UR physician will work with your physician and you to resolve any differences. You, your physician, the hospital, and the medical claim office will be notified in writing of the decision regarding hospitalization. If there is a change in the admission date or the patient is transferred to another hospital, you or your physician must call the UR program and advise the review nurse of the change. If pre-admission review is not followed If you or your provider fail to follow the pre-admission procedures by not communicating with BCBSF and not providing your or your dependent s name, specific medical condition, and the specific treatment, service or product for which you are requesting approval, you will be notified of the failure within five days (or 24 hours in the case of an urgent care claim) and informed of the proper procedures to be followed. If the pre-admission review process is not followed and authorization is not obtained from a facility, benefits will be reduced to 50% of the allowed amount. The additional cost incurred because of the reduced benefits will not apply to the annual outof-pocket limit. Continued stay review Once you are in the hospital, your physician may request additional days in the hospital that were not identified during the initial pre-admission review. A continued stay review will be made and, if appropriate, the additional inpatient days will be authorized. If your inpatient stay exceeds the number of days that have been approved, benefits for the room and board charges for the additional days will be limited to 50%. The additional cost incurred because of the reduced benefits will not apply to the annual out-of-pocket limit. Claim review appeal procedures In the event that precertification is not granted for a service, the patient or the provider may appeal the noncertification decision. The noncertification appeals process does not apply to a decision that is based on the fact that the requested service is not covered or disputes regarding the dollar amount or number of covered visits that are limited under the plan. A written appeal must be made to BCBSF and the patient will be notified in writing of BCBSF s decision within 30 days of the date the appeal request was received. To file an appeal, refer to the BCBSF medical appeal process in the Claims and Appeals section of this document. Expedited review Appeals may be expedited when a delay could be detrimental to the patient s health. The request for an expedited review should be directed to BCBSF and must be accompanied by documentation of the medical necessity which qualifies the case for expedited review. The request for expedited review may be made orally or in writing. A review of the expedited appeal will be conducted within 72 hours of receiving the request and necessary information. You and BCBSF can transmit this information via telephone, fax machine or other similarly expeditious method. HRI-SUBS Rev. 23 Page 79 of 205

80 Case Management AUTHORIZED COPY BCBSF Standard and Choice Plans Case management is designed to address the special needs of those who suffer from a severe illness or injury. When appropriate, the UR program will assign a case manager (a health care professional) to work one-on-one with the patient and the patient s physician to develop a medical treatment plan and coordinate all required medical services. The UR program considers the patient s current medical status and course of treatment, the effectiveness of care, the short- and long-term implications of the treatment, and possible alternative treatment plans. Because each case is different, the case management function works differently for each patient. The goal is to provide the most appropriate care in a timely, efficient, and cost-effective manner. BCBSF retains the right to review the patient s medical status while treatment is in process. Benefits can be discontinued for previously approved medical treatment if the: Attending physician does not provide the medical records or physician reports needed to determine the effectiveness of the alternative medical treatment. Goal of the alternative medical treatment has been met. Alternative medical treatment is no longer beneficial to the patient. Maximum allowable benefit under the plan has been paid. Condition Management Program The condition management program, administered by Blue Cross Blue Shield, is available to all active and retired employees and their covered dependents who participate in the Standard or Choice Plan. The program is designed to provide you with tools and resources to gain a better understanding of certain chronic conditions. The condition management program provides access to a 24-hour, 365 days per year information and support line that is staffed with medical professionals familiar with symptoms and issues associated with the targeted chronic conditions. Condition specific interventions The condition management program offers health management services focusing on individuals with one or more of the following conditions: Asthma Cancer Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes Pregnancy The services offered are intended to supplement but not replace the existing physician-patient relationship. Confidentiality The condition management program maintains the confidentiality of all patient-specific clinical information received from patients, their family members and their health care providers. Confidential information will not be disclosed to Progress Energy or others without your express written consent except when required by law, or (subject to applicable law) to a third party (e.g., an auditor contracted by the plan to review the program practices, including its clinical records, to evaluate the performance of the program administrator). HRI-SUBS Rev. 23 Page 80 of 205

81 BCBSF Standard and Choice Plans Covered Expenses Medical expenses covered under the BCBSF Standard and Choice medical plan options are summarized on the following pages; however this list may not be all-inclusive. To be an eligible expense, the expense must be incurred for services that are medically necessary as determined by BCBSF or qualify as preventive care. If you have questions about the eligibility of a covered medical expense, contact BCBSF for verification (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). (See the BCBSF Standard or Choice Plan Summary Chart for additional information on benefit levels.) Acupuncture Must be performed by a licensed physician or a licensed acupuncturist. Allergy testing and treatment Ambulance service To nearest facility where treatment can be obtained; must meet emergency services criteria or be part of a monitored authorized care plan. Ambulatory surgical centers Anesthesia charges In connection with a covered surgical procedure. Bariatric surgery Morbid obesity/severe obesity, with qualifying co-morbidities, provided that medical necessity is established based on BCBSF medical policy. Coverage includes office visits/consultations and surgery as deemed appropriate provided the patient has not previously undergone the same or similar procedure while covered under a Progress Energy-sponsored medical plan or a predecessor plan. This coverage could include gastric bypass, laparoscopic (LAP) banding, etc. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Psychological consultation/testing may be considered under the MHSA benefit plan. Blood and blood products and their administration Breast reconstructive surgery and implanted prostheses Incident to mastectomy. Cardiac therapy (see Therapy) Chemotherapy and radiation therapy Concurrent physician care Consultations Provided by a physician if the attending physician requests the consultation and the consulting physician prepares a written report. Contraceptive devices and implants Coverage includes the insertion or removal of and any medically necessary examination associated with the use of a covered contraceptive device or implant. Covered contraceptives are intrauterine devices, diaphragms, and implanted hormonal contraceptives. HRI-SUBS Rev. 23 Page 81 of 205

82 BCBSF Standard and Choice Plans Covered Expenses Dental care Limited to care and treatment initiated within 62 days of an accidental dental injury provided such services were for the treatment of damage to sound natural teeth (dentist s and oral surgeon s charges payable as in-network). Anesthesia and hospital or facility charges in connection with dental procedures when hospitalization or general anesthesia is required for children age seven or younger with a complex dental condition, patients with incapacitating mental or physical conditions, developmental disabilities, or other situations determined as medically necessary by BCBSF; the attending dentist must certify that the criteria have been met. (Coverage does not include any professional fees, except for the anesthesiologist.) Diabetic treatment Covered as follows: out-patient self-management training and educational services and nutritional counseling (including all medically appropriate and necessary equipment and supplies), to treat diabetes, if the patient s treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary. Diagnostic services Diagnostic services when ordered by a physician are limited to the following: Radiology, ultrasound and nuclear medicine, Magnetic Resonance Imaging (MRI). Laboratory and pathology services (laboratory services are not subject to the deductible if conducted by or sent to an independent lab or if part of a wellness exam). Services involving bones or joints of the jaw (e.g., services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic services are necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. Approved machine testing (e.g., electrocardiogram [EKG], electroencephalograph [EEG]) and other electronic diagnostic medical procedures. Genetic testing for the purposes of explaining current signs and symptoms of a possible hereditary disease. Dialysis treatment For renal disease. Durable medical equipment Durable medical equipment when provided by a durable medical equipment provider and when prescribed by a physician, limited to the most cost effective durable equipment, that meets the individual's needs as determined by BCBSF; contact BCBSF prior to obtaining equipment. (See Durable medical equipment in the Expenses Not Covered list for exclusions.) Emergency room $50 copayment will apply in addition to deductible and coinsurance; copayment waived if admitted, or if Medicare is primary. Eye care Coverage includes the following services: Physician services, soft lenses or sclera shells, for the treatment of aphakic patients. Initial glasses or contact lenses and examinations following cataract surgery. Physician services to treat an injury or disease to the eyes. (See Eye care in the Expenses Not Covered list for exclusions.) Foot orthotics If custom molded and designed shoe inserts or supportive devices for the feet and if they were prescribed by a physician to treat a medical problem or deformity. HRI-SUBS Rev. 23 Page 82 of 205

83 BCBSF Standard and Choice Plans Covered Expenses Home health care By an accredited agency in accordance with plan established by your physician and pre-authorized by BCBSF; does not include meals, custodial care, or housekeeping services. Hospice care Payable as in-network, unlimited. Hospitalization Emergency and maternity admissions For all unplanned admissions to a hospital in the state of FL that is not a BCBSF provider, the patient must ensure that the physician or the hospital contacts BCBSF by telephone within 24 hours of the admission or the first business day following a weekend or holiday admission. In the event the patient s condition makes it impossible for the patient to ensure that BCBSF is notified within the applicable time frame, the patient must ensure that BCBSF is notified as soon as possible. Inpatient/outpatient services Hospitalization for both in- or out-of-network providers must be precertified. You are responsible for ensuring that all precertification requirements have been met prior to receiving services or entering the hospital. If hospitalization is not precertified, benefits will be reduced to 50% of the allowed amount. For admissions to out-of-network facilities, a hospital copayment will apply, in addition to the deductible and coinsurance. You are responsible for ensuring that all precertification requirements have been met. Hospital inpatient charges are covered for room and board and charges for general nursing care and ancillary services while confined as a bed patient. If intensive care or other specialized care is necessary, the rate for the specialized care room will be considered a covered charge. Hospital outpatient charges are covered for ancillary services, including general nursing care, use of operating and delivery rooms, anesthesia, dressings, casts, laboratory examinations, and other medically necessary services provided by the hospital for the diagnosis and treatment of the patient s condition. Mammograms Massage therapy (see Therapy) Mastectomy services Mental health and substance abuse Mental health and substance abuse services are administered by ValueOptions. (See the Employee Assistance and Mental Health & Substance Abuse Services Plan section.) Nutritional counseling Up to 12 visits per calendar year if medically necessary. Occupational therapy (see Therapy) Orthotic devices Including braces and trusses for the leg, arm, neck and back and special surgical corsets when prescribed by a physician. (See Orthotic devices in the Expenses Not Covered list.) HRI-SUBS Rev. 23 Page 83 of 205

84 Covered Expenses Osteoporosis Screening, diagnosis, and treatment. AUTHORIZED COPY BCBSF Standard and Choice Plans Ostomy supplies Outpatient therapies (see Therapy) Oxygen Expenses for oxygen, the equipment necessary to administer it, and the administration of oxygen. Physical therapy (see Therapy) Physician services For medical or surgical health care services provided by a physician. Prescription drugs You may purchase prescriptions that are covered under the three-tiered Prescription Drug Program through Catalyst Rx at participating retail pharmacies or through Walgreens, the mail order drug service. The three-tiered Prescription Drug Plan requires separate copays/coinsurance depending on whether you elect generic, preferred brand name, or non-preferred brand name drugs. Prior authorization Note: Any single prescription fill (not cumulative fills) that costs the plan greater than $750 retail or $2,250 mail order will require prior authorization by Catalyst Rx. When your pharmacist enters the claim in the Catalyst Rx system, he/she will receive a system prompt from Catalyst Rx indicating the need for prior authorization and inform you to contact Catalyst Rx customer service to start the process. You should call Catalyst Rx customer service at to initiate the prior authorization and provide customer service with your physician s contact information (physician s name/phone number). The turnaround time once Catalyst Rx has received the information from your physician is generally hours. Eligible drugs Drugs that are covered under the Prescription Drug Program: Legend drugs or controlled substances that bear the statement "Caution: Federal Law prohibits dispensing without prescription" (except those listed under exclusions). Diabetic syringes, glucose test strips, and supplies. Oral contraceptives. Injectables, such as insulin, Imitrex and Depo-Provera. Compound drugs. Over-the-counter (OTC) Prilosec if you have a prescription, you are eligible to purchase Prilosec OTC at the generic copay. Your prescription will need to be presented to the pharmacist for confirmation so the copay can be applied. Sleep aids will be limited to 10 pills per prescription as recommended by the manufacturer. Impotency drugs (such as Viagra, Caverject, and Muse) if medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones if the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (only for morbid obesity). Prenatal vitamins with a prescription. HRI-SUBS Rev. 23 Page 84 of 205

85 Covered Expenses (See Prescription drugs in the Expenses Not Covered list for excluded items.) To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: AUTHORIZED COPY BCBSF Standard and Choice Plans Catalyst Rx Customer Service Walgreens (mail order) Customer Service Refills Prescription drug claims cannot be filed with BCBSF and the copayments and coinsurance do not apply to the deductible or out-of-pocket limits. Formulary Generic - Generic drugs have the same active chemical composition as brand name drugs but are generally available at a lower cost. Generic drugs become available when the patent on the original brand name drug expires, enabling pharmaceutical companies to replicate the chemical formula of the brand name drug. Preferred Brand Name - Preferred brand name drugs are brand name drugs that are on a preferred list. Preferred brand name drugs generally are more cost effective than most other brand name drugs. A formulary listing of preferred brand name drugs may be obtained from the Employee Service Center or at Formulary preferred brand name options are designed to deliver the highest quality prescription drugs at the best possible price without impacting the effectiveness of the patient's therapy. The formulary listing includes many of the most effective and highly utilized drugs. The formulary copays/coinsurance and specific drugs within the formulary are subject to change as new drugs and generic alternatives become available. Non-preferred Brand Name - Non-preferred brand name drugs are brand name drugs not on the preferred list. They are generally the most expensive and will require the highest copay/coinsurance. Specialty drugs - Specialty medications must be purchased through the Walgreens Specialty Pharmacy only and members will need to contact Walgreens Specialty Pharmacy by calling to participate. Specialty medications are limited to a 30-day supply whether they are picked up at a retail location or delivered via mail service. Formulary Advantage Program The Formulary Advantage Program encourages the safe and cost-effective use of prescription drugs by taking a step approach to the coverage of certain high-cost medications. This means that you may need to first try a proven, lower-cost alternative saving both you and the plan money before you progress to a more costly treatment, if necessary. Drug classes subject to this program include certain brand name antidepressants and sleep aids, as well as select brand name medications used to treat hypertension, migraines, nasal allergies, osteoporosis and stomach ulcers/heartburn. If you have previously tried a lower-cost generic or recommended brand name alternative and it did not work for you, your healthcare provider can contact Catalyst Rx directly to request a prior authorization. If you have not received prior approval from Catalyst Rx, prescriptions written for higher-cost brand name medications will not be covered by the plan and you will be responsible for 100% of the medication s cost at the pharmacy. HRI-SUBS Rev. 23 Page 85 of 205

86 BCBSF Standard and Choice Plans Covered Expenses This program is not required for members under age 18 and other exceptions may apply. Please call the Catalyst Rx Member Services Department at for more information. Mail order drug service Walgreens, the mail order drug service, may be used for maintenance medications that are taken on a continuing basis. To use Walgreens, the prescription should be written for a 90-day supply when appropriate and the number of refills indicated on the prescription. You should also complete and submit Walgreens Mail Service Registration and Prescription Order Form (FRM-SUBS-20112). Note: If the prescription is written for less than a 90-day supply (e.g., for a 30-day supply with 3 refills) it may only be filled with a 30-day supply but the copayment will be the same as for a 90-day supply. You should allow at least 14 days for the prescription to be processed and returned to you. Pill splitting Many medications come in various strengths or doses. However, you may not be aware that in many cases, the cost of each pill does not vary much (if at all) based on the dosage. Progress Energy offers voluntary pill-splitting for eligible medications. You will pay the 30-day copay/coinsurance (or 90-day copay for mail order) and use a pill splitting device. For example, if you take 25mg Zocor, you may purchase a 30-day supply (or 90-day supply for mail order) of 50mg Zocor and use a pill splitting device to cut the medication into two 25mg doses. In this example, you will double your supply. Only certain medications are eligible for pill splitting. If you take an eligible medication, the Catalyst Rx claims system will prompt your pharmacist to ask you if you are interested in taking advantage of this program. This program will be voluntary; you will not be required to use it. For mail order, the physician must write the prescription for a 180-day supply and note that you want to participate in the pill splitting program. Prescription drug copayment/coinsurance The drug copayment/coinsurance amount is based on the number of days supply (up to 30 days at participating retail pharmacies and up to 90 days for mail order) and whether the prescription is filled with generic, preferred brand name or non-preferred brand name drugs. If the patient elects to have the prescription filled with a brand name drug when the prescription was written to allow generic substitution, an elective copayment amount will apply. The elective copayment will equal $10 plus the difference in the cost between the brand name and generic drug. Some medications come in various strengths or doses and in many cases, the cost of each pill does not vary based on the dosage. Voluntary pill splitting is offered for eligible medications. If you take an eligible medication, the Catalyst Rx claims system will prompt your pharmacist to ask you if you are interested in taking advantage of this program. Purchasing drugs from participating pharmacies To purchase covered drugs at participating pharmacies, present your Catalyst Rx card to the pharmacist at the time you submit the prescription. Call Catalyst Rx or search for a listing of participating pharmacies. If you live in an area where there are no participating pharmacies or you have a prescription filled on an emergency basis, you may be reimbursed by Catalyst Rx for the charges, less the appropriate copayment/coinsurance, using Catalyst Rx Reimbursement Form (FRM-SUBS-01117). Requests for reimbursement must be filed within 12 months of the date the prescription was filled. Retain copies for your records in case you need to refer to them. HRI-SUBS Rev. 23 Page 86 of 205

87 Covered Expenses Preventive care Preventive care expenses include: AUTHORIZED COPY BCBSF Standard and Choice Plans Wellness examinations covered for active and retired employees and covered spouses or domestic partners. Frequency and type of tests performed will be determined by the physician based on the patient s individual needs. The claim must be filed with a primary diagnosis of screening. (See the BCBSF Standard and Choice Plan Summary Charts for level of benefits.) Annual mammograms beginning at age 35, covered for employees and eligible dependents who are covered under the plan; however, the claim must be filed with a primary diagnosis of screening. Colorectal screening covered for active and retired employees and their covered dependents. Frequency and type of tests performed will be determined based on generally accepted guidelines and approved by the Benefits Administrator. In-network Routine/wellness/screening and diagnostic colonoscopies will be paid at 100% with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Out-of-network - Routine/wellness/screening and diagnostic colonoscopies will be paid at 60% of the allowed amount with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Children are covered up to the 17 th birthday while in or out of the hospital. Covered expenses include physician visits, laboratory tests, and routine immunizations. The claim must be filed with a primary diagnosis of screening. For claims to be processed as wellness (with the exception of colorectal screening), the exam and related laboratory and/or screenings must be coded with a primary diagnosis coding of screening. If a medical condition is diagnosed and treated during an initial or follow-up visit for a wellness exam or preventive care, the treating physician may apply the appropriate diagnostic or treatment code. The charges for this diagnosis or treatment may require you to pay a copay, deductible and/or coinsurance. Prosthetic devices The following prosthetic devices are covered when prescribed by a physician: Artificial hands, arms, feet, legs and eyes, including permanent implanted lenses following cataract surgery. Appliances needed to effectively use artificial limbs or corrective braces. Penile prosthesis and surgery to insert penile prosthesis when necessary in the treatment of organic impotence resulting from treatment of prostate cancer, diabetes mellitus, peripheral neuropathy, medical endocrine causes of impotence, arteriosclerosis/postoperative bilateral sympathectomy, spinal cord injury, pelvic-perineal injury, post-prostatectomy, post-priapism, epispadias, and exstrophy. Skilled nursing facility Charges for up to 150 days per calendar year if the patient s condition requires the level of nursing care available in a skilled nursing facility. Speech therapy (see Therapy) Spinal manipulation (see Therapy) HRI-SUBS Rev. 23 Page 87 of 205

88 Covered Expenses Surgical procedures Surgical procedures performed by a physician including the following: Sterilization (tubal ligations and vasectomies), regardless of medical necessity. AUTHORIZED COPY BCBSF Standard and Choice Plans Surgery to correct deformity which was caused by disease, trauma, birth defects, growth defects or prior therapeutic processes. Oral surgical procedures for excisions of tumors, cysts, abscesses, and lesions of the mouth. Surgical treatment of diseases when medical criteria are met as determined by BCBSF, unless covered under the Progress Energy-sponsored dental plan; out-of-network dentist's and oral surgeon's charges payable as in-network with deductible and coinsurance. Surgical procedures involving bones or joints of the jaw (e.g., temporomandibular joint [TMJ]) and facial region if, under accepted medical standards, such surgery is necessary to treat conditions caused by congenital or developmental deformity, disease, or injury (out-of-network dentist's and oral surgeon's charges payable as in-network with deductible and coinsurance). Surgical procedures performed on a patient for the treatment of morbid obesity (e.g., intestinal bypass, stomach stapling, balloon dilation) and the associated care provided the patient has not previously undergone the same or similar procedure while covered under the Progress Energy-sponsored medical plan or a predecessor plan. Services of a physician for the purpose of rendering a second surgical opinion and related diagnostic services to help determine the need for surgery. Therapy Outpatient therapies listed below when ordered by a physician or other health care professional licensed to perform such services: Cardiac therapy: services provided under the supervision of a physician, or an appropriate provider trained for cardiac therapy, for the purpose of aiding in the restoration of normal heart function in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery (maximum duration per program of 12 weeks). Occupational therapy: services provided by a physician or occupational therapist for the purpose of aiding in the restoration of a previously impaired function lost due to a medical condition. Physical therapy: services provided by a physician or physical therapist for the purpose of aiding in the restoration of normal physical function lost due to a medical condition. Massage therapy: massage provided by a physician, massage therapist, or physical therapist when prescribed as being medically necessary by a physician licensed pursuant to Florida Statutes Chapter 458 (Medical Practice), Chapter 459 (Osteopathy), Chapter 460 (Chiropractic) or Chapter 461 (Podiatry); the physician s prescription must specify the number of treatments. Speech therapy: services of a physician, speech therapist or licensed audiologist to aid in the restoration of speech loss or an impairment of speech as a result of sickness, disease, injury or certain congenital anomalies. Spinal manipulations: services by physicians for manipulations of the spine to correct a slight dislocation of a bone or joint that is demonstrated by x-ray. Calendar year maximum is 50 combined visits (physical, occupational, speech, cardiac, spinal manipulations, and massage therapy). Reimbursement for physical medicine modalities/procedures is limited to four treatments per day not to exceed the benefit maximum. Cardiac therapy is limited to a maximum duration of 12-weeks per program. Reimbursement for physical therapy evaluation/re-evaluation (including physical performance testing) is limited to 1 initial evaluation and 2 re-evaluations within 6 months (180 days), same provider, same diagnosis/condition unless documented as to medical necessity for medical review. HRI-SUBS Rev. 23 Page 88 of 205

89 Covered Expenses AUTHORIZED COPY BCBSF Standard and Choice Plans A patient may be allowed to go beyond the current maximum visit limit only if a request is made by or on behalf of the patient, a treatment plan is submitted and prior approval is obtained from BCBSF based on medical necessity. Transplant services Transplant services are limited to the procedures listed below, if coverage has been predetermined by BCBSF and if performed at a facility acceptable to BCBSF, subject to the conditions and limitations described below. Transplant includes pre-transplant, transplant and post-discharge services, and treatment of complications after transplantation. BCBSF will pay benefits only for services, care and treatment received or in connection with a: Bone marrow transplant, as defined herein, which is specifically listed in the applicable Chapter of the Florida Administrative Code or covered by Medicare as described in the most recently published Medicare Coverage Issues Manual issued by the Health Care Financing Administration. BCBSF will cover the cost of donating bone marrow by a donor to a plan participant to the same extent such cost would be covered for a plan participant and subject to the same limitations and exclusions as would be applicable to a plan participant. Coverage for the reasonable costs of searching for the donor will be limited to a search among immediate family members and donors identified through the National Bone Marrow Donor Program. Corneal transplant Heart transplant Heart-lung combination transplant Liver transplant Kidney transplant Pancreas Pancreas transplant performed simultaneously with a kidney transplant Lung - whole, single, or whole bilateral transplant In order to ensure that a proposed transplant is covered, the patient should notify or the patient's physician should notify BCBSF in advance of the patient's initial evaluation for the procedure. Corneal and kidney transplants do not require prior benefit determination. BCBSF will make a prior benefit determination concerning the proposed transplant; however, BCBSF must be given the opportunity to evaluate the clinical results of the patient's initial evaluation for the transplant as well as any applicable protocols. Once coverage for the transplant is predetermined, BCBSF will advise the patient or the patient's physician of the coverage decision. For covered transplants, and all related complications, BCBSF will cover: Hospital and physician expenses provided that such services will be paid in accordance with the same terms and conditions for care and treatment of any other covered condition. Donor costs and organ acquisition for transplants, other than bone marrow transplants, provided such costs are not covered in whole or in part by any other insurance carrier, organization or person other than the donor s family or estate. (See Transplants in the Expenses Not Covered list for exclusions.) HRI-SUBS Rev. 23 Page 89 of 205

90 BCBSF Standard and Choice Plans Expenses Not Covered The following goods and services are not covered. This list may not be all-inclusive. For questions regarding coverage, contact BCBSF (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). General exclusions include, but are not limited to: Acupuncture treatments except when performed by a licensed physician or a licensed acupuncturist. Air purification systems. Assisted reproductive therapy (infertility) including, but not limited to, associated services, supplies, and medications for in-vitro fertilization (IVF); gamete intrafallopian transfer (GIFT) procedures; zygote intrafallopian transfer (ZIFT) procedures; artificial insemination (AI); embryo transport; surrogate parenting; donor semen and related costs including collection and preparation; and infertility treatment medication. Any health care services not specifically listed in the Covered Expenses list, unless such services are specifically required to be covered by applicable law. Any health care services provided by a physician or other health care provider who is an immediate family member (spouse, domestic partner, children or parents) of the employee, spouse or domestic partner. Any health care services provided to a dependent deemed ineligible (see Dependents in the Eligibility section). Any health care services received prior to an employee's or dependent s effective date or after the date an employee's or dependent s coverage terminates. Any health care services rendered at no charge. Any health care services that are not medically necessary as determined by BCBSF; the ordering of a service by a health care provider does not in itself make such service medically necessary or a covered service. Any health care services to diagnose or treat a condition that, directly or indirectly, resulted from or is in connection with: War or an act of war, whether declared or not. The patient s participation in, or commission of, any act punishable by law as a felony, or that constitutes riot, or rebellion. The patient s engagement in an illegal occupation. Services received at military or government facilities including service in the armed forces, reserves and/or National Guard. Court ordered care or treatment, unless otherwise covered. Any health care services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group. Any health care services to treat a work-related condition to the extent the employee is covered or required to be covered by Workers Compensation law. Any service or supply to diagnose or treat any condition resulting from or in connection with an employee's job or employment will not be covered, except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers Compensation and that lack of coverage did not result from any intentional action or omission by that individual. Bunion treatment except by capsular or bone surgery. Charges for letters or other documents regarding treatment. Chiropractic maintenance treatments. HRI-SUBS Rev. 23 Page 90 of 205

91 BCBSF Standard and Choice Plans Expenses Not Covered Complications of non-covered services, including the diagnosis or treatment of any condition that is a complication of a non-covered health care service (e.g., health care services to treat a complication of cosmetic surgery are not covered). Cosmetic surgery and related services and supplies; surgery is covered if the surgery is to correct the effects of birth defects, accidental injury, or reconstructive procedures to replace diseased tissue. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Costs related to telephone consultations, failure to keep a scheduled appointment, or completion of any form/or medical information. Counseling. (See the Employee Assistance and Mental Health & Substance Abuse Services section.) Custodial care or rest cures. Dental procedures except those listed under covered. Dependent child pregnancy - expenses for the newborn child are not covered unless the newborn is legally adopted by the employee or the employee obtains legal guardianship within 30 days of date of birth. (Maternity expenses for the eligible dependent daughter are covered.) Durable medical equipment exclusions: Durable medical equipment that is primarily for convenience and/or comfort; modifications to motor vehicles and/or homes such as wheelchair lifts or ramps; water therapy devices such as jacuzzis, hot tubs, swimming pools or whirlpools; exercise and massage equipment; electric scooters; hearing aids; air conditioners; humidifiers; water purifiers; pillows, mattresses or waterbeds; escalators, elevators or stair glides; emergency alert equipment; handrails; heat appliances; and dehumidifiers. (See Durable medical equipment in the Covered Expenses list.) Educational treatment including reading clinics and special schools for mentally retarded or behaviorally impaired individuals. Elective abortion procedures. Experimental or investigational services as determined by BCBSF, except as otherwise covered under the bone marrow transplant provision of the transplant services. Eye care exclusions include: Eyeglasses or contact lenses and examinations except following cataract surgery or to treat keratoconus. Health care services to diagnose or treat vision problems, including but not limited to: any surgical procedure performed primarily to correct or improve myopia or other refractive disorders (e.g., radial keratotomy, PRK and LASIK), that are not a direct consequence of trauma or prior ophthalmic surgery; eye examinations; eye exercises or visual training; eye glasses and contact lenses and their fitting. (See Eye care in the Covered Expenses list.) Genetic screening, including the evaluation of genes to determine if they are carriers of an abnormal gene that puts them at risk for a disease. Health check-ups, premarital examinations, and immunizations except those specifically listed as covered preventive care expenses. Hearing aids. HRI-SUBS Rev. 23 Page 91 of 205

92 BCBSF Standard and Choice Plans Expenses Not Covered Oral surgery for the primary purpose of which is to improve the appearance or self-perception of an individual, except as provided in the Covered Expenses list. Orthodotic devices Expenses for the following are excluded: Arch supports, orthopedic shoes, sneakers, ready-made compression hose or support hose, or similar type devices/appliances regardless of intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease. (See Orthotic devices in the Covered Expenses list.) Orthomolecular therapy, including nutrients, vitamins (except prenatal vitamins with a prescription) and food supplements. Outpatient pre-operative and post-operative care in excess of that normally provided for surgery. Personal comfort, hygiene or convenience items and services deemed to be not medically necessary and not directly related to the treatment of the patient. Prescription Drugs that are not covered under the Prescription Drug Program offered by Catalyst Rx (or Walgreens for mail order): Drugs that may be purchased without a prescription (over-the-counter drugs). Fertility medications, injections, and treatments. Ostomy supplies (claims may be filed with BCBSF for reimbursement; subject to deductible and coinsurance). Therapeutic appliances or devices, support garments, or other non-medical items. Drugs covered by BCBSF, including those administered in an inpatient facility, physician s office or outpatient facility that are not usually self administered. Nicorette or other tobacco cessation products. Impotency drugs (such as Viagra, Caverject, and Muse) unless medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones unless the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (unless for morbid obesity). Refills beyond one year of original prescription date (six months for controlled drugs). Experimental or investigational drugs. Drugs used for cosmetic purposes. Drugs covered under Workers Compensation or any other federal or state program. To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: Catalyst Rx Customer Service Walgreens (Mail order) Customer Service Refills Prescription drugs cannot be filed with BCBSF. (See Prescription drugs in the Covered Expenses list.) Private duty nursing care rendered at any location. HRI-SUBS Rev. 23 Page 92 of 205

93 BCBSF Standard and Choice Plans Expenses Not Covered Refractory procedures including charges for any procedure performed for the purpose of correcting myopia, hyperopia, or astigmatism, and expenses related to such procedures. Reversal of sterilization procedures. Routine foot care or podiatry including treatment of toenails, bunions, corns, calluses, fallen arches, flat feet, weak feet, chronic foot strain or over-the-counter shoe inserts. Routine hearing examinations. Speech therapy for problems not caused by illness or injury; initial evaluation will be covered. Sports-related devices and services used to affect performance primarily in sports-related activities; all expenses related to physical conditioning programs such as athletic training, body building, exercise, fitness, flexibility, and diversion or general motivation. Temporomandibular joint syndrome (TMJ) treatment; except those charges specifically listed under covered expenses. Other TMJ charges may be eligible for coverage under the Progress Energy-sponsored dental plan. Charges for oral surgery and appliances may be eligible for coverage under the Progress Energy-sponsored dental plan. After individual consideration and review of the patient s history, expenses may not be covered if treatment is deemed not medically necessary or when diagnostic tests and procedures proposed do not meet the medical criteria. Training and educational programs or materials, including, but not limited to programs or materials for pain management and vocational rehabilitation. Transplant procedures or services that are excluded: Transplant procedures not included in the list above, or otherwise excluded under this plan (e.g., experimental or investigational transplant procedures). Transplant procedures involving the transplantation or implantation of any non-human organ or tissue. Transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered by BCBSF. Transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ. Any organ, tissue, marrow, or stem cells that is/are sold rather than donated to the patient. Any bone marrow transplant, as defined herein, that is not specifically listed in the applicable Chapter of the Florida Administrative Code or covered by Medicare pursuant to a national coverage decision made by the Health Care Financing Administration as evidenced in the most recently published Medicare Coverage Issues Manual. Any service in connection with identification of a donor from a local, state or national listing, except in the case of a bone marrow transplant. The reasonable cost of searching for a donor is covered and will be limited to a search among immediate family members and donors identified through the National Bone Marrow Donor Program. Any transportation costs for the patient or the patient's family to and from the approved facility. Any direct, non-medical costs for the patient to and from the approved facility. Any temporary lodging. Any artificial heart devices (if used as a bridge to transplant). Transportation except for medically necessary ambulance service. Weight control services including any service to lose, gain, or maintain weight, including without limitation: any weight control/loss program; appetite suppressants; dietary regimens; food or food supplements; exercise programs; equipment; whether or not it is part of a treatment plan for a condition. Wigs and/or cranial prostheses. HRI-SUBS Rev. 23 Page 93 of 205

94 UnitedHealthcare Standard and Choice Plus Plans UnitedHealthcare (UHC) Standard and Choice Plus Plans The UHC Standard and Choice Plus medical plans are comprehensive plans that reimburse you for covered hospital and medical expenses on a fee-for-service basis. Each time you need medical care, you decide if you want to use a provider who participates in UHC s network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. If you use an in-network provider, you will be eligible for the highest level of benefits from the Standard or Choice Plus medical plan in which you are enrolled. Enrollment Eligibility To participate in the UHC Standard or Choice medical plan, you and your dependents must (1) meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section), (2) live or work in areas where UHC providers are located and be either: An active regular, full-time employee including eligible dependent (regardless of Medicare eligibility). A LTD recipient including eligible dependent (regardless of Medicare eligibility). A retiree including eligible dependent (eligibility for the Choice Plus plan ends once a participant becomes Medicare eligible). A surviving dependent including eligible dependent (eligibility for the Choice Plus plan ends once a participant becomes Medicare eligible). Medicare-eligible participants LTD recipients, retirees and surviving dependents should apply for and purchase Medicare Part B when you or your dependent first becomes eligible for Medicare, and you should use providers who accept Medicare. UHC will assume you have purchased Medicare Part B and use providers who accept Medicare, and will coordinate benefits accordingly, regardless of whether or not you are actually covered under Part B or actually use providers who accept Medicare. This means that if you do not enroll in Medicare Part B when you become eligible or if you use providers who do not accept Medicare and then incur expenses that would be covered by Medicare Part B, you will be responsible for paying the full cost of those expenses. They will not be covered or paid by the UHC medical plans. For active regular, full-time employees, you and your covered dependents are not required to apply for and purchase Medicare Part B as long as you remain an active regular, full-time employee. Retired employees and surviving dependents and the dependents of both who are eligible to continue Progress- Energy-sponsored medical coverage and who are eligible for Medicare can be covered in the UnitedHealthcare Standard medical plan. If you are retired or are a surviving dependent and enrolled in the UHC Choice Plus medical plan, you and your dependents will need to change to one of the other Progress Energy-sponsored medical plan options for which you are eligible by the later of: During annual enrollment for the year in which you or your dependent will become eligible for Medicare; or No later than the month in which you or your covered dependent becomes eligible for Medicare. HRI-SUBS Rev. 23 Page 94 of 205

95 Medical and Prescription Drug ID Cards AUTHORIZED COPY UnitedHealthcare Standard and Choice Plus Plans If you enroll in either the UnitedHealthcare Standard or Choice Plus option, you will receive: UnitedHealthcare medical ID cards. The medical ID card should be presented to your physician and all other health care providers (except pharmacies) whenever services are received. If you have questions about your ID card or need additional cards, you should call UnitedHealthcare. A prescription drug ID card from Catalyst Rx. You must use your Catalyst Rx ID card (and not your UnitedHealthcare medical ID card) when you have prescriptions filled at your local pharmacy. Your Catalyst Rx ID card will contain your name, member ID number, and the prescription drug program group number. The pharmacist uses this information to verify eligibility and copayment/coinsurance amounts. The card will also list your covered dependents' names. HRI-SUBS Rev. 23 Page 95 of 205

96 UnitedHealthcare Standard and Choice Plus Plans 2012 UHC STANDARD PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses. For prescription drugs, copays or coinsurance applies. For most other covered expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, a patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Note: Copays, coinsurance, and deductibles shown are amounts paid by participant. Annual deductible 1 $1,500 individual/$3,000 family in- or out-of-network (coinsurance applies thereafter) Out-of-pocket limit 2 $4,000 individual/$8,000 family in- or out-of-network Maximum lifetime plan benefit Unlimited The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Covered at 100% 3 Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse service 4 Prescription drugs at participating pharmacies 5 Generic Covered at 100% innetwork 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Walgreen s Retail (up to 30 days) Mail Order (up to 90 days) $10 copay $25 copay Preferred Brand Name 20% coinsurance $75 copay ($25 minimum; $50 maximum) Non-Preferred Brand Name 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Specialty 7 Once the deductible is met, the following charges are subject to coinsurance: In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, non-surgical injections) Physician (includes family practice, OB/GYN, and 20% 40% internal medicine unless practicing in a specialty area) Specialist 20% 40% Office/surgical procedures (including MRI, PET, CT scans 20% 40% and nuclear medicine) Urgent care center 8 20% 20% Emergency room 9 20% 20% Hospital inpatient services Inpatient services (room, lab, x-ray) 20% 10, 11 40% Providers (physician, consulting physician, surgeon) 20% 40% 10 Providers (radiologist, anesthesiologist, pathologist, laboratory, ER physician) 20% 12 10, 12 40% Outpatient services Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, consulting physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, laboratory, ER physician) HRI-SUBS Rev. 23 Page 96 of % 20% 20% 20% 12 40% 10 40% 10 40% 10 10, 12 40%

97 Occupational/physical/speech therapy; spinal manipulation 13, 14 AUTHORIZED COPY UnitedHealthcare Standard and Choice Plus Plans 20% 40% 10 Durable medical equipment 20% 40% Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the usual and customary limit, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include prescription drug copays or coinsurance, charges in excess of U&C amount, services not pre-certified, or non-covered services. Out-of-pocket limit is maximum amount of deductible and coinsurance you must pay during a plan year. 3. Out-of-network charges are subject to usual and customary (U&C) limits. 4. Services are provided through ValueOptions and must be pre-certified. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Treatment must meet urgent care criteria. 9. $50 copay required in addition to deductible and coinsurance; must meet emergency care criteria. 10. If not pre-certified, benefits reduced to 50% of U&C amount (not applicable if Medicare is primary). 11. $400 out-of-network hospital copay required in addition to deductible and coinsurance % coinsurance if performed at an in-network facility or on the same day as an in-network provider visit; 40% coinsurance if performed at an out-of-network facility. 13. Limited to 60 visits per year for all therapies combined. Authorization required for in-network or out-of-network services to be covered. 14. Spinal manipulation is not covered out-of-network. Authorization required in-network. HRI-SUBS Rev. 23 Page 97 of 205

98 UnitedHealthcare Standard and Choice Plus Plans 2012 UHC CHOICE PLUS PLAN SUMMARY CHART This option pays 100% for covered in-network adult or child wellness expenses. Copays apply to some prescription drugs and innetwork office visits for physician, specialist, in-network outpatient mental health/substance abuse, and urgent care. For most other covered expenses, after satisfying the annual deductible, this option pays a percentage of the covered expenses (coinsurance). Each time medical care is needed, the patient decides which physician to use. A higher level of benefits applies when an in-network provider is used. Plan Provisions Annual deductible 1 Out-of-pocket limit 2 Maximum lifetime plan benefit Note: Copays, coinsurance, and deductibles shown below are amounts paid by participant. The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Mammograms Routine adult physical/wellness exams (including related tests and GYN exams) Well baby/child visits (including immunizations) Mental health/substance abuse services 4 Prescription drugs at participating pharmacies 5 $500 individual/$1,000 family in- or out-of-network (coinsurance applies thereafter) $1,500 individual/$3,000 family in- or out-of-network Unlimited Covered at 100% 3 Covered at 100% in-network 40% out-of-network 3 See the Mental Health & Substance Abuse Summary Chart. Catalyst Rx Retail (up to 30 days) Walgreen s Mail Order (up to 90 days) Generic Preferred Brand Name $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) Non-Preferred Brand Name 30% coinsurance $125 copay ($50 minimum; $75 maximum) Elective 6 Specialty 7 Once the deductible is met, the following charges are subject to coinsurance. Copays, not coinsurance and deductible, apply to in-network office and any urgent care visits. In-Network Out-of-Network 3 Physician office services (includes exams, diagnosis, lab services, non-surgical injections) Physician (includes family practice, OB/GYN, and internal medicine unless practicing in a specialty area) Specialist $35 40% Office/surgical procedures (including MRI, PET, CT 20% 40% scans and nuclear medicine) Urgent care center 8 $35 $35 Emergency room 9 20% 20% Hospital inpatient services Inpatient services (room, lab, x-ray) Providers (physician, consulting physician, surgeon) Providers (radiologist, anesthesiologist, pathologist, laboratory, ER physician) Outpatient services Outpatient facility fee Outpatient facility services (lab, x-ray) Providers (physician, consulting physician, surgeon) HRI-SUBS Rev. 23 Page 98 of 205 $25 20% 20% 20% 11 20% 20% 20% 40% 40% 10 40% 10 10, 11 40% 40% 10 40% 10 40% 10

99 UnitedHealthcare Standard and Choice Plus Plans Providers (radiologist, anesthesiologist, pathologist, 20% 11 10, 11 40% laboratory, ER physician) Occupational/physical/speech therapy; spinal manipulation 12, 13 $35 40% 10 Durable medical equipment 20% 40% Deductible is the amount you must pay each calendar year before the plan pays a benefit. Examples of charges that do not apply towards the deductible include services that require a copay, charges over the usual and customary limit, charges for services that are not precertified, expenses that are not covered, mental health and substance abuse services, preventive care and prescription drug charges. 2. Does not include office or urgent care visit copays or prescription drug coinsurance and copays, charges in excess of U&C, services not pre-certified, or non-covered services. Out-of-pocket limit is maximum amount of deductible and coinsurance you must pay during a plan year. 3. Out-of-network charges are subject to usual and customary (U&C) limits. 4. Services are provided through ValueOptions and must be pre-certified. 5. Prescription drugs are provided through Catalyst Rx. Prior review or certification is required for some drugs. 6. Elective copay equals $10 plus difference in cost between the brand name and generic drug. Applies if patient elects brand name when the prescription is written to allow generic substitution. Does not apply for mail order prescriptions. 7. Specialty medications must be purchased through the Catalyst Rx Specialty Program in order to be eligible for coverage. The prescription can be filled for up to a 30-day supply. Retail costs apply to specialty medication. 8. Treatment must meet urgent care criteria. 9. $50 copay required in addition to deductible and coinsurance; must meet emergency care criteria. 10. If not pre-certified, benefits reduced to 50% of U&C % coinsurance if performed at an in-network facility or on the same day as an in-network provider visit; 40% coinsurance if performed at an out-of-network facility. 12. Maximum 60 visits/year for all therapies combined. Authorization required for in-network or out-of-network services to be covered. 13. Spinal manipulation is not covered out-of-network. Authorization required for in-network services to be covered. HRI-SUBS Rev. 23 Page 99 of 205

100 UnitedHealthcare Standard and Choice Plus Plans How the UnitedHealthcare Standard and Choice Plus Plans Work These plans include a network of selected hospitals, physicians and other health care providers who have contracted to provide health care services at negotiated rates. Benefits under the UHC Standard and Choice Plus Plans are administered based on whether or not the covered services were received from an in-network provider or an out-ofnetwork provider. Benefits for covered services provided by in-network and out-of-network providers are reimbursed as follows: In-network - The "In-Network" benefit levels are used to process your claims when you receive covered medical services from a provider who is participating in the network. Out-of-network - If you choose not to use an in-network provider, your claims are processed using the "outof-network" benefit levels. Services received outside of North Carolina If you receive covered services from an out-of-network provider, you will pay a deductible and higher coinsurance and you may have to file a claim for reimbursement. Also, since the cost of medical procedures may vary widely among out-of-network providers, you may wish to discuss the cost of the specific procedure with the provider before receiving the services so you can determine your out-of-pocket costs. If you are traveling If you are traveling out of the service area or to a foreign country and require non-routine medical treatment, you may see a local physician, or if the situation meets the criteria for urgent care or medical emergency, you may go to an urgent care center or hospital emergency room. You may be required to pay the bill at the time of the service. To be reimbursed, you should complete a UnitedHealthcare Health Claim Transmittal Form (FRM-SUBS-01062), attach the original itemized receipt, and a copy of your UnitedHealthcare medical ID card, and mail it to UnitedHealthcare. If your child attends school out of state If your eligible child lives or attends school out of your area, you may cover the child under UnitedHealthcare. In order for services to be covered at the in-network level, please be sure UnitedHealthcare has a network in the area where your child lives or attends school. If there is not a network available, all services will be covered at the out-ofnetwork level of care. When your child returns home on school breaks, he or she can also seek services with UnitedHealthcare providers. Questions For questions regarding UnitedHealthcare Standard and Choice Plus Plans medical claims, benefits, participating providers or pre-certification, call UnitedHealthcare at Usual and customary (U&C) limits Under UnitedHealthcare, covered expenses are paid based on a usual and customary (U&C) limit (sometimes referred to as the allowed amount ). The U&C amount is the prevailing rate charged for comparable services by providers located within the same geographical area. Charges for covered services received from providers participating in UnitedHealthcare s network generally are within the U&C limit. If you receive covered services from an out-of-network provider and the charges are above the U&C amount, you are responsible for paying the additional amount. The amount in excess of the U&C limit does not apply to the deductible or out-of-pocket limit. HRI-SUBS Rev. 23 Page 100 of 205

101 UnitedHealthcare Standard and Choice Plus Plans Deductible A deductible is the dollar amount you must pay each calendar year before benefits are payable for covered services that require you to pay a percentage of the charge (coinsurance). The deductible is combined for in- and out-ofnetwork services. The BCBSNC Standard or Choice Plans have an individual deductible for each person you cover (including dependents) up to a combined family deductible. When a covered individual meets his or her individual deductible or when several covered family members expenses combine to satisfy the family deductible, the plan will begin paying benefits for covered expenses that require coinsurance. Refer to the Summary Charts for specific deductible amounts. The following amounts do not apply toward the annual deductible and thus are not counted when determining whether the annual deductible has been met: Copayments Charges over the usual and customary limit Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Inpatient newborn care services (well baby) Preventive care Prescription copays and coinsurance If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Coinsurance and copayments under the Standard Plan For charges from in-network providers (including doctor s office visits, surgery, outpatient procedures and inpatient expenses), after you have met your annual deductible, you pay a percentage of the cost of the covered expenses (called coinsurance). The plan pays the remainder of the covered charges. Deductibles and coinsurance do not apply to in-network preventive care. When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the usual and customary limit. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require that you pay the entire bill at the time of service and file a claim with UHC. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Standard Plan as described in the Summary Chart. Coinsurance and copayments under the Choice Plus Plan When you have an office visit with an in-network physician or specialist, you pay a flat amount called a copayment. You do not have to meet a deductible for services that require a copayment. Office visit copayments include exams, diagnosis, lab tests, and non-surgical injections. If lab or other tests are conducted in a doctor s office in preparation for an office visit or in a follow-up visit and you do not see the physician, the tests are not subject to an additional copayment. For allergy shots, you must pay a copayment or the actual cost of the injection, whichever is less. If an office visit includes a surgical procedure or high level radiology (MRI, PET, CT scans and nuclear medicine), deductible and coinsurance amounts apply. If an office visit is billed separately from the surgical procedure, a copayment will apply to the office visit. Note: When Medicare or other medical insurance is primary, copayment amounts do not apply; deductible and coinsurance amounts do apply. Copayments, deductibles and coinsurance do not apply to in-network preventive care. HRI-SUBS Rev. 23 Page 101 of 205

102 UnitedHealthcare Standard and Choice Plus Plans For most other covered in-network expenses (such as outpatient procedures, hospital charges and surgery), you pay a percentage of the cost of the covered expense (called coinsurance) after you have met your deductible. UHC pays the remainder of the covered charges. When you receive services from an out-of-network provider, you pay a percentage of the covered expenses (coinsurance) after the deductible has been met. The plan pays the remainder of covered charges up to the usual and customary limit. Deductibles do not apply to out-of-network preventive care. Some out-of-network providers may require you to pay the entire bill at the time of service and file a claim with UHC. Prescription drug copayments or coinsurance applies to generic, preferred brand name or non-preferred brand name drugs under the Choice Plus Plan as described in the Summary Chart. Copayments do not apply towards the out-of-pocket limit or the deductible. Out-of-pocket limit The deductible and coinsurance amounts you pay apply to your out-of-pocket limit. If you reach the annual out-ofpocket limit, UnitedHealthcare will pay 100% of U&C charges that are incurred for the rest of the year if the charges are subject to deductible and coinsurance. The out-of-pocket limit is combined for in- and out-of-network charges. If the annual family out-of-pocket limit has been met, no additional coinsurance amounts or deductibles will apply for that year. The following expenses do not apply toward the out-of-pocket limit and thus are not counted when determining whether the out-of-pocket limit has been met: Copayments Charges over the usual and customary limit Charges for services that are not precertified (if precertification is required for such services) Expenses that are not covered Prescription copays and coinsurance If you transfer to a different Progress Energy-sponsored medical plan option during a plan year, amounts that have accumulated toward your annual deductible and out-of-pocket limit will be transferred and applied to the other option (excludes HMOs). Contact the Employee Service Center to request the transfer. New surviving dependents and COBRA participants who elect to continue company-sponsored medical coverage may also request that their accumulated balances be transferred to their new coverage. Utilization Review Program (referred to as Care Coordination) The Care Coordination Review (CCR) program is designed to encourage an efficient system of care for covered members by identifying and addressing possible unmet covered health care needs. This may include admission counseling, inpatient care advocacy, and certain discharge planning and disease management activities. The Care Coordination activities are not a substitute for the medical judgment of your physician; however, the ultimate decision as to what medical care covered members actually receive must be made by the member and the physician. The CCR program is triggered when UHC receives notification of an upcoming treatment or service. For services that require CCR, if the review is not done for out-of-network charges, benefits are payable at 50% of U&C. Items subject to this are: Inpatient facility Home health care Durable medical equipment (over $1,000 for out-of-network charges) Reconstructive procedures HRI-SUBS Rev. 23 Page 102 of 205

103 UnitedHealthcare Standard and Choice Plus Plans Maternity services (if stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section) Skilled nursing facility Therapies You may be contacted by UHC if you are receiving treatments subject to the Care Coordination process. Likewise, if you have any questions, you may contact UHC s Care Coordination staff by calling the toll-free number shown on your ID card. Pre-admission review When hospitalization is recommended for you or one of your dependents, you or your physician should call as soon as possible but no later than five business days prior to the admission date to begin the pre-admission review process. Note: Pre-admission review is not required if Medicare is primary. The pre-admission review number for UHC is During the pre-admission review, a nurse discusses the case with your physician. If your physician and the nurse agree that your treatment should take place on an inpatient basis, the admission and an appropriate number of inpatient days will be authorized. If there is a change in the admission date or the patient is transferred to another hospital, you or your physician must notify the CCR nurse of the change. If your physician and the nurse agree instead that treatment can be performed on an outpatient basis, outpatient benefits will be provided. If your physician and the nurse do not agree on the need for inpatient hospitalization, the case will be referred to a CCR staff physician of the appropriate specialty. The CCR physician will work with your physician and you to resolve any differences. You, your physician, the hospital, and the medical claim office will be notified in writing of the decision regarding hospitalization. Prior notification for out-of-network outpatient surgery or admissions For out-of-network outpatient surgery or admissions to out-of-network facilities, the patient or family member must contact UnitedHealthcare at least 10 working days prior to the admission or surgery date or as soon as possible after the admission is scheduled. If services are not precertified, benefits are reduced to 50% of U&C. Certain out-of-network charges may be considered in-network if your physician obtains prior authorization from UHC due to the unavailability of an in-network facility. If you choose to receive inpatient hospital treatment from an out-of-network provider, you must notify UHC in advance. Your physician must obtain authorization from UHC if the following services are received from an out-of-network provider; otherwise benefits will be reduced to 50% of U&C. Durable medical equipment (over $1,000) Home health care Occupational, physical and speech therapy Skilled nursing facility If pre-admission review is not followed If you or your provider fail to follow the pre-admission procedures by not communicating with UHC and not providing your or your dependent s name, specific medical condition, and the specific treatment, service or product for which you are requesting approval, you will be notified of the failure within five days (or 24 hours in the case of an urgent care claim) and informed of the proper procedures to be followed. If the pre-admission review process is not followed and authorization is not obtained for out-of-network facilities, benefits for all charges related to the hospital stay will be reduced to 50% of U&C. The additional cost incurred because of the reduced benefits will not apply to the annual out-of-pocket limit. HRI-SUBS Rev. 23 Page 103 of 205

104 UnitedHealthcare Standard and Choice Plus Plans Continued stay review Once you are in the hospital, your physician may request additional days in the hospital (that were not identified during the initial pre-admission review process). A continued stay review will be made and, if appropriate, the additional inpatient days will be authorized. If your inpatient stay exceeds the number of days that have been approved, benefits for the room and board charges for the additional days will be limited to 50%. The additional cost incurred because of the reduced benefits will not apply to the annual out-of-pocket limit. Claim review appeal procedures In the event that precertification is not granted for a service, the patient or the provider may appeal the noncertification decision. The noncertification appeals process does not apply to a decision that is based on the fact that the requested service is not covered or disputes regarding the dollar amount or number of covered visits that are limited under the Standard or Choice Plus Plan. A written appeal must be made to UHC within 15 calendar days of the noncertification. UHC will review the request and consult with providers who are certified or licensed in the same health category as the patient s provider. The patient will be notified in writing of UHC s decision within 30 days of the date the appeal request was received. Expedited review Appeals may be expedited when a delay could be detrimental to the patient s health. The request for an expedited review should be directed to UHC and must be accompanied by documentation of the medical necessity which qualifies the case for expedited review. The request for expedited review may be made orally or in writing. A review of the expedited urgent appeal will be conducted within 72 hours of receiving the request and necessary information. You and UHC can transmit this information via telephone, fax machine or other similarly expeditious method. Case Management Case management is designed to address the special needs of those who suffer from a severe illness or injury. When appropriate, the CCR program will assign a case manager (a health care professional) to work one-on-one with the patient and the patient s physician to develop a medical treatment plan and coordinate all required medical services. The CCR program considers the patient s current medical status and course of treatment, the effectiveness of care, the short- and long-term implications of the treatment, and possible alternative treatment plans. Because each case is different, the case management function works differently for each patient. The goal is to provide the most appropriate care in a timely, efficient, and cost-effective manner. UHC retains the right to review the patient s medical status while treatment is in process. Benefits can be discontinued for previously approved medical treatment if the: Attending physician does not provide the medical records or physician reports needed to determine the effectiveness of the alternative medical treatment. Goal of the alternative medical treatment has been met. Alternative medical treatment is no longer beneficial to the patient. Maximum allowable benefit has been paid. Condition Management Program The condition management program, administered by UnitedHealthcare, is available to all active and retired employees and their covered dependents who participate in the Standard or Choice Plus Plan. The program is designed to provide you with tools and resources to gain a better understanding of certain chronic conditions. HRI-SUBS Rev. 23 Page 104 of 205

105 UnitedHealthcare Standard and Choice Plus Plans The condition management program provides access to a 24-hour, 365 days per year information and support line that is staffed with medical professionals familiar with symptoms and issues associated with the targeted chronic conditions. Condition specific interventions The condition management program offers health management services focusing on individuals with one or more of the following conditions: Asthma Cancer Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Diabetes Pregnancy The services offered are intended to supplement but not replace the existing physician-patient relationship. Confidentiality The condition management program maintains the confidentiality of all patient-specific clinical information received from patients, their family members and their health care providers. Confidential information will not be disclosed to Progress Energy or others without your express written consent except when required by law, or (subject to applicable law) to a third party (e.g., an auditor contracted by the plan to review the program practices, including its clinical records, to evaluate the performance of the program administrator). Covered Expenses Medical expenses covered under the UHC Standard and Choice Plus medical plan options are summarized on the following pages; however this list may not be all-inclusive. To be an eligible expense, the expense must be incurred for services that are medically necessary as determined by UHC or qualify as preventive care. If you have questions about the eligibility of a covered medical expense, contact UHC for verification (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). (See the UHC Standard or Choice Plus Plan Summary Chart for additional information on benefit levels.) Acupuncture Must be performed by a licensed physician or a licensed acupuncturist. Allergy testing and treatment Ambulance service To the nearest facility where treatment can be obtained; must meet emergency services criteria or be part of a monitored authorized care plan. Ambulatory surgical centers Anesthesia charges In connection with a covered surgical procedure. Bariatric surgery Morbid obesity/severe obesity, with qualifying co-morbidities, provided that medical necessity is established based on UHC medical policy. Coverage includes office visits/consultations and surgery as deemed appropriate provided the patient has not previously undergone the same or similar procedure while covered under a Progress Energy-sponsored medical plan or a predecessor plan. This coverage could include gastric bypass, laparoscopic (LAP) banding, etc. Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Psychological consultation/testing may be considered under the MHSA benefit plan. HRI-SUBS Rev. 23 Page 105 of 205

106 Covered Expenses Blood and blood products and their administration AUTHORIZED COPY UnitedHealthcare Standard and Choice Plus Plans Breast reconstructive surgery and implanted prostheses Incident to mastectomy. Chemotherapy and radiation therapy Chiropractic care (see Therapy) Contraceptive devices and implants Coverage includes the insertion or removal of and any medically necessary examination associated with the use of a covered contraceptive device or implant. Covered contraceptives are intrauterine devices, diaphragms, and implanted hormonal contraceptives. Dental treatment Covered dentist's and surgeon's charges payable as in-network regardless of place of dental service; facility charges will be paid based on the network status of the facility for the: Removal of tumors and lesions of the mouth. Inpatient and outpatient facility charges for surgical treatment of diseases when medical criteria are met as determined by UHC, unless covered under the Progress Energy-sponsored dental plan. Accidental injury to sound natural teeth, gums, or jaw occurring from an external source while the patient is covered under UHC (treatment for accidental injury must be authorized by UHC and begin within 72 hours of the accident and coverage is limited to 12 months). Anesthesia and hospital or facility charges in connection with dental procedures when hospitalization or general anesthesia is required for children below the age of nine years, patients with serious mental or physical conditions, patients with significant behavior problems, or other situations determined medically necessary by UHC; the attending dentist must certify that the criteria have been met. (Coverage does not include any professional fees, except for the anesthesiologist.) Diabetic treatment Covered as follows: self-management training and education, equipment, and laboratory procedures. (See Prescription drugs for diabetic supplies covered by Catalyst Rx.) Diagnostic services Such as x-rays, metabolism tests, radioisotope tests, lab tests, and mammograms (routine screening mammograms limited to one per calendar year). Dialysis treatment For renal disease. Durable medical equipment Durable medical equipment rental (not to exceed the purchase price), purchase (if more economical), or repair or replacement (except due to misuse or loss). Durable medical equipment is equipment that may be repeatedly used, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. UHC authorization required. Prior notification on out-of-network durable medical equipment for amounts over $1,000. (See Durable medical equipment in the Expenses Not Covered list for exclusions.) HRI-SUBS Rev. 23 Page 106 of 205

107 UnitedHealthcare Standard and Choice Plus Plans Covered Expenses Emergency room Must meet the emergency services criteria When an emergency occurs inside or outside the service area, you should contact your physician for guidance. If this is not possible, you should seek medical attention at the closest emergency facility. If admitted to the hospital, UHC must be notified within one business day. You should also contact your physician for any necessary follow-up care. A $50 copayment will apply for emergency treatment. The copayment will be waived if you are admitted to the hospital. If the care does not meet the emergency criteria, charges will not be covered. In addition to the $50 copayment, the deductible and coinsurance apply. Any medical emergency requiring immediate attention is covered if it threatens a member s life or limb. An emergency is defined as an unforeseen illness or accident in which the onset of symptoms is both sudden and so severe as to require immediate medical or surgical treatment. This includes illnesses or accidental injuries that are life threatening or that a prudent layperson would expect to result in one of the following: 1) serious impairment to bodily functions, organs, or parts; 2) placing the patient s health at risk; or 3) placing a pregnant woman s and/or her unborn child s health at risk. Foot orthotics If custom molded from a mold of the patient's foot and prescribed by a qualified provider. Home health care By an accredited agency in accordance with plan established by your physician; care must be authorized by UHC for out-of-network providers; home health care does not include meals, custodial care, or housekeeping services. Hospice care Must be authorized by UHC payable as in-network. Hospital services Emergency and maternity admissions If you or your dependent is admitted to the hospital for maternity or emergency treatment, the CCR staff must be notified within one business day of the admission. Inpatient services Hospital inpatient charges are covered for room and board and charges for general nursing care and ancillary services. If intensive care or other specialized care is necessary, the rate for the specialized care room will be considered a covered charge. All inpatient hospital services require prior notification from your physician. Outpatient services Hospital outpatient charges are covered for ancillary services, including general nursing care, use of operating and delivery rooms, anesthesia, dressings, casts, laboratory examinations, and other services authorized by UHC provided by the hospital for the diagnosis and treatment of the patient s condition. Some outpatient services require prior notification from your physician. See Prior Notification for a list of these outpatient services. For out-of-network outpatient surgery or admissions to out-of-network facilities, the patient or family member must contact UHC at least 10 working days prior to the admission or surgery date or as soon as possible after the admission is scheduled. Infertility treatment Diagnostic tests to determine cause of infertility and surgery to correct defects. Mammograms Mastectomy services HRI-SUBS Rev. 23 Page 107 of 205

108 UnitedHealthcare Standard and Choice Plus Plans Covered Expenses Mental health and substance abuse Mental health and substance abuse services are administered by ValueOptions. (See the Employee Assistance and Mental Health & Substance Abuse Services Plan section for benefit information.) Morbid obesity treatment (see Bariatric surgery) By a registered dietician or a diabetic teaching nurse is covered up to three visits per year when order by the physician. Nutritional counseling Up to 12 visits per calendar year if medically necessary. Occupational therapy (see Therapy) Ostomy supplies Oxygen and rental equipment for oxygen administration Physical therapy (see Therapy) Physician fees For medical care to diagnose or treat an illness or injury. Prescription drugs You may purchase prescriptions that are covered under the three-tiered Prescription Drug Program through Catalyst Rx at participating retail pharmacies or through Walgreens, the mail order drug service. The threetiered Prescription Drug Plan requires separate copays/coinsurance depending on whether you elect generic, preferred brand name, or non-preferred brand name drugs. Eligible drugs Drugs that are covered under the Prescription Drug Program offered by Catalyst Rx (or Walgreens for mail order): Legend drugs or controlled substances that bear the statement "Caution: Federal Law prohibits dispensing without prescription" (except those listed under exclusions). Diabetic syringes, glucose test strips, and supplies. Oral contraceptives. Injectables, such as insulin, Imitrex and Depo-Provera. Compound drugs. Over-the-counter (OTC) Prilosec if you have a prescription, you are eligible to purchase Prilosec OTC at the generic copay. Your prescription will need to be presented to the pharmacist for confirmation so the copay can be applied. Sleep aids - will be limited to 10 pills per prescription as recommended by the manufacturer. Impotency drugs (such as Viagra, Caverject, and Muse) if medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones if the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (only for morbid obesity). Prenatal vitamins with a prescription. (See Prescription drugs in the Expenses Not Covered list for excluded items.) HRI-SUBS Rev. 23 Page 108 of 205

109 Covered Expenses To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: AUTHORIZED COPY UnitedHealthcare Standard and Choice Plus Plans Catalyst Rx Customer Service Walgreens (mail order) Customer Service Refills Prescription drug claims cannot be filed with UHC and the copayments and coinsurance do not apply to the deductible or out-of-pocket limits. Formulary Generic - Generic drugs have the same active chemical composition as brand name drugs but are generally available at a lower cost. Generic drugs become available when the patent on the original brand name drug expires, enabling pharmaceutical companies to replicate the chemical formula of the brand name drug. Preferred Brand Name - Preferred brand name drugs are brand name drugs that are on a preferred list. Preferred brand name drugs generally are more cost effective than most other brand name drugs. A formulary listing of preferred brand name drugs may be obtained from the Employee Service Center or at Formulary preferred brand name options are designed to deliver the highest quality prescription drugs at the best possible price without impacting the effectiveness of the patient's therapy. The formulary listing includes many of the most effective and highly utilized drugs. The formulary copays/coinsurance and specific drugs within the formulary are subject to change as new drugs and generic alternatives become available. Non-preferred Brand Name - Non-preferred brand name drugs are brand name drugs not on the preferred list. They are generally the most expensive and will require the highest copay/coinsurance. Specialty drugs - Specialty medications must be purchased through the Walgreens Specialty Pharmacy only and members will need to contact Walgreens Specialty Pharmacy by calling to participate. Specialty medications are limited to a 30-day supply whether they are picked up at a retail location or delivered via mail service. Formulary Advantage Program The Formulary Advantage Program encourages the safe and cost-effective use of prescription drugs by taking a step approach to the coverage of certain high-cost medications. This means that you may need to first try a proven, lower-cost alternative saving both you and the plan money before you progress to a more costly treatment, if necessary Drug classes subject to this program include certain brand name antidepressants and sleep aids, as well as select brand name medications used to treat hypertension, migraines, nasal allergies, osteoporosis and stomach ulcers/heartburn. If you have previously tried a lower-cost generic or recommended brand name alternative and it did not work for you, your healthcare provider can contact Catalyst Rx directly to request a prior authorization. If you have not received prior approval from Catalyst Rx, prescriptions written for higher-cost brand name medications will not be covered by the plan and you will be responsible for 100% of the medication s cost at the pharmacy. This program is not required for members under age 18 and other exceptions may apply. Please call the Catalyst Rx Member Services Department at for more information. HRI-SUBS Rev. 23 Page 109 of 205

110 UnitedHealthcare Standard and Choice Plus Plans Covered Expenses Mail order drug service Walgreens, the mail order drug service, may be used for maintenance medications that are taken on a continuing basis. To use Walgreens, the prescription should be written for a 90-day supply when appropriate and the number of refills indicated on the prescription. You should also complete and submit Walgreens Mail Service Registration and Prescription Order Form (FRM-SUBS-20112). Note: If the prescription is written for less than a 90-day supply (e.g., for a 30-day supply with 3 refills) it may only be filled with a 30-day supply but the copayment will be the same as for a 90-day supply. You should allow at least 14 days for the prescription to be processed and returned to you. Allow an additional week for a new prescription. Pill splitting Many medications come in various strengths or doses. However, you may not be aware that in many cases, the cost of each pill does not vary much (if at all) based on the dosage. Progress Energy offers voluntary pill-splitting for eligible medications. You will pay the 30-day copay/coinsurance (or 90-day copay for mail order) and use a pill splitting device. For example, if you take 25mg Zocor, you may purchase a 30-day supply (or 90-day supply for mail order) of 50mg Zocor and use a pill splitting device to cut the medication into two 25mg doses. In this example, you will double your supply. Only certain medications are eligible for pill-splitting. If you take an eligible medication, the Catalyst Rx claims system will prompt your pharmacist to ask you if you are interested in taking advantage of this program. This program will be voluntary; you will not be required to use it. For mail order, the physician must write the prescription for a 180-day supply and note that you want to participate in the pill splitting program. Prescription drug copayment/coinsurance The drug copayment/coinsurance amount is based on the number of days supply (up to 30 days at participating retail pharmacies and up to 90 days for mail order) and whether the prescription is filled with generic, preferred brand name, or non-preferred brand name drugs. If the patient elects to have the prescription filled with a brand name drug when the prescription was written to allow generic substitution, an elective copayment amount will apply. The elective copayment will equal $10 plus the difference in the cost between the brand name and generic drug. Prior authorization Note: Any single prescription fill (not cumulative fills) that costs the plan greater than $750 retail or $2,250 mail order will require prior authorization by Catalyst Rx. When your pharmacist enters the claim in the Catalyst Rx system, he/she will receive a system prompt from Catalyst Rx indicating the need for prior authorization and inform you to contact Catalyst Rx customer service to start the process. You should call Catalyst Rx customer service at to initiate the prior authorization and provide customer service with your physician s contact information (physician s name/phone number). The turnaround time once Catalyst Rx has received the information from your physician is generally hours. Purchasing drugs from participating pharmacies To purchase covered drugs at participating pharmacies, present your Catalyst Rx card to the pharmacist at the time you submit the prescription. Call Catalyst Rx or search for a listing of participating pharmacies. If you live in an area where there are no participating pharmacies or you have a prescription filled on an emergency basis, you may be reimbursed by Catalyst Rx for the charges, less the appropriate copayment/coinsurance, using Catalyst Rx Reimbursement Form (FRM-SUBS-01117). Requests for reimbursement must be filed within 12 months of the date the prescription was filled. Retain copies for your records in case you need to refer to them. HRI-SUBS Rev. 23 Page 110 of 205

111 UnitedHealthcare Standard and Choice Plus Plans Covered Expenses Preventive care Certain preventive care expenses are covered. Benefits are available in- and out-of-network. Covered preventive care expenses include: Colorectal screening available to covered active and retired employees and their dependents when received from their physician. Frequency and type of tests performed will be determined by the provider based on the patient s individual needs. In-network Routine/wellness/screening and diagnostic colorectal procedures (i.e., colonoscopy) will be paid at 100% with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Out-of-network Routine/wellness/screening and diagnostic colorectal procedures (i.e., colonoscopy) will be paid at 60% of U&C with no deductible if performed in a physician s office, outpatient facility, or ambulatory surgical center. Well-child visits - for eligible dependents. Covered expenses include physician visits, laboratory tests, and routine immunizations; however, the claim must be filed with a primary diagnosis of screening. Wellness examinations - available to covered active and retired employees and their dependents when received from their physician. Frequency and type of tests performed will be determined by the provider based on the patient's individual needs; however, the claim must be filed with a primary diagnosis of screening. Mammograms annual mammograms covered at 100% for covered employees and eligible dependents; however, the claim must be filed with a primary diagnosis of screening. For claims to be processed as wellness (with the exception of colorectal screening), the exam and related laboratory and/or screenings must be coded with a primary diagnosis coding of screening. If a medical condition is diagnosed and treated during an initial or follow-up visit for a wellness exam or preventive care, the treating physician may apply the appropriate diagnostic or treatment code. The charges for this diagnosis or treatment may require you to pay a copay, deductible and/or coinsurance. Prosthetic appliances and orthopedic braces For initial purchase and fitting; expenses are covered for rental (not to exceed the purchase price), purchase (if more economical), or repair or replacement (except due to misuse or loss). A prescription from the physician is required. Second surgical opinions Sexual dysfunction Treatment to restore sexual function including penile implants when authorized by UHC; $5,000 maximum benefit. Skilled nursing facility Charges for up to 150 days per calendar year if the patient s condition requires the level of nursing care available in a skilled nursing facility; care must be authorized by UHC. Speech therapy (see Therapy) Spinal manipulation (see Therapy) HRI-SUBS Rev. 23 Page 111 of 205

112 Covered Expenses Sterilization procedures for either sex (including elective sterilization) AUTHORIZED COPY UnitedHealthcare Standard and Choice Plus Plans Surgery For treatment of an illness or injury and surgical procedures required to correct birth defects; coverage includes post-operative care normally provided as part of the surgical procedure. Temporomandibular joint syndrome (TMJ) Coverage includes office visits, consultations, physical therapy, and surgical procedures as authorized by UHC to treat conditions caused by congenital or developmental deformity, disease, or injury. Hospital charges (including anesthesia and other ancillary charges) are covered when incurred due to an accidental injury or disease in the temporomandibular joint. Therapy Limited to 60 visits per year for all therapies combined except for cardiac rehabilitation and pulmonary rehabilitation. The cardiac rehabilitation limit is 36 visits per year and the pulmonary rehabilitation is 20 visits per year. This is in addition to the 60 combined therapy visits per year. A patient may be allowed to go beyond the current 60 visit limit only if a request is made by or on behalf of the patient, a treatment plan is submitted and prior approval is obtained from the Benefits Administrator based on medical necessity. Chiropractic care including spinal manipulation - UHC authorization required for in-network or out-ofnetwork services; benefits not available for out-of-network spinal manipulations. Occupational therapy - services provided by a physician or occupational therapist for the purpose of aiding in the restoration of a previously impaired function; UHC authorization required for out-ofnetwork services. Physical therapy - services provided by a physician or physical therapist to restore normal physical function. UHC authorization required for out-of-network services. Speech therapy - services of a physician, speech therapist or licensed audiologist to aid in the restoration of speech loss or an impairment of speech as a result of sickness, disease, injury or congenital anomaly; UHC authorization required for out-of-network services. Cardiac rehabilitation limited to 36 visits per year. Pulmonary rehabilitation limited to 20 visits per year. Transplants Access to hospitals for approved organ transplants is provided through the United Resource Network program. Benefits will not be provided if prior authorization from UHC is not received. Approved procedures include, but are not limited to, the following organ and tissue transplants: heart, liver, liver/small bowel, small bowel, bone marrow, cornea, pancreas, kidney, pancreas/kidney, heart/lung, lung or double lung. Facilities chosen as members of the United Resource Network are nationally recognized for their delivery of these highly specialized procedures. Limited benefits are paid for transportation, lodging, and necessary living expenses for the patient and one companion if the patient is referred by a case manager to an out-of-area facility for an organ or tissue transplant. The companion must either be a spouse or domestic partner, family member, or guardian of the patient. Necessary living expenses include expenses such as meals, but do not include items such as child care, house sitting charges, kennel boarding, or reimbursement of any wages lost by the companion during the patient s stay in a referred facility. Benefits for transportation, lodging, and necessary living expenses are subject to a $10,000 lifetime plan maximum. Reimbursement amounts over $50 per person (you may include lodging for one companion of the patient) per day for lodging expenses are considered by the IRS to be excess benefits and would be reported as taxable to the recipient. HRI-SUBS Rev. 23 Page 112 of 205

113 UnitedHealthcare Standard and Choice Plus Plans Covered Expenses Urgent care When an urgent care condition occurs, you should first contact your physician for guidance. If you are unable to reach your physician, you may access one of UHC s participating Urgent Care Facilities for acute care needs. When using a participating Urgent Care Facility, you will pay a copayment. If you access a non-participating facility, you will be responsible for paying the charge in full and submitting the claim to UHC for your reimbursement. An urgent care condition is one that occurs suddenly and unexpectedly, requiring prompt diagnosis or treatment. If immediate care is not provided for the condition, the individual could reasonably be expected to suffer an extended illness, prolonged impairment, or require a more hazardous treatment. Examples of conditions that may require urgent care include earaches, muscle sprains, urinary tract infections, and minor wounds requiring stitches. Expenses Not Covered The following goods and services are not covered. This list may not be all-inclusive. For questions regarding coverage, contact UHC (except for prescription drugs); for prescription drugs, contact Catalyst Rx (or Walgreens for mail order). General exclusions include, but are not limited to: Acupuncture treatments except when performed by a licensed physician or a licensed acupuncturist. Air purification systems. Any health care services not specifically listed in the Covered Expenses list, unless such services are specifically required to be covered by applicable law. Any health care services or supplies that are not medically necessary according to accepted standards of medical practice or that are not related to the diagnosis or treatment of a given illness or injury as determined by UHC; the ordering of a service by a health care provider does not in itself make such service medically necessary or a covered service. Any health care services provided to a dependent deemed ineligible (see Dependents in the Eligibility section). Any health care services received: That are covered by any other benefit plan or insurance program that is sponsored by Progress Energy. By a patient who resides permanently outside of the United States or Canada. As a result of an illness or injury caused by war, rebellion, or riot. From a member of your or your spouse s or domestic partner s immediate family (spouse, domestic partner, children or parent) or from a person who normally resides in your home. As a result of illness or injury incurred while committing or attempting to commit a crime. Any health care services received prior to an employee's or dependent s effective date or after the date an employee's or dependent s coverage terminates. Any health care services rendered at no charge. Any health care services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group for conditions that federal, state, or local law requires to be treated in a public facility or for any treatment covered by any governmental body or agency unless payment is required by law. HRI-SUBS Rev. 23 Page 113 of 205

114 UnitedHealthcare Standard and Choice Plus Plans Expenses Not Covered Any health care services to treat a work-related condition to the extent the employee is covered or required to be covered by Workers Compensation law. Any service or supply to diagnose or treat any condition resulting from or in connection with an employee's job or employment will not be covered, except for medically necessary services (not otherwise excluded) for an individual who is not covered by Workers Compensation and that lack of coverage did not result from any intentional action or omission by that individual. Charges for letters or other documents regarding treatment. Chiropractic maintenance treatments including massage therapy. Cosmetic surgery and related services and supplies; surgery is covered if the surgery is to correct the effects of birth defects, accidental injury, or reconstructive procedures to replace diseased tissue. (Benefits must be precertified.) Surgery for the removal of excess skin is considered cosmetic and is not covered under the plan. Counseling. (See the Employee Assistance and Mental Health & Substance Abuse Services section.) Custodial care or respite cures. Dental procedures except those specifically listed as a covered expense under this plan; including surgical removal of bony-impacted teeth (all associated charges, such as professional fees, anesthesia, inpatient or outpatient facility charges). Dependent child pregnancy - expenses for the newborn child, unless the newborn is legally adopted by the employee or the employee obtains legal guardianship within 30 days of date of birth. (Maternity expenses for the eligible dependent daughter are covered.) Durable medical equipment exclusions: Durable medical equipment that is primarily for convenience and/or comfort; modifications to motor vehicles and/or homes such as wheelchair lifts or ramps; water therapy devices such as jacuzzis, hot tubs, swimming pools or whirlpools; exercise and massage equipment; electric scooters; hearing aids; air conditioners; humidifiers; water purifiers; pillows, mattresses or waterbeds; escalators, elevators or stair glides; emergency alert equipment; handrails; heat appliances; and dehumidifiers. (See Durable medical equipment in the Covered Expenses list.) Educational treatment including reading clinics and special schools for mentally retarded or behaviorally impaired individuals. Elective abortion procedures. Experimental and/or investigational services and/or unproven services or supplies and any related expenses as determined by UHC, except as otherwise covered under the bone marrow transplant provision of the transplant services. (See Transplants in the Covered Expenses list.) Eyeglasses or contact lenses and examinations except following cataract surgery or to treat keratoconus. Fertility treatments including drugs and charges for artificial insemination and in-vitro fertilization. Health check-ups, premarital examinations, and immunizations except those specifically listed in the Covered Expenses list. Hearing aids. Outpatient pre-operative and post-operative care in excess of that normally provided for surgery. Prescription drugs that are not covered under the Prescription Drug Program offered by Catalyst Rx (or Walgreens for mail order): HRI-SUBS Rev. 23 Page 114 of 205

115 UnitedHealthcare Standard and Choice Plus Plans Expenses Not Covered Drugs that may be purchased without a prescription (over-the-counter drugs). Fertility medications, injections, and treatments. Ostomy supplies (claims may be filed with UHC for reimbursement; subject to deductible and coinsurance). Therapeutic appliances or devices, support garments, or other non-medical items. Drugs covered by UHC, including those administered in an inpatient facility, physician s office or outpatient facility that are not usually self administered. Nicorette or other tobacco cessation products. Impotency drugs (such as Viagra, Caverject, and Muse) unless medically necessary due to an organic dysfunction; the attending physician must provide Catalyst Rx with written documentation certifying the medical necessity of the prescription; drugs are limited to a six-dose per month maximum. Growth hormones unless the attending physician provides Catalyst Rx with written authorization certifying the medical necessity of the prescription. Anorexiant and anti-obesity drugs (unless for morbid obesity). Refills beyond one year of original prescription date (six months for controlled drugs). Experimental or investigational drugs. Drugs used for cosmetic purposes. Drugs covered under Workers Compensation or any other federal or state program. To determine if a specific drug is covered, you should contact Catalyst Rx. For questions regarding having a prescription filled, call: Catalyst Rx Customer Service Walgreens (Mail order) Customer Service Refills Prescription drug claims cannot be filed with UHC and the copayments and coinsurance do not apply to the deductible or out-of-pocket limits. (See Prescription drugs in the Covered Expenses list.) Private duty nurses for inpatient hospital care. Refractory procedures including charges for any procedure performed for the purpose of correcting myopia, hyperopia, or astigmatism, and expenses related to such procedures. Reversal of sterilization procedures. Routine foot care or podiatry including treatment of toenails, bunions, corns, calluses, fallen arches, flat feet, weak feet, chronic foot strain or over-the-counter shoe inserts. Routine hearing examinations except those included as part of a wellness/preventive exam. Speech therapy for problems not caused by illness, injury or congenital anomaly. (See Therapy in the Covered Expenses list.) Temporomandibular joint syndrome (TMJ) treatment; except those charges specifically listed under covered expenses. Other TMJ charges may be eligible for coverage under the Progress Energy-sponsored dental plan. Charges for oral surgery and appliances may be eligible for coverage under the Progress Energy-sponsored dental plan. After individual consideration and review of the patient s history, expenses may not be covered if treatment is deemed not medically necessary or when diagnostic tests and procedures proposed do not meet the medical criteria. HRI-SUBS Rev. 23 Page 115 of 205

116 UnitedHealthcare Standard and Choice Plus Plans Expenses Not Covered Transportation except for ambulance service authorized by UHC or under the United Resource Network. Treatment or regimen, medical or surgical, for the purpose of reducing or controlling the weight of a member or for treatment of obesity, except for surgical treatment of morbid obesity when medically necessary and medical criteria is met. (See Bariatric surgery in the Covered Expenses list.) Weight reduction procedures designed to restrict your ability to assimilate food (such as gastric bypass, gastric balloons, jaw wiring, and stomach stapling) unless medically necessary. (See Bariatric surgery in the Covered Expenses list.) Wigs and/or cranial prostheses. HRI-SUBS Rev. 23 Page 116 of 205

117 AvMed and BlueCare HMO Plans AUTHORIZED COPY AvMed and BlueCare HMO Plans A Health Maintenance Organization (HMO) is a health care plan that provides comprehensive medical services through access to a coordinated system of health care delivery. You choose a primary care physician (PCP) for yourself and each covered member of your family from the HMO provider network. Your PCP coordinates your health care and arranges services received from hospitals, specialists, and other health professionals. You must use the physicians and facilities associated with the HMO network to receive benefits. Services received from non-hmo providers are not covered unless the services meet the emergency or urgent care criteria. Enrollment Eligibility To participate in either AvMed HMO or BlueCare HMO, you and your dependents must (1) meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section), (2) live or work in areas where participating providers are located (service areas listed below); and (3) be either: An active regular, full-time employee including eligible dependent (regardless of Medicare status). A non-medicare eligible retiree including non-medicare eligible dependent. A non-medicare eligible LTD recipient including non-medicare eligible dependent. A non-medicare eligible surviving dependent including non-medicare eligible dependent. HMO Network Service Areas AvMed HMO is available in the following FL counties: Alachua, Baker, Bradford, Broward, Citrus, Clay, Columbia, Miami-Dade, Dixie, Duval, Gilchrist, Hamilton, Hernando, Hillsborough, Lee, Levy, Manatee, Marion, Nassau, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole, St. Johns, Suwannee, and Union counties. In addition, employees living in the following Lake County zip codes are eligible: 34736, 34711, 34712, 34713, 34714, 34715, and BlueCare HMO is available in the following FL counties: Alachua, Baker, Bradford, Brevard, Broward, Charlotte, Citrus, Clay, Columbia, Miami-Dade, DeSoto, Dixie, Duval, Escambia, Flagler, Gilchrist, Hendry, Hernando, Hillsborough, Lake, Lee, Levy, Manatee, Marion, Martin, Nassau, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter, Suwannee, Volusia, and Walton counties. Medical and Prescription Drug ID Card If you enroll in either the AvMed HMO Plan or the BlueCare HMO option, you will receive a medical ID card but will not receive a separate prescription drug ID card. To purchase covered drugs at participating pharmacies, present your medical ID card to the pharmacist. The medical ID card should be presented to your physician and all other health care providers whenever services are received. HRI-SUBS Rev. 23 Page 117 of 205

118 AvMed HMO Plan 2012 AVMED HMO PLAN SUMMARY CHART This option pays 100% for adult or child wellness charges at participating physicians offices. Each member selects a primary care physician (PCP) from the AvMed network and all health care must be arranged by the PCP except in-network OB/GYN care. Copays apply to most services listed below. Deductible and coinsurance apply to out-of-network (OON) second surgical opinions, hospitalization, surgery and outpatient services as listed below. Most OON services are not covered. This chart is not all inclusive; you should contact AvMed for questions regarding coverage. Note: Copays, coinsurance and deductible shown are amounts paid by participant. Plan Provisions In-Network Choice of physician Each member selects PCP from AvMed network. All health care arranged by PCP except in-network OB/GYN care. Annual deductible 1 $500 individual/$1,000 family Annual out-of-pocket limit 2 $1,500 individual/$3,000 family Maximum lifetime plan benefit Unlimited The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Adult screenings Periodic health assessments and immunizations Well child care Covered at 100% Covered at 100% Covered at 100% Preventive dentistry Not covered Vision care Discounts available through Visionworks, For Eyes & CompBenefits. Mental health and substance abuse services 3 (services See the Mental Health & Substance Abuse Summary Chart. provided through ValueOptions and must be pre-certified) Prescription drugs at participating pharmacies 4 AvMed Medco Retail (up to 30 days) Mail Order (up to 90 days) Generic Preferred Brand Name $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) Non-Preferred Brand Name 30% coinsurance $125 copay ($50 minimum; $75 maximum) Copays, not coinsurance and deductible, apply to all services below except approved OON second surgical opinions: Physician's services Office visits Minor surgical procedures Second surgical opinion Urgent care center Emergency services Occupational/physical/speech therapy $25 PCP copay; $50 Specialist copay 5 $25 PCP copay; $50 Specialist copay 5 (in doctor's office) $25 PCP copay; $50 Specialist copay 5 in network; 40% coinsurance out-of-network (approval required for out-ofnetwork second surgical opinions) $40 copay in-network/$60 copay out-of-network $150 copay (waived if admitted) $20 copay; limited to 30 visits per calendar year for all therapy services combined $25 copay Spinal manipulation Once the deductible is met, coinsurance applies for most charges and copays applicable to some charges below: Hospital inpatient services Inpatient services (semi-private room, lab, x-ray) 20% of the contracted rate after deductible Providers (physician, specialist, surgeon, radiologist, 20% of the contracted rate after deductible anesthesiologist & pathologist) HRI-SUBS Rev. 23 Page 118 of 205

119 Outpatient services Outpatient facility fee Outpatient surgery Providers (physician, specialist, surgeon, radiologist, anesthesiologist, & pathologist, ) Laboratory tests Non-preventive diagnostic imaging tests (x-rays, etc.) MRI, PET, CAT Scans Therapeutic services (drug infusion therapy, etc.) Ambulance Maternity Delivery Pre/post delivery exams Durable medical equipment AUTHORIZED COPY AvMed HMO Plan 20% of the contracted rate after deductible 20% of the contracted rate after deductible 20% of the contracted rate after deductible $0 $10 copay/per test $25 copay $100 copay $100 copay; non-emergent covered when authorized 20% of the contracted rate after deductible $25 copay initial visit 20% of the contracted rate after deductible (benefits limited to $2,000/calendar year) 1. The annual deductible does not apply toward the annual out-of-pocket limit. 2. The annual out-of-pocket limit includes copayments and coinsurance amounts unless otherwise excluded. 3. Services are provided through ValueOptions and must be pre-certified. 4. The AvMed HMO Plan includes mandatory generic requirement for all prescriptions. If you or your physician request or require a brand name drug when a generic drug is available, you will be responsible for paying the cost difference between the brand name and generic drug plus the brand name copayment. This provision will apply even if the prescribing physician indicates on the prescription brand name medically necessary or dispense as written. Certain injectable drugs have a $75 copayment. Contact AvMed Member Services Department at AvMed for details. Prior review or certification is required for some drugs. 5. Additional charges will apply if outpatient diagnostic tests are performed in the Specialist s office. HRI-SUBS Rev. 23 Page 119 of 205

120 BlueCare HMO Plan 2012 BLUECARE HMO PLAN SUMMARY CHART This option pays 100% for adult or child wellness charges at participating physicians offices. Each member selects a primary care physician (PCP) from the BlueCare network and certain health care must be arranged by the PCP. Copays apply to most services listed below. Deductible and coinsurance apply to other services including out-of-network (OON) second surgical opinions, hospitalization, surgery and outpatient services as listed below. Most OON services are not covered. This chart is not all inclusive; you should contact BlueCare for questions regarding coverage. Plan Provisions Copays, coinsurance and deductible shown are amounts paid by participant. Choice of physician Each member selects PCP from BlueCare network. Certain health care arranged by PCP. Annual deductible $500 individual/$1,000 family Annual out-of-pocket limit 1 Maximum lifetime plan benefit The annual deductible does not apply to the following: Preventive care (primary diagnosis must be wellness) Adult screenings Periodic health assessments and immunizations Well child care Preventive dentistry Vision care Mental health & substance abuse services 2 Prescription drugs at participating pharmacies 3, 4 Generic Preferred Brand Name $2,000 individual/$4,000 family Unlimited Covered at 100% Covered at 100% Covered at 100% Not covered Discounts available through Davis Vision See the Mental Health & Substance Abuse Summary Chart. BlueCare Prim Retail (up to 30 days) Mail Order (up to 90 days) $10 copay $25 copay 20% coinsurance $75 copay ($25 minimum; $50 maximum) 30% coinsurance $125 copay ($50 minimum; $75 maximum) Non-Preferred Brand Name Copays, not coinsurance and deductible, apply to all services below except approved OON second surgical opinions: Physician's services Office visits Surgery (in-office) Second surgical opinion Providers (radiologist, anesthesiologist, pathologist) Urgent care center Emergency services Occupational/physical/speech/massage/cardiac therapy Chiropractic services (spine & back disorder treatment) $25 PCP; $50 Specialist $25 PCP; $50 Specialist $50 Specialist in network; 40% coinsurance OON $0 $50 copay $150 copay per visit-waived if admitted (members need to coordinate care with their PCP) $5 copay (62 days from first date services are rendered) $50 copay (maximum benefit of four modalities per day and annual maximum of 26 spinal manipulations) Once the deductible is met, coinsurance applies for most charges and copays applicable to some charges below: Hospital in-patient services In-patient services (semi-private room & board, lab & x-ray) 20% after deductible Providers (physician, surgeon, radiologist, anesthesiologist & $0 pathologist) In-patient (physical, speech, cardiac or occupational services) 20% after deductible Outpatient services Outpatient facility fee (hospital and/or ambulatory surgical center) 5 20% after deductible HRI-SUBS Rev. 23 Page 120 of 205

121 Outpatient surgery 5 Providers (physician, specialist, surgeon, radiologist, anesthesiologist, pathologist) Diagnostic laboratory tests X-rays MRI, MRA, PET, CAT scans & nuclear medicine Out-patient (physical, speech, cardiac or occupational services) AUTHORIZED COPY BlueCare HMO Plan 20% after deductible $0 $0 $0 20% after deductible 6 /$50 copay 6 $5 copay at an out-patient rehab facility or out-patient hospital Ambulance $0 Maternity Delivery Pre/post delivery exams 20% after deductible $25/$50 copay initial visit Durable medical equipment Motorized wheelchair $0 $500 copay plus 20% no deductible 1. The annual out-of-pocket limit includes the annual deductible, coinsurance and copays. 2. Services are provided through ValueOptions and must be pre-certified. 3. Prior review or certification is required for some drugs. 4. When a BlueCare member chooses to fill a brand name prescription when a lower cost generic equivalent is available, the member pays the brand copay and the cost difference between the brand name and generic drug (unless the provider has indicated on the prescription that the brand name prescription drug is medically necessary). 5. The 20% coinsurance after deductible is charged if services are rendered in an outpatient hospital setting or ambulatory surgical center. 6. The 20% coinsurance after deductible is charged if services are rendered in an outpatient hospital setting or ambulatory surgical center. Services rendered in a free-standing outpatient diagnostic facility (i.e., Advance Imaging Center) will apply the appropriate copay only. HRI-SUBS Rev. 23 Page 121 of 205

122 How the HMO Plans Work AUTHORIZED COPY AvMed and BlueCare HMO Plans When enrolling with an HMO, you must choose a primary care physician (PCP) for yourself and each eligible member of your family from the HMO provider network. You may choose a different PCP for each eligible member of your family. You should contact the PCP to make sure he or she is accepting new patients and is in the HMO network. Primary care physicians can be family physicians, internists, or pediatricians. Female patients may see, in addition to their regular PCP, an OB/GYN for prenatal and gynecological care. The OB/GYN must be a member of the HMO provider network. Your PCP coordinates your health care and arranges services received from hospitals, specialists, and other health professionals. You must use the physicians and facilities associated with the HMO network to receive benefits. Services received from non-hmo providers are not covered unless the services meet the emergency or urgent care criteria. Selecting or changing a PCP If you need help in selecting or changing a PCP, call the applicable HMO or visit the HMO website. For additional information, see Choosing HMO Primary Care Providers under Other Participant Notices of the Other Important Information section below. If your PCP should leave the HMO network, you will be notified and will need to select a new PCP. A physician leaving the network is not a qualifying event to allow you to change your medical election during the year. Services received outside of the HMO service areas Services received from non-hmo providers are not covered unless the services meet the emergency or urgent care criteria. If you are traveling Services received from non-hmo providers are not covered unless the services meet the emergency or urgent care criteria. If your child attends school out of state Services received from non-hmo providers are not covered unless the services meet the emergency or urgent care criteria. Prescription drugs The copays for prescription drugs under the HMO plans are based on the coverage provisions of each HMO. You should check with your HMO provider if you have any questions about the prescription drug copays, generic requirements, or coverage eligibility. Summary prescription drug information is provided on the Benefit Summary for each HMO. Questions For questions you may have regarding benefits provided under AvMed HMO and BlueCare HMO, contact the HMO provider you have selected for your benefit coverage: HMO Provider Telephone Number AvMed HMO BlueCare HMO HRI-SUBS Rev. 23 Page 122 of 205

123 AvMed and BlueCare HMO Plans If you are enrolled in an HMO, you may request a Certificate of Coverage from the HMO describing the services and exclusions of that HMO. Such documents are hereby incorporated by reference and made a part of this SPD. You should review this material carefully, since fully-insured HMOs are subject to state regulations that may supersede provisions of the plan that are otherwise generally applicable. HRI-SUBS Rev. 23 Page 123 of 205

124 Employee Assistance Program and Mental Health & Substance Abuse Services Section Contents EAP and MHSA Services Plan Employee Assistance Program Pgs ValueOptions Enrollment Eligibility 125 EAP ID Card 125 EAP Summary Chart 126 How the EAP Works 127 Questions 127 Mental Health & Substance Abuse Pgs Services ValueOptions (applies to Standard, Choice, Choice Plus, AvMed HMO and BlueCare HMO Plans) Enrollment Eligibility 128 ValueOptions ID Card 128 ValueOptions Summary Chart 129 How the ValueOptions Services Work 131 Questions 132 Covered Expenses 133 Expenses Not Covered 133 Mental Health & Substance Abuse Pgs Services BCBS/Magellan (applies to HDHP only) Enrollment Eligibility 136 BCBS/Magellan ID Card 136 BCBS/Magellan Summary Chart 137 How the BCBS/Magellan MHSA Services 138 Work Questions 139 Covered Expenses 140 Expenses Not Covered 140 HRI-SUBS Rev. 23 Page 124 of 205

125 Employee Assistance Program and Mental Health & Substance Abuse Services Employee Assistance Program - ValueOptions Employee Assistance Program ValueOptions The Employee Assistance Program (EAP) administered by ValueOptions is available to you and all members of your household. The EAP can assist you and your family to address personal issues such as stress, grief, legal and financial matters, substance abuse, marital and family difficulties that may be affecting you. ValueOptions provides confidential assessments, short-term counseling, treatment referrals, legal and financial services linkage, and treatment monitoring under the EAP. You do not have to be enrolled in a Progress Energy-sponsored medical plan to be eligible for EAP services. The EAP is a pre-paid benefit. If there is a recommendation for treatment beyond the EAP benefit limits, you and your dependents would need to utilize mental health and/or substance abuse (MHSA) benefits. Enrollment Eligibility To participate in the EAP, you must meet the Progress Energy-sponsored EAP criteria (see the Eligibility section). Enrollment is automatic; it does not require an election. EAP ID Card Identification cards are not issued. You must contact ValueOptions at for precertification prior to obtaining services. HRI-SUBS Rev. 23 Page 125 of 205

126 Employee Assistance Program and Mental Health & Substance Abuse Services Employee Assistance Program - ValueOptions Employee Assistance Program Summary Chart Administered by ValueOptions for all Progress Energy employees/retirees and household members In-Network Up to five in-network visits per issue - covered at 100% Benefits are not available Out-of-Network Precertification required 1 Services include: Counseling for marital, family, parental or other relational concerns, Occupational concerns, Work-life balance, Legal and financial assistance If there is a recommendation for treatment beyond the EAP benefit limits, you and your dependents would need to utilize MHSA benefits. 1. To obtain precertification, call ValueOptions at This summary is not a contract and contains only a general description of the plan. All benefits are subject to the terms and conditions of the respective plan documents. HRI-SUBS Rev. 23 Page 126 of 205

127 How the EAP Works AUTHORIZED COPY Employee Assistance Program and Mental Health & Substance Abuse Services Employee Assistance Program - ValueOptions Access to counseling You may request counseling services for yourself or members of your household. You should call ValueOptions directly at to precertify services and to set up an appointment with a counselor. You may also speak with a counselor by phone. In case of an emergency, a ValueOptions staff clinician can be reached 24 hours a day, seven days a week by calling this number. The EAP counselor will assess your personal issue and then assist in developing a plan of action to address the issue. Short-term confidential counseling is provided through ValueOptions for all types of personal issues, such as marital and family issues, drug and alcohol abuse, financial difficulties, mental health concerns, career and employment concerns, parenting issues, etc. Follow-up, including consultation and treatment monitoring, will be provided as needed. The EAP benefit is a five-session model (per issue or different problem per member) and is at no cost to the member. To access this benefit and other EAP services, call the plan s toll-free access number. A ValueOptions Clinical Care Manager will assess and refer you to an EAP Affiliate provider. There is no out-of-network EAP benefit. Fitness for Duty (FFD), Department of Transportation (DOT) and Nuclear Regulatory Commission (NRC) evaluations Based on Progress Energy s requirement to comply with provisions of the Nuclear Regulatory Commission or the Department of Transportation, ValueOptions may also assist in identifying cases that require compliance reporting and specialized treatment resources for FFD, DOT and NRC evaluations. Through this process ValueOptions may additionally require case monitoring or other recommended services. Confidentiality Conversations and visits with the ValueOptions EAP staff are strictly confidential. Information shared with ValueOptions cannot be disclosed unless a release is signed, except in limited circumstances as described below. Information may be provided without a release in the following circumstances: If information is disclosed that ValueOptions considers imminently life threatening to you or others, ValueOptions will take prudent steps to prevent the threatened danger. If instances of juvenile or elder care abuse or neglect are disclosed, state law may require that this information be reported to the appropriate state office. When you are within the scope of the NRC Fitness for Duty rule and it has been determined that your condition constitutes a hazard to yourself or others or that your security privileges requires additional assessment, ValueOptions is required to disclose this information to your employer's EAP staff, who will report it to your management. Pursuant to a subpoena, court order, regulatory order, or as otherwise required by law. Questions For questions regarding the Employee Assistance Program, call ValueOptions at HRI-SUBS Rev. 23 Page 127 of 205

128 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions Mental Health and Substance Abuse Services ValueOptions The mental health and substance abuse (MHSA) services administered by ValueOptions are available to you and your eligible dependents who are covered in any of the Progress Energy-sponsored medical plans except for the HDHP. If covered by the HDHP, refer to the section below regarding MHSA services administered by Magellan Behavioral Health. ValueOptions has an extensive network of mental health and substance abuse providers. To receive mental health and substance abuse services for participants enrolled in the Standard, Choice, Choice Plus, AvMed HMO and BlueCare HMO medical plan options, call ValueOptions at Enrollment Eligibility To receive MHSA services administered by ValueOptions, you must meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section) and be enrolled in the Standard, Choice, Choice Plus, AvMed HMO or BlueCare HMO medical plan option. ValueOptions ID Card You will not receive a ValueOptions identification card. Simply contact ValueOptions prior to receiving services. HRI-SUBS Rev. 23 Page 128 of 205

129 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions 2012 EAP AND MENTAL HEALTH & SUBSTANCE ABUSE SERVICES SUMMARY CHART ADMINISTERED BY VALUEOPTIONS (applies to the Standard medical plan options) Services In-Network Out-Of-Network 1 Employee Assistance Up to five visits (per issue) Not covered Precertification required 2 covered at 100% MHSA Annual deductible None None Annual out-of-pocket limit 3 $1,500 individual $3,000 family (integrated with medical) Maximum lifetime plan benefit Unlimited (integrated with medical) Unlimited (integrated with medical) Outpatient routine mental health & substance abuse office visit Coinsurance 20% coinsurance 40% coinsurance Inpatient mental health & substance abuse and outpatient higher levels of care 4, 5 Coinsurance Precertification required 2 20% coinsurance Yes 40% coinsurance Yes 1 Covered services received from an out-of-network provider will be subject to usual and customary limits. 2 To obtain precertification, call ValueOptions at Out-of-pocket limit includes coinsurance for mental health and substance abuse services and deductible and coinsurance for medical expenses. 4 Precertification is required for all inpatient and residential mental health and substance abuse treatment and certain outpatient levels of care or professional services including structured outpatient treatment, intensive outpatient treatment, ambulatory detox, home care, ECT treatment, methadone maintenance, suboxone treatment, biofeedback, hypnotherapy and all psychological testing by calling ValueOptions at If precertification is not obtained and a claim is filed, the claim will be denied. Services can be appealed by the member. A retrospective review process will be completed by ValueOptions to review the medical necessity of rendered services. If incurred services are approved, the claim can then be processed and paid under the out-of-network benefit. HRI-SUBS Rev. 23 Page 129 of 205

130 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions 2012 EAP AND MENTAL HEALTH & SUBSTANCE ABUSE SERVICES SUMMARY CHART ADMINISTERED BY VALUEOPTIONS (applies to the AvMed HMO, BlueCare HMO, Choice and Choice Plus medical plan options) Services In-Network Out-Of-Network 1 Employee Assistance Up to five visits (per issue) Not covered Precertification required 2 covered at 100% MHSA Annual deductible None None Annual out-of-pocket limit 3 $1,500 individual $3,000 family Maximum lifetime plan benefit Outpatient routine mental health & substance abuse office visit (integrated with medical) Unlimited (integrated with medical) Unlimited (integrated with medical) Copay/coinsurance $25 copay 40% coinsurance Inpatient mental health & substance abuse and outpatient higher levels of care 4, 5 Coinsurance Precertification required 2 20% coinsurance Yes 40% coinsurance Yes 1 Covered services received from an out-of-network provider are subject to usual and customary limits. 2 To obtain precertification, call ValueOptions at Out-of-pocket limit includes coinsurance and copays for mental health and substance abuse services and deductible and coinsurance for medical expenses. 4 Precertification is required for all inpatient and residential mental health and substance abuse treatment and certain outpatient levels of care or professional services including structured outpatient treatment, intensive outpatient treatment, ambulatory detox, home care, ECT treatment, methadone maintenance, suboxone treatment, biofeedback, hypnotherapy and all psychological testing by calling ValueOptions at If precertification is not obtained and a claim is filed, the claim will be denied. Services can be appealed by the member. A retrospective review process will be completed by ValueOptions to review the medical necessity of rendered services. If incurred services are approved, the claim can then be processed and paid under the out-of-network benefit. HRI-SUBS Rev. 23 Page 130 of 205

131 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions How the ValueOptions MHSA Services Work ValueOptions role in administering these services includes conducting a brief assessment, providing referrals, certifying care based on medical necessity, and processing claims. ValueOptions clinical staff collects only that information necessary to determine before, during or after services are furnished that proposed treatment is medically necessary. To receive mental health and substance abuse services, you should call ValueOptions at before beginning treatment. For emergency services, you may call at any time. ValueOptions is staffed by trained professionals 24 hours a day, seven days a week. When you call, a customer service representative will ask you to provide background information including a brief description of the concern, the patient's name and the employee's name and Social Security number. Then you'll be connected with a clinical care manager who will assist you (or the family member) in obtaining the right kind of professional assistance with the appropriate type of provider. Precertification of treatment is a requirement for admission to an inpatient facility, residential treatment center, partial hospitalization program, or an intensive outpatient program or for outpatient treatment. If selected, out-of-network benefits are available and likewise require precertification under the plan. These benefits are paid under the out-of-network benefit schedule. In case of emergency A mental health or substance abuse emergency is a condition in which the patient is a danger to him or herself or others. If an emergency arises and you cannot call ValueOptions, go immediately to any convenient hospital emergency facility. If you are admitted to the hospital on an emergency basis, you must call ValueOptions at within 48 hours of admission to the hospital. If you cannot call, have a family member, friend or the hospital make the call. If ValueOptions is not notified of an out-of-network admission, claims will be denied and your provider can file an appeal. After being stabilized, a patient who is admitted to an out-of-network facility in an emergency situation may be asked to transfer to an in-network facility for continuing treatment. Copayments and coinsurance The outpatient benefit applies a $25 copayment/20% coinsurance per authorized visit for all in-network outpatient mental health/substance abuse visits. Out-of-network outpatient mental health/substance abuse visits are subject to coinsurance of 40% of the provider s usual and customary rates, plus any amount above usual and customary rates. The inpatient benefit applies 20% coinsurance per authorized visit for all in-network inpatient mental health/substance abuse visits. Out-of network inpatient mental health/substance abuse visits are subject to coinsurance of 40% of the provider s usual and customary rates, plus any amount above usual and customary rates. Providers Outpatient mental health and substance abuse treatment is covered if the provider is either a psychiatrist, a psychologist, or master s level clinician who is licensed to practice independently without supervision. ValueOptions will certify services with Developmental Behavioral Pediatricians (medical doctors and pediatricians) who have completed a three-year fellowship in developmental behavioral pediatrics to provide outpatient services to members who are 18 and under. A higher level of benefits will apply if the treatment is precertified by ValueOptions and a network provider is seen. HRI-SUBS Rev. 23 Page 131 of 205

132 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions Usual and customary (U&C) limits U&C limits will apply to covered services received from an out-of-network provider or outpatient treatment that is not precertified. Usual and customary is the rate most providers typically charge for that service in that geographic area under similar circumstances. Benefits will not be paid for any amount over the usual and customary limit. Confidentiality All services provided by ValueOptions and all provider treatments are on a strictly confidential basis. Except as required by law, ValueOptions will not disclose to anyone that you have inquired about mental health or substance abuse benefits or are seeking or receiving treatment, unless a release is signed. However, in the following circumstances information may be provided without a release: If information is disclosed that ValueOptions considers imminently life threatening to you or others, ValueOptions will take prudent steps to prevent the threatened danger. If instances of juvenile or elder care abuse or neglect are disclosed, state law may require that this information be reported to the appropriate state office. If in the course of a clinical review and after-care planning it is recommended that the employee not return to a safety-sensitive or regulated employment position, the employee and/or ValueOptions will need to advise Progress Energy EAP. Pursuant to a subpoena, court order, regulatory order, or as otherwise required by law. Questions Call ValueOptions at for questions regarding the mental health and substance abuse services (except participants in the HDHP). HDHP participants should refer to the section below regarding MHSA services administered by Magellan Behavioral Health. Precertification Inpatient and alternative levels of mental health and substance abuse treatment must be precertified by ValueOptions to be covered. Precertification of essential care can be completed by calling ValueOptions at Methadone and or Suboxone Substance Abuse treatment requires precertification. Both are considered under the outpatient benefit. Pre-approval required The following services require pre-approval by ValueOptions even if treatment has already been recommended. For example, your therapist or hospital may have received approval to begin treatment; however, you must also get preapproval from ValueOptions to assure coverage for any of the specialized services listed below: Psychological testing Biofeedback Hypnotherapy Sodium amytal interviews Electroconvulsive therapy Consultations by another mental health professional (except emergencies) HRI-SUBS Rev. 23 Page 132 of 205

133 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions Covered Expenses Treatment services for psychiatric and substance abuse conditions are provided and include those listed below. This list may not be all-inclusive; contact ValueOptions for questions regarding coverage. Acute inpatient treatment, including substance abuse detoxification and rehabilitation Residential treatment centers Partial hospitalization programs Intensive outpatient programs Outpatient treatment with licensed providers including psychiatrists, psychologists, clinical social workers, psychiatric nurses, and licensed professional counselors Methadone maintenance or substance abuse treatment with use of Suboxone Medically necessary services are those that are: Intended to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable condition (ICD-9 or DSM-IV-TR) that threatens life, causes pain or suffering, or results in illness or infirmity. Expected to improve an individual s condition or level of functioning. Individualized, specific, and consistent with symptoms and diagnosis, and not in excess of patient s needs. Essential and consistent with nationally acceptable standard clinical evidence generally recognized by mental health or substance abuse care professionals or publications. Reflective of a level of service that is safe, where no equally effective, more conservative, and less costly treatment is available. Not primarily intended for the convenience of the recipient, caretaker, or provider. No more intensive or restrictive than necessary to balance safety, effectiveness, and efficiency. Not a substitute for non-treatment services addressing environmental factors. Expenses Not Covered The following services are not covered. This list may not be all-inclusive; contact ValueOptions for questions regarding coverage. Acupuncture. Accommodations, services, supplies, or other items determined as neither clinically nor medically necessary. Administrative psychiatric services when these are the only services rendered. Any service or supply listed under general exclusions of the medical plan. Any testing, evaluation, consultation, therapy, service, treatment or supplies that are covered as benefits under the medical plan. Autism Spectrum Disorder with the exception of brief diagnostic and evaluation services and co-morbid outpatient Medication Management Services. For this condition under the HMO plans, please call your customer services benefits center for additional details. (Note: FL law covers these under medical services.) Bioenergetics therapy. Carbon dioxide therapy. Chart review. Confrontation therapy. Consultation with a mental health professional for adjudication of marital, child support, or custody cases. Crystal healing treatment. Cult deprogramming. Custodial care. Durable medical equipment for light box or photo-stimulation therapy. Eating disorder and gambling programs based solely on the 12-step model. HRI-SUBS Rev. 23 Page 133 of 205

134 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions Expenses Not Covered Educational evaluation testing, consultations, therapy, rehabilitation, remedial education, services, supplies or treatment for developmental disabilities, communication disorders, or learning disabilities regardless of any cost to the beneficiary or if the beneficiary takes advantage of such services. Educational treatment including reading clinics and special schools for mentally retarded or behaviorally impaired individuals. Environmental ecology treatment. EST (Erhard) or similar motivational services. Examinations or treatments exclusively required as a part of a legal proceeding or a court order if not medically necessary. Experimental or investigative treatments. Expressive therapies (art, poetry, movement, psychodrama) as separately billed services. Guided imagery. Hemodialysis for schizophrenia. Hyperbaric or normobaric oxygen therapy. Items specifically for personal comfort, hygiene or convenience, such as television, telephone, or private room for inpatient care; housekeeping, homemaker or meal services for outpatient care. L-Tryptophan and vitamins, except thiamine injections on admissions for alcoholism or with a diagnosis of nutritional deficiency. Marathon therapy. Megavitamin therapy, nutritional formulas, food supplements, or special diets. Narcotherapy with LSD. Orthomolecular therapy. Outpatient or over-the-counter medications or prescriptions. Pervasive Developmental Disorders, except for co-morbid psychiatric illness. Primal therapy. Private duty nursing. Private rooms (except when required for infection control). Psychological camps for treatment of ADHD or weight management. Psychological testing, except when pre-certified as medically necessary. Rolfing. Sedative action electrostimulation therapy. Sensitivity training. Services not authorized by ValueOptions. Sex therapy (without a DSM IV diagnosis). Speech therapy. Substance dependency treatment programs not using a medical model detox protocol (if indicated) in collaboration with ASAM (American Society of Addiction Medicine) treatment protocol staging. Supervision of clinical treatment practitioners or team. Testing, evaluation, consultation, therapy, services, supplies, or treatment for personal or professional growth and development, professional licensure, certificate or registration. Testing, therapy, service, supplies, or treatment that does not meet national standards of mental health professional practice; or which have not been found to be efficacious or beneficial by quality review peer committees, evidenced in professional literature and available clinical information. Testing, therapy, service, supplies or treatment for conditions that are identified as by the DSM-IV as NOT being attributable to a mental disorder, but are conditions that may be the focus of clinical attention (i.e., V- Codes). Testing, therapy, service, supplies or treatment for organic disorders, dementia, primary neurological, neurodevelopmental, neuro-cognitive disorders, except for associated treatable and acute behavioral manifestations. HRI-SUBS Rev. 23 Page 134 of 205

135 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - ValueOptions Expenses Not Covered Therapy, services or treatment of autism spectrum disorders except for the initial diagnostic evaluation, medically necessary psychological testing and assessment/treatment of co-morbid/secondary covered conditions. Training analysis (Tuitional or Orthodox). Transcendental meditation. Transcranial Magnetic Stimulation (TMS). Travel, whether or not recommended or prescribed as part of treatment. Treatment for chronic, intractable pain at a pain control center or through a pain control program. Treatment of sexual addiction, co-dependency, or any other behavior that does not have a DSM IV diagnosis. Treatment or consultation provided via the telephone, electronic transmission, skype, or other non-in-person modalities, unless determined to be medically necessary. Vocational assessment/school assessment or psychotherapy in conjunction with a required educational program. Treatment or therapy for Worker s Compensation cases. Z therapy. HRI-SUBS Rev. 23 Page 135 of 205

136 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - BCBSNC/Magellan Mental Health and Substance Abuse Services for the HDHP BCBSNC/Magellan BCBSNC/Magellan administers the mental health and substance abuse services for participants enrolled in the High Deductible Health Plan. Its role under this plan includes conducting a brief assessment, providing referrals, certifying care based on medical necessity, and processing claims. BCBSNC/Magellan has an extensive network of mental health and substance abuse providers. To receive mental health and substance abuse services if enrolled in the HDHP, call Magellan for inpatient and outpatient facility services at Enrollment Eligibility To receive MHSA services administered by BCBSNC/Magellan, you must meet the Progress Energy-sponsored medical plan eligibility criteria (see the Eligibility section) and be enrolled in the HDHP. BCBS/Magellan ID Card You will receive a BCBSNC identification card but not a separate Magellan identification card. You should contact Magellan prior to receiving services. HRI-SUBS Rev. 23 Page 136 of 205

137 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - BCBSNC/Magellan 2012 EAP AND MENTAL HEALTH & SUBSTANCE ABUSE SERVICES SUMMARY CHART BCBSNC/MAGELLAN (applies to the HDHP) Services In-Network Out-Of-Network 2 Outpatient mental health & substance abuse Administered by Magellan Behavioral Health Inpatient mental health & substance abuse Administered by Magellan Behavioral Health Deductible Out-of-pocket maximum Precertification from Magellan required for outpatient facilities 1 100% after deductible Unlimited office visits Precertification required 1 100% after deductible No lifetime maximum on number of days 100% of allowed amount after deductible Unlimited office visits 100% of allowed amount after deductible No lifetime maximum on number of days Integrated with medical/prescription drugs and applied to the HDHP deductible of $2,500 self only/$5,000 self plus one or family (in- or out-ofnetwork) Integrated with medical/prescription drugs and applied to the HDHP outof-pocket maximum of $2,500 self only/$5,000 self plus one or family (inor out-of-network) Lifetime plan maximum Unlimited Employee Assistance Program (EAP) Up to five in-network visits per issue are covered at 100%. Not covered Precertification required Administered by ValueOptions These services include counseling for family, child, and work-life issues. Legal and financial assistance is available as well. For more information, contact ValueOptions at If covered services are received from in-network providers but precertification is not obtained from Magellan, the services will be considered out-of-network and subject to allowed amount limits. 2 Covered services received from an out-of-network provider or treatment that is not precertified will be subject to allowed amount limits. Charges in excess of allowed amount limits will be the responsibility of the employee. HRI-SUBS Rev. 23 Page 137 of 205

138 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - BCBSNC/Magellan How the BCBSNC/Magellan MHSA Services Work When you need inpatient or outpatient facility mental health or substance abuse treatment, you should call a Magellan Behavioral Health customer service representative at The Magellan Behavioral Health customer service representative will refer you to an appropriate in-network provider and will give you the information you need to receive services. To schedule an office visit, search for a participating provider on the BCBSNC website at and schedule your appointment directly with the provider. You do not need certification for office visits. You may also contact BCBS customer service for assistance in identifying a mental health professional. In order to receive in-network benefits for non-emergency inpatient and outpatient care: You or your provider must receive certification in advance from Magellan Behavioral Health, except for office visit services. You must go to a Blue or Magellan network provider. You should work with your doctor or other professional provider to make sure that certification has been obtained for partial day/night, intensive therapy, or inpatient services. See "Utilization Management." Contact Magellan Behavioral Health at for in-network certification. You must contact Magellan Behavioral Health at directly for inpatient or outpatient mental health and substance abuse services, either in or outside of North Carolina, to request prior review and receive certification, except for office visit services and in emergency situations. In the case of an emergency, please notify BCBS and/or Magellan as soon as reasonably possible, but in any case within 48 hours. Magellan is staffed by trained professionals 24 hours a day, seven days a week. When you call Magellan, a customer service representative will ask you to provide background information including a brief description of the concern, the patient's name, the employee's name and the member ID number. Then you'll be connected with a clinical care manager who will assist you (or the family member) in obtaining the right kind of professional assistance with the appropriate type of provider. Precertification of treatment is required for any admission to an inpatient or outpatient facility, residential treatment center, partial hospitalization program, or an intensive outpatient program or outpatient treatment. In-network facilities must be used. You may choose to go to an out-of-network provider without certification. You will be responsible for the difference between the allowed amount and the provider's full charge if you do not receive certification in advance from Magellan Behavioral Health for inpatient and outpatient services. Out of network benefit level You may choose to go to an out-of-network provider without certification. You will receive coverage at the out-ofnetwork benefit level and will be responsible for the difference between the allowed amount and the provider's full charge. In case of emergency A mental health or substance abuse emergency is a condition in which the patient is a danger to him or herself or others. If an emergency arises and you cannot call Magellan, go immediately to any convenient hospital emergency facility. If you are admitted to the hospital on an emergency basis, you must call Magellan at within 48 hours of admission to the hospital. If you cannot call, have a family member, friend or the hospital make the call. HRI-SUBS Rev. 23 Page 138 of 205

139 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - BCBSNC/Magellan Magellan must be notified within 48 hours of emergency admissions to both in-network and out-of-network facilities. If Magellan is not notified, you may be responsible for paying any charges over the allowed amounts in addition to the applicable deductible. After being stabilized, a patient who is admitted to an out-of-network facility in an emergency situation may be asked to transfer to a network facility for continuing treatment. Coinsurance and deductible After satisfying the deductible, in-network services are covered at 100%. Out-of-network services are subject to the deductible and then covered at 100% of the allowed amount. Providers Outpatient mental health and substance abuse treatment is covered if the provider is either a psychiatrist, psychologist, or master s level clinician who is licensed to practice independently without supervision. Magellan will certify services with Developmental Behavioral Pediatricians (medical doctors and pediatricians) who have completed a three-year fellowship in developmental behavioral pediatrics to provide outpatient services to members who are 18 and under. A higher level of benefits will apply if the treatment is precertified by Magellan and a network provider is seen. Allowed amounts Allowed amounts will apply to covered services received from an out-of-network provider or outpatient treatment that is not precertified. The allowed amount is the charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC. In the case of providers that have not entered into an agreement with BCBSNC, the allowed amount will be the lesser of the provider's actual charge or a reasonable charge established by BCBSNC using a methodology that is applied to comparable providers for similar services under a similar health benefit plan. Benefits will not be paid for any amount over the allowed amount limit. Confidentiality All services provided by Magellan and all provider treatments are on a strictly confidential basis. Except as required by law, Magellan will not disclose to anyone that you have inquired about mental health or substance abuse benefits or are seeking or receiving treatment, unless a release is signed. However, in the following circumstances information may be provided without a release: If information is disclosed that Magellan considers imminently life threatening to you or others, Magellan will take prudent steps to prevent the threatened danger. If instances of juvenile or elder care abuse or neglect are disclosed, state law may require that this information be reported to the appropriate state office. Pursuant to a subpoena, court order, regulatory order, or as otherwise required by law. Questions Call Magellan Behavioral Health at or BCBSNC Customer Service at for questions regarding the mental health and substance abuse services for participants enrolled in the HDHP. Precertification Inpatient and alternative levels of mental health and substance abuse treatment must be precertified by Magellan or will be considered out of network and subject to allowed amount limits. Methadone maintenance services require precertification. HRI-SUBS Rev. 23 Page 139 of 205

140 Employee Assistance Program and Mental Health & Substance Abuse Services MHSA Services - BCBSNC/Magellan Covered Expenses Office Visit Services Certification by Magellan Behavioral Health is not required for office visit services. The following professional services are covered when provided in an office setting: Evaluation and diagnosis Group therapy Individual and family counseling Medically necessary biofeedback and neuropsychological testing Outpatient Services Covered outpatient treatment services when provided in a mental health or substance abuse treatment facility include: Each service listed in this section under office visit services. Intensive therapy services (less than four hours per day and minimum of nine hours per week). Partial day/night hospitalization services (minimum of four hours per day and 20 hours per week). Inpatient Services Covered inpatient treatment services also include: Detoxification to treat substance abuse Semiprivate room and board Residential treatment facilities Medically necessary services are those that are: Intended to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable condition (ICD-9 or DSM-IV-TR) that threatens life, causes pain or suffering, or results in illness or infirmity. Expected to improve an individual s condition or level of functioning. Individualized, specific, and consistent with symptoms and diagnosis, and not in excess of patient s needs. Essential and consistent with nationally acceptable standard clinical evidence generally recognized by mental health or substance abuse care professionals or publications. Reflective of a level of service that is safe, where no equally effective, more conservative, and less costly treatment is available. Not primarily intended for the convenience of the recipient, caretaker, or provider. No more intensive or restrictive than necessary to balance safety, effectiveness, and efficiency. Not a substitute for non-treatment services addressing environmental factors. Expenses Not Covered Mental Health and Substance Abuse Services exclusions and limitations Counseling with relatives about a patient with mental illness, alcoholism, drug addiction or chemical dependency. Inpatient confinements that are primarily intended as a change of environment. Psychoanalysis. HRI-SUBS Rev. 23 Page 140 of 205

141 Dental Plan AUTHORIZED COPY Dental Plan UMR Important Dental Plan Info Pgs Primary and Secondary Coverage 142 Dental Premium Plan Pgs Enrollment Eligibility 144 Dental ID Cards 144 Dental Plan Coverage Options 144 Dental Premium Plan Summary Chart 145 How the Dental Premium Plan Works 146 Covered Expenses 147 Expenses Not Covered 149 HRI-SUBS Rev. 23 Page 141 of 205

142 Important Dental Plan Information AUTHORIZED COPY Dental Plan UMR Primary and Secondary Coverage If you and your eligible dependents are covered under this plan and another employer-sponsored dental plan, benefits under this plan will be coordinated with the other plan. Under coordination of benefits, the primary plan provides benefits until its limits are reached. Then the secondary plan provides benefits based on the amount not paid by the primary plan. Primary and secondary responsibility for a claim is usually determined as follows: The plan without a claims coordination provision is primary, and the plan with a claims coordination provision is secondary. When both plans have coordination provisions, the plan covering the active employee is primary and the plan covering a spouse or domestic partner of an active employee is secondary. A plan that covers an active employee or a dependent of an active employee is primary to a plan that covers the person as an inactive (retired or terminated) employee or as a dependent of an inactive employee. If a determination of responsibility cannot be made using the above guidelines, the plan that has covered the person the longest will be primary. Dependent Children If a dependent child is covered by two or more employer-sponsored plans, the "birthday rule" will apply unless there has been a divorce. Under the birthday rule, the plan of the parent whose birthday occurs first in the year is primary regardless of the year of birth. For example, the plan of the parent with a February birthday is primary to the parent with a May birthday. The father s plan will be primary if a plan does not contain the birthday rule. If there has been a divorce and the courts have assigned financial responsibility for a child s dental care to one parent, that parent s plan is primary. Otherwise, in the case of divorce: The plan of the parent with custody pays first, and the plan of the stepparent pays second. The plan of the parent without custody pays third (second if there is no stepparent or the stepparent does not participate in an employer-sponsored dental plan). How coordination of benefits works When this plan is secondary, benefits are coordinated with benefit payments from the other dental plan. This means that the total amount paid under all plans can be equal to, but not greater than, the total of expenses considered usual and customary. Under the coordination of benefits provision, the primary plan provides benefits until its limits are reached. The secondary plan then provides benefits based on the amount not paid by the primary plan until the limits of the secondary plan are reached. If a third plan is involved, it then provides benefits. The total amount paid by all applicable plans cannot be greater than the total amount of the allowable expense. When this plan is secondary, it gives you credit for savings resulting from coordination. This credit is used to provide payments for allowable expenses that would not have been paid if it were the only plan involved in the claim. This can result in 100% coverage of allowable expenses. HRI-SUBS Rev. 23 Page 142 of 205

143 Dental Plan UMR After all plans have paid benefits, you are responsible for any remaining charges including amounts in excess of the U&C limit. The total amount paid by the plan under the coordination process cannot be greater than the amount that normally would be paid for the claim involved. Medicare Medicare normally excludes most dental expenses, but when coverage is available and Medicare is primary, the coordination of benefits provisions will apply. If you are actively employed and are covered both by this plan and by Medicare, this plan will be your primary plan. Generally, Medicare is primary only if you are retired and are age 65 or over, or if you have been disabled and received Social Security benefits for 24 months. When you are eligible for Medicare and this plan is secondary, UMR assumes that you have purchased Medicare Part B and provides benefits accordingly, whether or not you have purchased it. It is your responsibility to apply for and purchase Medicare Part B coverage when you or your dependent becomes eligible for Medicare. HRI-SUBS Rev. 23 Page 143 of 205

144 Dental Premium Plan AUTHORIZED COPY Dental Plan UMR Under the Dental Premium Plan, benefits are paid based on the coverage category in which the expense falls. All charges are subject to usual and customary (U&C) limits. You are responsible for amounts over the U&C limits and above the annual plan maximum. Dental provider charges are covered, up to the U&C limits, if they are necessary for the care of your teeth as determined by the Benefits Administrator and if the services are started and completed while you are covered under the plan. There are no restrictions on where you live within the United States to be eligible to enroll in the Dental Premium Plan. There is not a preferred network of primary dental care providers and you can obtain dental care nationwide. The plan is administered by UMR. Enrollment Eligibility To participate in the Dental Premium Plan, you must meet the Progress Energy-sponsored dental plan eligibility criteria (see the Eligibility section) and be either (1) an active regular, full-time employee including eligible dependent; (2) an eligible LTD recipient including eligible dependent; (3) an eligible retiree including eligible dependent or (4) an eligible surviving dependent including eligible children. Note: Former Florida Power Corporation (non-bargaining employees), Progress Fuels Corporation (corporate employees) and Progress Telecom Corporation employees who were eligible for benefits under the FlexPower program and who retired on or before January 1, 2002 and their surviving dependents are not eligible for the Progress Energy Dental Plan. Dental ID Cards You will not receive a dental ID card from UMR. Before dental services are rendered, please inform your dentist that you or your dependent is a dental plan member with UMR. To obtain an information card, go to FRM-SUBS Dental Plan Coverage Options You may choose from the following options: No Coverage Coverage under the Premium Plan HRI-SUBS Rev. 23 Page 144 of 205

145 Dental Plan UMR Deductible (annual) Plan maximum (annual) Preventive (two visits per person per year) Basic restorative Fillings Oral surgery Root canals Extractions Oral surgery to remove bony impacted teeth Major restorative Crowns Bridges Dentures Orthodontia 1 All charges are subject to U&C limits. Dental Premium Plan 1 Summary Chart $50 per person $1,500 per person Covered at 100% up to annual plan maximum No deductible 20% employee coinsurance after deductible 20% employee coinsurance after deductible $2,000 per person lifetime plan maximum 50% employee coinsurance after deductible 50% employee coinsurance No deductible $2,000 per person lifetime plan maximum HRI-SUBS Rev. 23 Page 145 of 205

146 Dental Plan UMR How the Dental Premium Plan Works You can obtain dental care nationwide as there is not a preferred network of primary dental care providers. Predetermination of Benefits You may request a predetermination of benefits before dental treatment begins if the treatment will cost $200 or more. The review determines the extent of your coverage and what benefits are available. To request a predetermination of benefits, have your dentist submit a statement to UMR describing the condition, the planned course of treatment, and an estimate of charges. UMR will prepare a determination of benefits that shows what coverage will be available and any alternative treatments identified through the predetermination process. You will be responsible for any charges in excess of the predetermined coverage amount if you and your dentist select a course of treatment that costs more than the approved amount. Predetermination does not provide a guarantee of benefit payments. For example, if the annual plan maximum has been exhausted or your participation in the plan ends, no benefits will be paid even if a particular treatment plan has been reviewed and approved for coverage. Alternative methods of treatment The predetermination process examines possible alternative courses of treatment. When alternative courses of treatment are available, benefits under the plan will be limited to the charges for the less expensive treatment. Such alternatives are likely to be encountered when planning certain restorative treatments or the use of prosthodontics. Restorative/reconstructive The plan may authorize coverage for the use of amalgam instead of gold, baked porcelain restorations, crowns, or jackets, if amalgam will function adequately. In such cases, you will pay the cost difference for the more expensive treatment. Prosthodontics Charges for prosthodontic appliances are limited to the cost of cast chrome or acrylic partial dentures if they will restore the dental arch satisfactorily. The excess cost will be your responsibility if you and your dentist decide to use a more elaborate or precision appliance. Also, the excess costs will be your responsibility if you and your dentist decide to use personalized or specialized techniques instead of standard practices. The replacement of dentures and fixed bridgework will be a covered expense only if the existing appliances cannot be made serviceable. Payment is based on the cost of repair. Replacement is covered only if the appliance involved has been in use for a minimum of five years. Dental benefits are paid based on the coverage category in which the expense falls. Dental provider charges are covered up to the U&C limits if they are necessary for the care of your teeth as determined by UMR, and if the services are started and completed while you are covered under the dental plan. Questions To verify eligibility for coverage, you or the provider may call UMR at with the following information: Patient s name and date of birth Employee s name and Social Security number Group number: Progress Energy HRI-SUBS Rev. 23 Page 146 of 205

147 Dental Plan UMR Usual and customary (U&C) limit Covered dental expenses are paid based on the usual and customary (U&C) limit. Usual and customary refers to the prevailing rate charged by providers in your area for similar services. UMR (formerly Fiserv Health), the Benefits Administrator, is responsible for determining the U&C limit. You are responsible for paying any amounts over the U&C limit. Deductible The deductible each calendar year is $50 per person. This means that each covered individual pays the first $50 of covered expenses each year for Basic and/or Major restorative services before the plan will pay benefits for these services. The deductible does not apply for preventive and orthodontic services. The amount you pay for expenses above the U&C limit does not apply toward the deductible. Coinsurance and maximums The coinsurance amount is the percentage of U&C charges you pay for eligible expenses. All charges are subject to U&C limits. The maximum amount the plan will pay each year for eligible expenses is called the annual plan maximum. You are responsible for amounts over the U&C limit and above the annual or lifetime maximum. Covered Expenses Dental expenses covered under the UMR dental plan are summarized on the following pages; however this list may not be all-inclusive. To be an eligible expense, the expense must be incurred for services that are necessary as determined by UMR according to established dental practices. If you have questions about the eligibility of a covered dental expense, contact UMR for verification. (See the Dental Premium Plan Summary Chart for additional information on benefit levels.) Preventive services Eligible preventive services include: Emergency exams and emergency palliative (pain-relieving) care that does not necessarily effect a cure. Fixed or removable space maintainers for children under age 19 to replace or maintain space for prematurely lost teeth. Full-mouth x-rays once in every 36 consecutive months per person, bite-wing x-rays twice in a calendar year per person, and other x-rays as required for diagnoses of specific conditions (except for orthodontia cases, which are covered separately). Routine oral examinations and prophylaxis (cleaning and scaling of teeth) twice per calendar year per person. Topical fluoride application to exposed tooth surfaces twice per calendar year for children under age 19. Topical sealant application to exposed tooth surfaces once every two calendar years for children under the age of 19. Basic restorative services Eligible basic restorative services include: Administration of anesthesia or analgesia when medically necessary and provided in conjunction with oral or dental surgery. Alveolectomy (preparation of the mouth for dentures) involving at least six consecutive tooth sockets and performed as an independent procedure (not performed at the time the teeth are extracted). Charges for consultation if the consulting dentist does not perform the surgical procedure in question. Dental root resection (apicoectomy). Endodontic treatment (procedures generally used to prevent and treat diseases of the dental pulp and the tip of the root) including root canal therapy. Excision of radicular (root) or dentigerous (surrounding the tooth) cysts. Fillings (amalgam, plastic, synthetic porcelain and composite). HRI-SUBS Rev. 23 Page 147 of 205

148 Dental Plan UMR Covered Expenses Injection of antibiotic drugs by the attending dentist. Intravenous sedatives when medically necessary and provided in conjunction with oral surgery. Oral surgery to remove bony impacted teeth subject to $2,000 per person lifetime maximum; oral surgery dental codes for impacted teeth are: D7230, D7240, D7241, D9220, and D9221. Other oral surgery if not covered under a Progress Energy-sponsored medical plan. Periodontal cleanings and treatment (procedures generally used to prevent and treat diseases of the gums including gingivectomy). Surgical or non-surgical extraction. Surgical treatment of temporomandibular joint syndrome (TMJ) if not covered under a Progress Energysponsored medical plan. Major restorative services Eligible major restorative services include: Initial installation of fixed bridgework (prosthetics) to replace missing natural teeth including inlays and crowns as abutments; excludes periodontal splinting and replacement of wisdom teeth. Initial installation of full or partial removable dentures to replace missing natural teeth and adjoining structures and any adjustments during the first six months following installation; excludes replacement of wisdom teeth. Installation of implants and related services such as implant-supported prosthetics (abutments or retainer crowns placed over the implant) or implant removal; replacement of implants will be covered only if the existing implant cannot be made serviceable and was installed at least five years prior to the replacement. Inlays, onlays, crowns, or gold fillings but only when the teeth involved cannot be restored with amalgam, plastic, synthetic porcelain or composite fillings. Non-surgical treatment of temporomandibular joint syndrome (TMJ) if not covered under a Progress Energy-sponsored medical plan. Repair or re-cementing of crowns, bridgework, dentures, etc., at least six months after the initial installation and no more often than once every 36 consecutive months. Replacement of existing dentures or bridgework or the addition of teeth to existing partial dentures or bridgework, but only if: The existing denture or bridge cannot be made serviceable and was installed at least five years prior to the replacement; or The existing denture or bridge is an immediate temporary device that cannot be made permanent; or The replacement or addition is the result of the loss of another natural tooth after the existing denture or bridge was installed. Normally a denture is replaced by a denture, but if a professionally adequate result can be achieved only with bridgework, then the bridgework will be considered a covered expense. Orthodontic services Eligible orthodontic expenses include: Active treatment including the necessary dental appliances such as braces. Diagnostics including radiography and modeling. Surgical treatment including extraction. Retention treatment which follows the course of active treatment. HRI-SUBS Rev. 23 Page 148 of 205

149 Dental Plan UMR Covered Expenses Orthodontic services are covered for participating employees, spouses or domestic partners and eligible dependent children under the age of 26. UMR administers orthodontia expenses based on a reasonable payment schedule or service contract that includes the expense detail provided with the claim. A reasonable payment schedule or service contract must be prepared by the orthodontist and must illustrate what orthodontia services are to be provided, when the services are planned to be provided (identified by month and year), and the corresponding projected expenses associated with those services. An example of a reasonable payment schedule or service contract may include a down payment for initial services provided and subsequent proportional payments in anticipation of follow-up services. Example: You enter a contract agreement with the orthodontist for a total fee of $4,500 with a down payment paid at the time the braces are installed and 16 monthly payments for the remaining charges. In order to determine benefits under the plan, UMR will use 25% or $1,125 as the initial down payment. The difference of $3,375 ($4,500 - $1,125) will be divided by 16 (months in treatment) to determine the monthly amount to be considered for payment by the plan ($ in this example). Benefits will be paid at 50% of the U&C amount until the maximum is reached. If the provider offers a discount to the member for paying the full amount in advance (or as one lump sum payment), you will then need to request that the provider break the services out to reflect what the contract agreement would have been, had you paid in monthly installments. This breakdown can then be used to claim reimbursement from the plan. UMR will consider 25% of the total cost (within U&C) and will pay 50% of that amount initially. The remaining balance will be divided by the number of months treatment is required and 50% of the monthly amount will be paid each month until the $2,000 orthodontic maximum has been met, as long as the person's coverage remains in effect. If the treatment plan is completed early, payment of the remaining amount up to $2,000 will be made upon appropriate notification from the orthodontist. Orthodontic payments will not be made for longer than the duration of the predetermined and approved treatment plan. Only one statement is necessary when applying for orthodontic benefits. It should be completed by you and the orthodontist at the beginning of the active treatment plan. The orthodontist should indicate the estimated total cost of the program and the total length of time for orthodontic treatment. Orthodontic payments are made only as described above and are not based on any payment schedule you may arrange with the orthodontist. Expenses Not Covered The plan does not cover the items and services listed below. The list may not be all-inclusive. Contact UMR at if you have questions as to whether or not a particular expense is covered. Amounts in excess of U&C as determined by UMR. Basic or major restorative services when treatment was begun before an employee or dependent became a participant in the plan. Charges for failure to keep appointments. Cosmetic services. Dietary or hygiene instructions. Duplicate prosthetics or appliances or replacement of missing, lost, or stolen dentures or bridgework. Intravenous sedatives (except when medically necessary for oral surgery). HRI-SUBS Rev. 23 Page 149 of 205

150 Dental Plan UMR Expenses Not Covered Myofunctional therapy. Periodontal splinting. Porcelain applied to crowns and false teeth to match the color of remaining teeth on other than the ten upper and lower front teeth. Prosthetics that were ordered when the person was not covered by the plan or that were installed more than two calendar months after coverage under the plan ended. Replacement of congenitally missing teeth. Services by other than an appropriate provider. Services covered by any other benefit plan or insurance program paid for or sponsored by the company. Services or supplies that are not necessary or that are experimental in nature according to accepted standards of dental practice or that are not recommended or approved by the attending dentist. Services provided by a member of your or your spouse's or domestic partner s immediate family (spouse, domestic partner, children or parents) or by a person who resides in your home. Services received as a result of dental disease or injury caused by war, rebellion, or riot. Services received as a result of dental disease or injury incurred while committing or attempting to commit a crime. Services received by someone who resides permanently outside of the United States or Canada. Services received in any employer-sponsored clinic or medical department. Services, supplies, or expenses other than those specifically listed as covered expenses. Treatment for the purpose of altering vertical dimension, restoring occlusion, splinting or replacing tooth structure lost as a result of abrasion, attrition or erosion unless covered elsewhere in this document. Treatment not approved by the Department of Health and Human Services, the Food and Drug Administration, or the American Dental Association. Treatment that is covered by any governmental body or agency unless payment is required by law. Treatment that is covered by Workers' Compensation. Orthodontic exclusions and limits The following limits and exclusions apply specifically to orthodontic benefits: Charges for replacement, or repair of any appliance furnished under the treatment plan, or for any duplicate device or appliance are not covered. If orthodontic services end for any reason before the approved treatment is completed, coverage terminates the date the services end. Benefit payments up to the individual lifetime plan maximum may resume if treatment resumes and the person is still covered under the plan. The orthodontist must show that the misalignment of your teeth is severe enough to cause problems with normal mouth functions (chewing, speaking, breathing, etc.) and that the proposed treatment is not merely cosmetic but will correct or substantially improve the condition. UMR has the right to confirm and approve the treatment plan. Your orthodontist must submit a treatment plan to UMR. The diagnosis must show that your condition consists of a handicapping malocclusion that is abnormal and correctable. The plan reserves the right to review your dental records, including x-rays and study models, to determine whether the orthodontia is eligible for coverage. HRI-SUBS Rev. 23 Page 150 of 205

151 Vision Service Plan AUTHORIZED COPY Vision Plan Section Contents Vision Service Plan Pgs Enrollment Eligibility 152 Vision ID Card 152 Vision Plan Coverage Options 152 Vision Service Plan Summary Chart 153 How the Vision Plan Works 154 HRI-SUBS Rev. 23 Page 151 of 205

152 Vision Plan Vision Service Plan Vision Service Plan The Progress Energy-sponsored Basic and Optional vision plan options are administered by Vision Service Plan (VSP) and are separate from the medical plan offered by Progress Energy. The vision providers listed in the medical plan provider directories are to be used only for medically-related ophthalmological problems. Vision benefits are provided based on the plan allowances for the plan in which you are enrolled. There are no restrictions on where you live within the United States to be eligible to enroll in either of the vision plan options. Enrollment Eligibility You are eligible for vision coverage if you meet all of the requirements explained in the Eligibility section of this document. If you elect vision coverage for yourself, you may also enroll your eligible dependents. Note: Former Florida Power Corporation (non-bargaining employees), Progress Fuels Corporation (corporate employees) and Progress Telecom Corporation employees who were eligible for benefits under the FlexPower program and who retired on or before January 1, 2002 and their surviving dependents are not eligible for the Progress Energy Vision Plan. Vision ID Card With VSP, you don't need an ID card to visit a VSP network doctor. Simply call a VSP network doctor to schedule an appointment. Be sure to tell the doctor you are a VSP member when making your appointment. The doctor and VSP handle the rest! However, if you wish to print an ID card, go to sign in under the Members section, and follow the instructions under Member Vision Card. Vision Plan Coverage Options You may choose from the following options if you are eligible for Progress Energy-sponsored vision coverage: Basic Plan (covers eye exams and discounts on eyewear and services) Optional Plan (covers eye exams and eyewear) HRI-SUBS Rev. 23 Page 152 of 205

153 Vision Plan AUTHORIZED COPY Vision Plan Vision Service Plan Vision Service Plan Benefit Summary Chart Benefit In-Network Out-of-network (Reimbursed up to amount shown) 1 Basic Exam (one per calendar year) $15 copay Covered up to $50 Lens and frames discount (unlimited use) 20% discount 2 Not covered Contact lens exam 15% discount Not covered Laser surgery 5% - 15% discount 3 Not covered Optional Exam (one per calendar year) $15 copay Covered up to $50 Eyewear (lenses every calendar year/frames every other $20 copay 4, 5, 6 Covered up to specific allowance calendar year) below, after $20 copay Single vision lenses, lined bifocal lenses, lined trifocal lenses or lenticular lenses (every calendar year) Covered in full $50; $75; $100; $125 respectively Progressive lenses $50 copay $75 Anti-reflective coatings $25 copay Not covered Frames (every other calendar year) Covered up to $155 allowance 6, 7 $70 Elective contact lenses 8 Covered up to $130 allowance (in lieu of frames/lenses) 9 $105 Medically necessary contacts 8 Covered in full $210 Laser surgery 5% - 15% discount 3 Not covered 1. Out-of-network charges reduced by applicable in-network copay before reimbursements are calculated. Out-of-network reimbursements cannot exceed in-network benefits for same service. 2. Unlimited use of the 20% discount on glasses and nonprescription sunglasses. 3. Average discount percentage is 15% off the usual and customary price. If the laser center is offering a temporary price reduction, 5% off the advertised price if it is less than the discounted price % discount applies to additional glasses purchased the same day as the member s eye exam from the same VSP doctor who provided the exam. 20% discount applies to unlimited additional pairs of glasses valid through any VSP doctor within 12 months of the last covered eye exam. 5. Optional items (e.g., UV coatings and tinted lenses) are not covered but are available at VSP discounted member pricing. 6. If contacts are chosen in lieu of glasses, member receives up to 20% discount on prescription and nonprescription glasses as well as sunglasses. Services must be received within 12 months from any VSP doctor. 7. Wide selection of frames covered in full. If frame chosen costs more than plan allowance, member pays difference based on VSP discounted member pricing minus 20%. 8. Contact lenses must be doctor-prescribed, as required for certain medical conditions, and VSP-approved. 9. If contacts are chosen instead of glasses, up to a $130 allowance applies towards cost of contacts. Visit the VSP website at and click on rebates and special offers or call the VSP Customer Service Department at HRI-SUBS Rev. 23 Page 153 of 205

154 How the Vision Plan Works AUTHORIZED COPY Vision Plan Vision Service Plan To receive the highest level of vision benefits, you must use providers who are participating in the VSP network. If you use an in-network provider and pay full cost for the exam (for instance, a new hire whose eligibility has not been established) and then submit the claim to VSP, you will receive reimbursement as if you had gone to an out-ofnetwork provider. To receive reimbursement at the in-network level, you must identify yourself as a VSP member and have the in-network provider submit the claim. You may use providers who are not members of the VSP network, and VSP will reimburse you for out-of-network charges up to the out-of-network plan limit. Under the Basic Plan, employees and their covered dependents may receive annual eye exams from VSP network providers with a copayment. They may also receive discounts on eyewear as well as sunglasses from any VSP network doctor who provided the eye exam within the last 12 months. Under the Optional Plan, participants receive an annual eye exam and may select eyewear that is covered under the plan such as lenses and frames or contacts. They may also receive discounts on additional eyewear as well as sunglasses from any VSP network doctor who provided the eye exam within the last 12 months. There are separate in-network copayments for the exam and eyewear under the Optional Plan. VSP Laser VisionCare Program VSP offers members the option of laser vision correction surgery at a discounted fee when obtained through VSP contracted doctors, surgeons, and laser centers. Program availability may vary based on location and regulatory approval. Details about VSP's Laser VisionCare Program may be found at the Laser VisionCare Learning Source area of VSP's website at or by calling How to Use In-Network Services There is no vision ID card for the plan. However, you may click here for an information card you can cut out and carry for reference. To use your in-network vision benefits, follow the steps listed: 1. Call a VSP doctor and make an appointment. To locate a VSP doctor, log onto the VSP website at or call VSP at Once on the home page, click on Members. Click on Find a VSP Network Doctor. Fill in requested information and submit. 2. When you call for an appointment, tell the doctor you are a VSP member through Progress Energy and give your name, date of birth, and the last four digits of your Social Security number. The doctor will verify your eligibility and benefits with VSP. If both you and your spouse or domestic partner are employed by a participating subsidiary of Progress Energy and you are covered as a dependent under your spouse's or domestic partner s coverage, you should also give your spouse's or domestic partner s Social Security number. 3. During your doctor visit, pay the $15 eye exam copayment. 4. If you are enrolled in the Optional Plan and select eyewear, pay the $20 materials copayment. When selecting eyewear, you should ask if the items you are choosing are covered by the Optional Plan. If the materials are not covered by the Optional Plan or are covered but exceed the plan allowance, you will be required to pay the additional cost. Claims and Appeals For information regarding filing a claim, see Vision Service Plan in the Claims and Appeals section. HRI-SUBS Rev. 23 Page 154 of 205

155 Claims and Appeals AUTHORIZED COPY Claims and Appeals Section Contents Claims and Appeals Pgs Acts of Third Parties 156 Benefit Claims and Appeals Procedures 157 Medical Claims Filing 165 BCBSNC Medical Appeals Process 167 UHC and BCBSF (PPO) Medical Appeals 170 Process AvMed HMO and BlueCare HMO 171 Appeals Process ValueOptions Claims Filing 172 ValueOptions - Appeals Process 173 BCBS/Magellan - MHSA Claims Filing 177 BCBS/Magellan - Appeals Process 178 UMR - Dental Claims Filing 180 UMR - Dental Appeals Process 181 VSP - Vision Claims Filing 183 VSP - Vision Appeals Process 184 HRI-SUBS Rev. 23 Page 155 of 205

156 Acts of Third Parties AUTHORIZED COPY Claims and Appeals Acts of Third Parties In the event you suffer an injury or illness caused by a third party, you assign to Progress Energy any rights against the third party to recover benefits received from a Progress Energy-sponsored health benefit plan for that injury or illness. You should notify the Plan Administrator that a third party is responsible for costs. In addition, you grant Progress Energy, on behalf of the plan, an equitable lien, on a first-dollar basis, against any recovery that you have against any party, up to the amount of expenses advanced to you by the plan. You may be asked to sign an agreement to repay the plan for any claims that were paid by the plan that are or may be the responsibility of a third party. For example, if you are injured by another person and incur $1,000 in covered expenses and you recover the $1,000 in a lawsuit, you must repay the plan the $1,000 paid for those covered expenses. Similarly, if you incur $1,000 in covered expenses in an accident and later the automobile insurance pays the $1,000, you must repay the plan for those expenses. If you do not sign a reimbursement agreement or do not repay the plan or otherwise fail to cooperate with these provisions, the Plan Administrator may stop payment on future claims, obtain a refund from payments previously made to providers, obtain a payment from the third party, or take other appropriate action. The plan s rights of recovery may be from the third party, any liability or other insurance covering the third party, the insured s own uninsured motorist insurance, under-insured motorist s insurance, any medical payments, or no-fault or school insurance coverage. This provision also applies to maintenance of benefits. For example, if you receive healthcare services and receive benefits from the plan and later another group plan pays for the same charges, the plan may recover the overpaid or duplicated benefits from you, the healthcare provider, or the other plan. Common law doctrines such as the make whole rule, the common fund rule, comparative fault, and similar doctrines are inapplicable to benefits paid under the plan. HRI-SUBS Rev. 23 Page 156 of 205

157 Claims and Appeals Benefit Claims and Appeals Procedures Benefit Claims and Appeals Procedures The following are two different types of claims that may be made under the Progress Energy health benefit plans: Claims for plan benefits. Claims as to whether an individual is eligible to participate in or obtain coverage under, or whether an eligible individual is enrolled for participation in or coverage under, the plan or a particular plan option (referred to as an eligibility or enrollment claim ). Claims for Plan Benefits The Benefits Administrators for your plan options have been delegated the authority from the Plan Administrator to decide initial claims for plan benefits, as the initial claim administrators, and denied claims for plan benefits on review, as the denied claim reviewers. In connection with deciding initial claims and reviewing denied claims, each Benefits Administrator has the authority to interpret the applicable plan, decide claims-related questions and make factual determinations, each in its sole discretion. Such interpretations, decision and factual determinations shall be controlling, unless overturned through the Progress Energy medical plan s voluntary external review program described below. Progress Energy and the Plan Administrator have no discretionary authority with respect to claims for plan benefits. Each Benefits Administrator may have specific claim determination procedures that comply with the applicable legal requirements described in this section but that may include additional details or steps that you should be aware of. Such claims submission procedures for your plan benefits are described in the following sections of this SPD for the plan options in which you participate. You also can obtain additional information by calling the Employee Service Center or applicable Benefits Administrator. To file a valid claim for plan benefits, you (or your authorized representative) must follow the claim submission procedures for the applicable plan as described in the following sections of this SPD that are applicable to the plan options in which you participate and any updating materials. Initial Claim Specific instructions about submitting claims are included in the following sections of this SPD. Generally, claims must be submitted in writing. Often, there are time limits that apply to submitting a claim. Make sure you know the time limits of each plan. If you delay submitting your claim, you could lose benefits. Once your claim has been documented and you have filled out all the necessary forms, your claim generally is processed within the timeframes described below based on the type of claim it is. Denial of Initial Claim If any part of your claim is denied, you will be notified in writing. This notice will contain: The specific reason or reasons for the denial. Reference to the specific plan provisions on which the denial is based. A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary. A description of the plan s internal review procedures, the time limits applicable to such procedures and how to initiate an appeal, including a statement of your rights to bring a civil action under Section 502(a) of ERISA following any final internal adverse benefit determination on appeal. If an internal rule, guideline, protocol or other similar criterion was relied on in the denial, either the specific rule, guideline, protocol or other similar criterion (or a statement that such a rule, guideline, protocol or similar criterion was relied upon in the denial) and that a copy of such rule, guideline, protocol, or criterion will be provided free of charge upon request. HRI-SUBS Rev. 23 Page 157 of 205

158 Claims and Appeals Benefit Claims and Appeals Procedures If the denial is based on a medical necessity or experimental or investigative treatment, either a clinical or scientific explanation of the denial, applying the terms of the plan to your medical circumstances, or a statement that such clinical or scientific explanation will be provided free of charge upon request. In addition to the content described immediately above, a denial notice under the medical plan will be provided in a culturally and linguistically appropriate manner as required by the Patient Protection and Affordable Care Act and in accordance with any applicable implementing regulations or other federal agency guidance and will also include the following: Information sufficient to identify the claim involved. Notification of the opportunity to request the diagnosis and treatment codes associated with the claim involved, including their respective meanings, and to have such information provided upon request. A description of the plan s external review procedures, the time limits applicable to such procedures and how to initiate an external appeal. Contact information for any applicable office of health insurance consumer assistance or ombudsman established to assist individuals with the internal claims and appeals process. Appeals If any part of your claim is denied, you or your authorized representative may appeal the decision made on your claim. Generally, you have 180 days from the time you re notified of the denial of your claim to appeal. Your appeal must be in writing. You should describe the decision you are appealing and state the reasons why you think the decision made on your claim was incorrect. You or your authorized representative will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information related to your claim, and will be able to submit written comments, documents and other information relevant to your appeal. Appeals should be directed to the Benefits Administrator with which you filed your initial claim. If you do not file an appeal within the time permitted, your claim will be deemed abandoned and you may not reassert it under these procedures or in a court or any other venue. If you fail to raise issues or present evidence on appeal, you may not be able to raise those issues or present that evidence in any later proceeding or judicial review of your claim. Your claim will be given a full and fair review. Someone other than an individual involved in the initial claim, or a subordinate of such individual, will make the determination on appeal. The decision on review will not give deference to the initial adverse claim determination. If the claim determination is based in whole or in part on a medical judgment, including a determination with regard to whether a particular treatment, drug or other item is experimental, investigational, or not medically necessary or appropriate, a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment will be consulted. This professional will be an individual who is neither an individual who was consulted in connection with the initial claim determination nor a subordinate of any such individual. A decision on your appeal will ordinarily be made within the timeframes described below based on the type of claim. Denial of Appeals You will be notified regarding the decision on your appeal in writing. If your appeal is denied, the denial notice will contain: The specific reasons for the denial of your appeal. Reference to the specific plan provisions on which the denial of your appeal is based. A statement regarding your right, upon request and free of charge, to access and receive copies of documents, records and other information relevant to the claim. A statement regarding your right to sue under Section 502(a) of ERISA following any final internal adverse benefit determination and about any available voluntary alternative dispute resolution options. HRI-SUBS Rev. 23 Page 158 of 205

159 Claims and Appeals Benefit Claims and Appeals Procedures If an internal rule, guideline, protocol or other similar criterion was relied on in the denial, either the specific rule, guideline, protocol or other similar criterion (or a statement that such a rule, guideline, protocol or similar criterion was relied upon in the denial) and that a copy of such rule, guideline, protocol, or criterion will be provided free of charge upon request. If the denial is based on a medical necessity or experimental or investigative treatment, either a clinical or scientific explanation of the denial, applying the terms of the plan to your medical circumstances, or a statement that such clinical or scientific explanation will be provided free of charge upon request. The statement: You and your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency. In addition to the content described immediately above, an appeal denial notice under the medical plan will be provided in a culturally and linguistically appropriate manner as required by the Patient Protection and Affordable Care Act and in accordance with any applicable implementing regulations or other federal agency guidance and will also include the following: Information sufficient to identify the claim involved. Notification of the opportunity to request the diagnosis and treatment codes associated with the claim involved, including their respective meanings, and to have such information provided upon request. A description of the plan s external review procedures, the time limits applicable to such procedures and how to initiate the external appeals process. Contact information for any applicable office of health insurance consumer assistance or ombudsman established to assist individuals with the internal claims and appeals and external review processes. Claims and Appeal Time Limits for Disability Determinations Special timeframes apply to claims and appeals involving disability determinations. Notification of Initial Determination Disability benefit claim determinations will be made within 45 days of receipt by the applicable Benefits Administrator of all information necessary for determination of your claim. If extra time is needed to process your claim, you will be notified that up to an additional 60 days is required. If the extension is necessary due to your failure to submit enough information, the notice will also specify what information is needed. The determination period will be suspended on the date the Benefits Administrator sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. You will have 45 days to respond to the request for information. Appeal of Determination If you receive an adverse benefit determination, you have 180 days from the time you re notified of the denial of your claim to appeal the decision in accordance with the Appeals section above. Your appeal must be in writing. A decision on your appeal will ordinarily be made within 45 days (or within 90 days if special circumstances require an extension). Group Health Plan Claims and Review Time Limits Different timeframes apply to claims and appeals under the Progress Energy health benefit plans, depending on the type of claim made under the applicable plan. Notification of Initial Determination After you make your claim for benefits in accordance with plan procedures, the following time limits apply: HRI-SUBS Rev. 23 Page 159 of 205

160 Claims and Appeals Benefit Claims and Appeals Procedures Urgent Care Claims (medical and dental plans only) An urgent care claim is one in which the plan determines that the application of non-urgent care time frames could seriously jeopardize the life or health of the claimant, the ability of the claimant to regain maximum function, or in the judgment of a physician would subject the claimant to severe pain that cannot be adequately managed otherwise. If your claim involves urgent care, you will be notified of the benefit determination (whether adverse or not) as soon as possible, but no later than 72 hours after receipt of the claim by the Benefits Administrator. If the Benefits Administrator is not provided sufficient information to make a decision, you will be notified within 24 hours after receipt of the claim. You will have a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the needed information. You will be notified of the decision on your claim as soon as possible, but generally no later than 48 hours after receipt of the information by the Benefits Administrator. Pre-Service Claims (medical and dental plans only) A pre-service claim is one in which the plan conditions the receipt of benefits, in whole or part, on approval of the benefit in advance of obtaining medical care. If you have a pre-service claim, you will be notified of the benefit determination no later than 15 days after receipt of the claim by the Benefits Administrator. The Benefits Administrator may extend this period for up to 15 days, if necessary. If extra time is needed to process your claim, you will be notified. If the extension is necessary due to your failure to submit enough information, the notice will also specify what information is needed. The determination period will be suspended on the date the Benefits Administrator sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. You will have 45 days to respond to the request for information. Post-Service Claims (all health benefit plans) A post-service claim is any claim for a benefit under a health benefit plan that is not an urgent care claim or a preservice claim. If you have a post-service claim, you will be notified of the benefit determination within 30 days after receipt of the claim by the Benefits Administrator. The Benefits Administrator may extend this period for up to 15 days, if necessary. If extra time is needed to process your claim, you will be notified. If the extension is necessary due to your failure to submit enough information, the notice will also specify what information is needed. The determination period will be suspended on the date the Benefits Administrator sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. You will have 45 days to respond to the request for information. Concurrent Care Decisions (medical and dental plans only) If the Benefits Administrator has previously approved an ongoing course of treatment to be provided over a period of time or number of treatments, you will be notified of any reduction or termination of the course of treatment in sufficient time before the end of the approved course of treatment to allow you to appeal the benefit determination. If you request an extension of the course of treatment beyond the approved period of time or number of treatments and the claim involves urgent care, a determination will be made as soon as possible, and you will be notified of the benefit determination within 24 hours (provided you make the request at least 24 hours prior to the end of the course of treatment). HRI-SUBS Rev. 23 Page 160 of 205

161 Claims and Appeals Benefit Claims and Appeals Procedures Appeal of Determination If you receive an adverse benefit determination, you have 180 days to appeal the decision in accordance with the Appeals section above. Generally, your appeal must be in writing. However, for some plans, you may be able to register your appeal by telephone. In addition, you may be able to appeal the denial of any part of your initial appeal through a second level appeal process. These two levels of appeal may be mandatory for pre-service and post-service claims. However, urgent care claims are only subject to one mandatory level of appeal. To the extent required by applicable law under the medical plan: You will be allowed to review your claim file and to present evidence and testimony as part of the internal claims and appeals process. The Benefits Administrator will provide you, free of charge, with any new or additional evidence considered, relied upon or generated by the plan (or at the direction of the plan) in connection with your appeal as soon as possible and sufficiently in advance of the date on which it provides you with notice of its determination on appeal, so that you will have a reasonable opportunity to respond prior to that date. If the denial of your appeal is based on a new or additional rationale, the Benefits Administrator will provide you, free of charge, with the new or additional rationale as soon as possible and sufficiently in advance of the date on which it provides you with notice of its determination on appeal, so that you will have a reasonable opportunity to respond prior to that date. Urgent Care Claims (medical and dental plans only) If your claim involves urgent care, you can request an expedited appeal of an adverse benefit determination orally or in writing. You will be provided all necessary information by telephone, facsimile, or other available expeditious method. You will be notified of the benefit determination on appeal no later than 72 hours after receipt of the appeal by the Benefits Administrator. Pre-Service Claims (medical and dental plans only) If you have a pre-service claim, you will be notified of the benefit determination on appeal within 30 days if the plan provides for only one appeal of an adverse benefit determination or within 15 days for each appeal if the plan provides for two mandatory appeals of an adverse determination. Post-Service Claims (all health benefit plans) If you have a post-service claim, you will be notified of the benefit determination on appeal within 60 days if the plan provides for only one appeal of an adverse benefit determination or within 30 days for each appeal if the plan provides for two mandatory appeals of an adverse determination. Concurrent Care Claims (all health benefit plans) If you have a concurrent care claim, you will be notified of the benefit determination on appeal within 30 days if the plan provides for only one appeal of an adverse benefit determination or within 15 days for each appeal if the plan provides for two mandatory appeals of an adverse determination. Voluntary External Review Program (medical & MHSA plans only) Under the medical plan (including MHSA services benefits), once you have exhausted the internal claims and appeals process described above, you may be able to file an appeal with an independent review organization (IRO) that is accredited to conduct external review. External review is available only after internal appeals are exhausted and is available only for certain types of adverse benefit determinations, as defined by federal regulations. HRI-SUBS Rev. 23 Page 161 of 205

162 Claims and Appeals Benefit Claims and Appeals Procedures If you wish to file a request for external review, you must submit your request within 4 months of the date of your receipt of the Benefits Administrator s final internal adverse determination on your appeal. Contact the Benefits Administrator at the telephone number shown on your ID card for more information on how to file a request for external review of your appeal. The Benefits Administrator will determine if your appeal is eligible for the voluntary external review program and will provide you with a written notice of its determination. If your request is complete but not eligible for external review, the notice will include the reason or reasons for the denial and contact information for the Employee Benefits Security Administration. If your request is not complete, the notice will describe the information or materials needed to make the request complete, and, in order to pursue an external review, you must provide the required information within the 4-month filing period or within the 48-hour period following receipt of the notification, whichever is later. If your claim is eligible for external review, the Benefits Administrator will assign your claim to an IRO. The IRO will notify you of the acceptance of your claim for external review, and this notice will include a statement that you may submit to the IRO in writing within 10 business days following receipt of the notice any additional information the IRO should consider in conducting the external review. The IRO will review all of the information and documents it receives in a timely manner. You will receive written notice of the final external review decision within 45 days after the IRO receives the request for external review. The notice will include the following: A general description of the reason for the request for external review, including information sufficient to identify the claim. The date the IRO received the assignment to conduct the external review and the date of the IRO decision. References to the evidence or documentation, including the specific coverage provisions and evidencebased standards, considered in reaching its decision. A discussion of the principal reason or reasons for its decision, including the rationale for its decision and any evidence-based standards that were relied on in making its decision. A statement that the determination is binding except to the extent that other remedies may be available under State or Federal law to you or the plan. A statement that judicial review may be available to you. Current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman. Eligibility and Enrollment Claims The Plan Administrator has the authority to decide initial eligibility or enrollment claims, as the initial claim administrators, and denied eligibility or enrollment claims on review, as the denied claim reviewers. In connection with deciding initial claims and reviewing denied claims, the Plan Administrator has the authority to interpret the applicable plan, decide claims-related questions and make factual determinations, each in its sole discretion. Such interpretations, decisions and factual determinations shall be controlling. Progress Energy has no discretionary authority with respect to eligibility or enrollment claims. To file a valid eligibility or enrollment claim, you (or your authorized representative) must follow the claim submission procedures as described in this SPD and any updating materials. Such a claim must be received by the Plan Administrator within 90 days after the end of the plan year in which you are claiming eligibility/enrollment should have occurred. HRI-SUBS Rev. 23 Page 162 of 205

163 Claims and Appeals Benefit Claims and Appeals Procedures Notification of Initial Determination Eligibility and enrollment claim determinations will be made within 30 days of receipt by the Plan Administrator of all information necessary for determination of your claim. If extra time is needed to process your claim, you will be notified that up to an additional 15 days is required. If the extension is necessary due to your failure to submit enough information, the notice will also specify what information is needed. The determination period will be suspended on the date the Plan Administrator sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice. You will have 45 days to respond to the request for information. Appeal of Determination If you receive an adverse claim determination, you have 180 days from the time you are notified of the denial of your claim to appeal the decision in accordance with the Appeals section above. Your appeal must be in writing and must be submitted to the Plan Administrator. A decision on your appeal will ordinarily be made within 60 days (or within 120 days if special circumstances require an extension). Timeline and Notification Requirements Time Limits To make initial claim determination Extension (if proper notice is given and delay is beyond the plan s control) To request missing information from claimant For claimant to provide missing information For claimant to request appeal To make determination on appeal Urgent Care Claims Pre-Service Care Claims Post- Service Claims Disability Claims Eligibility and Enrollment Claims 72 hours 15 days 30 days 45 days 30 days None 15 days 15 days 30 days (plus up to an additional 30 days) 15 days 24 hours 15 days 30 days 45 days 30 days 48 hours 45 days 45 days 45 days 45 days 180 days 180 days 180 days 180 days 180 days 72 hours 30 days (or 15 days, if plan provides two mandatory levels of appeal) 60 days (or 30 days, if plan provides two mandatory levels of appeal) 45 days (plus up to an additional 45 days) 60 days (plus up to an additional 60 days) HRI-SUBS Rev. 23 Page 163 of 205

164 Claims and Appeals Benefit Claims and Appeals Procedures Legal Action You have the right to bring a civil action under Section 502(a) of ERISA against a plan if you are not satisfied with the outcome of the internal claims and appeal procedure. Unless you have exhausted your internal administrative review rights under the plan, you generally are prohibited from bringing a civil action against the plan, the Benefits Administrator, the Plan Administrator or Progress Energy. If the plan provides for binding arbitration of any controversy between a plan participant or beneficiary and the plan, including, as applicable, its agents, employees, providers, and staff physicians, then any such controversy is subject to binding arbitration. No civil action may be brought after the deadline imposed by the applicable plan, or more than one year after the date on which your claim is denied on final internal appeal if there is no other plan-specific deadline. HRI-SUBS Rev. 23 Page 164 of 205

165 Claims and Appeals Medical Claims Filing Medical Claims Filing Medical A participant or beneficiary has a right to file a claim for benefits under the BCBSNC HDHP, BCBSNC Standard or Choice Plan, BCBSF Standard or Choice Plan, UnitedHealthcare Standard or Choice Plus Plan, BlueCare HMO or AvMed HMO option, ask if he or she has a right to any benefits under the plan, or appeal the denial of a claim for benefits under the plan. For purposes of the plans claims procedure, the term you includes any participant or beneficiary making a claim, inquiry or appeal and the authorized representative of such person. BCBSNC, BCBSF, UnitedHealthcare and AvMed, as the Benefits Administrators, have the responsibility and authority for making decisions about claims for benefits under their respective plan options. The Plan Administrator will be the Benefits Administrator with respect to determinations related to eligibility and enrollment claims. Filing medical claims For most in-network services, you will not have to file a claim. However, if you use out-of-network providers, you should pay the provider in full and file a claim to be reimbursed for eligible expenses. (Note: Out-of-network services for the HMO plans are generally not eligible for reimbursement.) To file for reimbursement, you should submit the medical claim form along with a copy of the original itemized bill containing the following information: Patient s name and date of birth Employee s name and member ID number Date of service Amount of charge Diagnosis Description of service Provider s name and address Other insurance information, if applicable (such as spouse s or domestic partner s name, employersponsored coverage, employer's name and address) Whether payment should be made to employee or provider Retain copies for your records in case you need to refer to them if you call regarding the claim. To access a claim form, click on the appropriate link: BCBSNC HDHP, BCBSNC Standard and Choice Plans, UnitedHealthcare Standard and Choice Plus Plans. To obtain a claim form for the AvMed HMO, BlueCare HMO or BCBSF Standard or Choice Plans, you will need to call the Customer Service number on your medical ID card. You must send the initial claim within 18 months of the date the expense was incurred for the BCBSNC HDHP, Standard and Choice Plans 12 months of the date the expense was incurred for the BCBSF Standard and Choice Plans 12 months of the date the expense was incurred for the UnitedHealthcare Standard and Choice Plus Plans To. BCBSNC Claims Department PO Box 35 Durham, NC Blue Cross Blue Shield of Florida PO Box Jacksonville, FL UnitedHealthcare PO Box Atlanta, GA HRI-SUBS Rev. 23 Page 165 of 205

166 You must send the initial claim within 12 months of the date the expense was incurred for the AvMed HMO Plan To. AvMed HMO PO Box Miami, FL AUTHORIZED COPY Claims and Appeals Medical Claims Filing 12 months of the date the expense was incurred for the BlueCare HMO Plan Blue Cross Blue Shield of Florida-HMO PO Box Jacksonville, FL Filing claims under more than one plan If medical coverage is provided by two or more plans, claims and itemized statements must be submitted to the primary plan first. When the primary plan responds, send a copy of that plan s explanation of benefits and copies of the bills to the secondary plan for payment consideration. If the Progress Energy-sponsored medical plan is secondary, it will not pay any benefit that would have been paid by the primary plan, even if the claim was not filed with the primary plan. Click here to see the Primary and Secondary Coverage section of this document for additional information on coverage under more than one plan. Medicare If you are covered under both Medicare and a Progress Energy-sponsored medical plan and Medicare is primary, your medical claims must be filed with Medicare first. If a member has been set up on Medicare crossover*, claims will automatically/electronically be sent to the Progress Energy-sponsored medical plan from Medicare. Claims submitted prior to the crossover being set up or out-of-network/out-of-state claims will have to be submitted directly to the Progress Energy-sponsored medical plan by the provider or member. The Medicare explanation of benefits and the itemized statement must be included with the claim and mailed to the appropriate address listed above. *Note: Initial set up of Medicare crossover occurs when you notify the Employee Service Center of your Medicare eligibility date. The Employee Service Center will update its system and notify your medical plan electronically to update your COB (Coordination of Benefits) information in their system. The Progress Energy-sponsored medical plans send bi-weekly files to Medicare notifying them of the updated Medicare eligible members. The initial Medicare crossover process can take anywhere from 3-5 weeks after Progress Energy s records have been updated. Progress Energy does not send future dated crossover information to the medical plans. HRI-SUBS Rev. 23 Page 166 of 205

167 Claims and Appeals BCBSNC Medical Appeals Process Medical Appeals Process BCBSNC Medical Appeals Process If precertification/prior plan approval is not granted for a service or a claim for services is denied by BCBSNC, you may request that your claim be reviewed. There is one level of appeal for Urgent Care Claims and two levels of appeal for Pre-Service Claims and Post-Service Claims (the first level of appeal is mandatory, but the second level of appeal is voluntary). The Benefits Administrator (BCBSNC) is responsible for making all appeal decisions. BCBSNC Appeals Review First Level (urgent care/ expedited prospective review, preservice and postservice) Step Steps to follow in the Appeals Process 1 Request a form for a first level appeal review by visiting the BCBSNC website at bcbsnc.com or by calling BCBSNC Customer Service at Any request for review should include: Employee's ID number Employee s name Patient's name Nature of the appeal Any other information that may be helpful for the review Although you are not allowed to attend a first level appeal review, BCBSNC asks that you send all of the written material you feel is necessary to make a decision. BCBSNC will use the material provided in the request for review, along with other available information, to reach a decision. Expedited Review You have the right to a more rapid or expedited review of a denial of coverage if a delay: (i) would reasonably appear to seriously jeopardize your or your dependent's life, health or ability to regain maximum function; or (ii) in the opinion of your provider, would subject you or your dependent to severe pain that cannot be adequately managed without the requested care or treatment. An expedited review may be initiated by calling BCBSNC Customer Service at Submit your written appeal within 180 days of the date on your claim denial notice to: BCBSNC Customer Service PO Box 2291 Durham, NC You will be notified in clear written terms of the decision within a reasonable time but no later than the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. Expedited reviews are discussed in detail under the Utilization Management Program in the applicable medical plan section of this SPD. If you are dissatisfied with the first level appeal review decision for pre-service or post-service claims, you have the right to a voluntary second level appeal review. Second level appeals are not allowed for benefits or services that are clearly excluded by this SPD, or quality of care complaints. HRI-SUBS Rev. 23 Page 167 of 205

168 BCBSNC Appeals Review Second Level (pre-service & postservice only) Step Steps to follow in the Appeals Process AUTHORIZED COPY Claims and Appeals BCBSNC Medical Appeals Process 1 Submit your written request for a voluntary second level appeal review within 180 days of the first level appeal review decision to: BCBSNC Customer Service PO Box 2291 Durham, NC Within ten business days after BCBSNC receives your request for a second level appeal review, the following information will be given to you: Name, address and telephone number of the appeal coordinator A statement of your rights, including the right to: Request and receive from BCBSNC all information that applies to your case Attend the second level appeal review meeting Present your case to the review panel Submit supporting material before and at the review meeting Ask questions of any member of the review panel Be assisted or represented by a person of your choosing, including a family member, an employer representative, or an attorney. 3 The second level review meeting, which will be conducted by a review panel coordinated by BCBSNC using external physicians and/or benefit experts, will be held within 45 days after BCBSNC receives a second level appeal review request. You will receive notice of the meeting date and location at least 15 days before the meeting. You have the right to a full review of your appeal even if you do not attend the meeting. A written decision will be issued to you within five business days of the review meeting. The second level appeal of a benefits dispute is voluntary under ERISA. It is not necessary to complete a second level appeal before bringing a civil action under Section 502(a) of ERISA. With respect to second-level reviews of benefits disputes: The plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to a second level appeal; Any statute of limitations or other defense based on timeliness will be tolled during the time that any such voluntary appeal is pending; You may submit a benefits dispute to a second level appeal only after completing a first level appeal; The plan will provide you, upon request, sufficient information relating to a second level of appeal to enable you to make an informed judgment about whether to request a second level of appeal; and No fees or costs will be imposed on you as part of a second level of appeal. If the Benefits Administrator fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Benefits Administrator decides in its discretion that you are entitled to them. HRI-SUBS Rev. 23 Page 168 of 205

169 Appeals Review External Review Step Independent Review Organization (IRO) AUTHORIZED COPY Claims and Appeals BCBSNC Medical Appeals Process 1 Once you have exhausted the internal claims and appeals process described above, you may be able to file an appeal with an independent review organization (IRO) that is accredited to conduct external review. External review is available only after internal appeals are exhausted and is available only for certain types of adverse benefit determinations, as defined by federal regulations. If you wish to file a request for external review, refer to the Voluntary External Review Program under the Benefit Claims and Appeals Procedures section above. HRI-SUBS Rev. 23 Page 169 of 205

170 Claims and Appeals UHC and BCBSF (PPO) Medical Appeals Process UnitedHealthcare (UHC) and BCBSF PPO Medical Appeals Process If precertification/prior plan approval is not granted for a service or a claim for services is denied by UHC or BCBSF, you may request that your claim be reviewed. There is one level of appeal for Urgent Care Claims, Pre-Service Claims and Post-Service Claims. The Benefits Administrator is responsible for making all appeal decisions. UHC and BCBSF PPO Plans Appeals Review First Level (urgent care, pre-service, and postservice ) Step Steps to follow in the Appeals Process 1 To appeal the denial of a claim for either UHC or BCBSF (PPO only), you must send a written request for review. (You may request an expedited appeal of a denied Urgent Care Claim.) Any request for review should include: Employee's ID number Employee s name Patient's name Nature of the appeal Any other information that may be helpful for the review 2 Submit your written appeal within 180 days of the date of the claim denial notice to the applicable Benefits Administrator listed below: UnitedHealthcare PO Box Salt Lake City, Utah BCBSF (PPO) Attn: Member Appeals PO Box Jacksonville, FL You will be notified in clear written terms of the decision within a reasonable time but no later than the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. If the Benefits Administrator fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Benefits Administrator decides in its discretion that you are entitled to them. Appeals Step Independent Review Organization (IRO) Review External Review 1 Once you have exhausted the internal claims and appeals process described above, you may be able to file an appeal with an independent review organization (IRO) that is accredited to conduct external review. External review is available only after internal appeals are exhausted and is available only for certain types of adverse benefit determinations, as defined by federal regulations. If you wish to file a request for external review, refer to the Voluntary External Review Program under the Benefit Claims and Appeals Procedures section above. HRI-SUBS Rev. 23 Page 170 of 205

171 Claims and Appeals AvMed HMO and BlueCare HMO Medical Appeals Process AvMed HMO and BlueCare HMO Appeals Process If your AvMed HMO or BlueCare HMO claim is denied, you may request that your claim be reviewed. The Benefits Administrators are responsible for making decisions regarding HMO appeals. For information on your rights to appeal, see the applicable HMO plan s Certificate of Coverage, which is hereby incorporated by reference and made a part of this SPD. HRI-SUBS Rev. 23 Page 171 of 205

172 Claims and Appeals ValueOptions Claims Filing ValueOptions - Claims Filing EAP and MHSA When you use a provider in the ValueOptions network, you will not have to file a claim. In-network providers file directly with ValueOptions. With in-network providers, you pay only the copayment/coinsurance portion of the bill for outpatient service. In-network providers may not bill you for the difference between their usual charges and the ValueOptions discounted rate. Filing MHSA out-of-network claims If you choose to use a non-network provider for outpatient or inpatient care, you will be required to file your own claims with ValueOptions and you will have to pay 40% of the usual and customary charge as well as any amount above the provider s usual and customary rate. Reimbursements are mailed to you and not the provider. To access a claim form, click on the following link ValueOptions claim form, contact ValueOptions at or at website or call the Employee Service Center at VoiceNet or You must send the initial claim within 12 months of the date of service Note: A claim form will be treated by the plan as having been filed on the date it is received. To ValueOptions Attn. Claims Dept. PO Box 1347 Latham, NY HRI-SUBS Rev. 23 Page 172 of 205

173 ValueOptions Appeals Process AUTHORIZED COPY Claims and Appeals ValueOptions - Appeals Process Noncertification determinations ValueOptions peer advisor (Psychiatrist or PhD licensed Psychologist) may not certify care if it determines that such care is not medically necessary for clinical reasons in a particular case. The provider or the patient may appeal a noncertification determination. There are two levels of appeal of a noncertification determination. Appeals Step Noncertification Appeals Process Review Level I 1 You or the provider must determine the type of appeal you have: urgent/expedited Level I appeal, retrospective appeal or standard appeal which are those under usual circumstances. Urgent/expedited Level I appeal - If a delay in making a decision might seriously jeopardize the life or health of the member, it is essential that the participating provider request an "expedited" Level I appeal immediately.* *The treating provider must be available to discuss the case. For expedited or urgent appeals, members must be in an inpatient level of care, but have not been already discharged, or the delay would impact the life/health of the member. In these cases, ValueOptions will make the Level I determination no later than three business days (or 72 hours, whichever is shorter) from the date of such request. As part of the appeals process, a member, designated representative, provider, or facility rendering service can submit written comments, documents, records, and other information relating to the case. ValueOptions takes all such submitted information into account in considering the appeal regardless of whether such information was submitted or considered in the initial consideration of the case. Retrospective appeal An appeal requested after a member has been discharged from the level of care or services under review have already been rendered. Standard appeal (one under usual circumstances) The two appeal descriptions above don t apply. 2 Submit a retrospective appeal within 180 calendar days of the noncertification notification and a standard appeal (one under usual circumstances) within 180 days of the noncertification notification to: ValueOptions (for all plans except HDHP) 3800 Paramount Parkway, Suite 300 PO Box Morrisville, NC Urgent/expedited Level I appeals see details in Step 1 above. 3 A retrospective appeal will be completed by ValueOptions within 30 calendar days. The retrospective review process evaluates and recommends if the services rendered are considered to be medically necessary. If services are approved, the claim is processed and paid under the out-of-network benefit. A standard appeal (one under usual circumstances) will be completed by ValueOptions within 15 calendar days of receipt of the appeal request and medical records. HRI-SUBS Rev. 23 Page 173 of 205

174 Appeals Review Step Noncertification Appeals Process AUTHORIZED COPY Claims and Appeals ValueOptions - Appeals Process Urgent/expedited Level I appeals see details in Step 1 above. If you are dissatisfied with the first level appeal review decision, you have the right to a voluntary second level appeal review. Second level appeals are not allowed for benefits or services that are clearly excluded by this SPD, or quality of care complaints. Level II (typically standards, not expedited) 1 If the member or provider receives an adverse benefit determination based on the Level I appeal, a voluntary Level II appeal may be requested for Behavioral Health Services. This appeal must be requested within 90 days of the Level I appeal decision. The patient or participating provider may request a Level II appeal within 90 days of the Level I appeal recommendation. This level of appeal involves a second review by a peer advisor or a committee of peers who are licensed in the same profession and in a similar specialty who managed the medical condition, procedure, or treatment and are neither the individual who made the original noncertification, or previous appeal decision, nor a subordinate of such individual. Using nationally recognized standard references for psychiatric and substance abuse treatment, this peer review process will determine whether the participating provider's treatment plan and services rendered are medically/psychologically necessary. The reviewer may contact the participating provider and/or ValueOptions by telephone to discuss specific aspects of the patient's signs and symptoms and the proposed treatment. 2 You or the provider must submit within 90 days to: ValueOptions (for all plans except HDHP) 3800 Paramount Parkway, Suite 300 PO Box Morrisville, NC Level II appeal determinations are made within 15 calendar days of the receipt of the Level II appeal request. The review will reconsider the appellant s request for medical necessity approval based on available clinical or provider records. The reviewer will render a decision in writing to the member, provider or facility. ValueOptions will notify the treatment provider and the patient of the results. ValueOptions will certify those services that are found to be medically/psychologically necessary through the Level II appeal process. The second level appeal of a benefits dispute is voluntary under ERISA. It is not necessary to complete a second level appeal before bringing a civil action under Section 502(a) of ERISA. With respect to second-level reviews of benefits disputes: The plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to a second level appeal; Any statute of limitations or other defense based on timeliness will be tolled during the time that any such voluntary appeal is pending; You may submit a benefits dispute to a second level appeal only after completing a first level appeal; The plan will provide you, upon request, sufficient information relating to a second level of appeal to enable you to make an informed judgment about whether to request a second level of appeal; and No fees or costs will be imposed on you as part of a second level of appeal. HRI-SUBS Rev. 23 Page 174 of 205

175 Claims and Appeals ValueOptions - Appeals Process If the Benefits Administrator fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Benefits Administrator decides in its discretion that you are entitled to them. Appeals Step Independent Review Organization (IRO) Review External Review 1 Secondary to the passage of the Patient Protection and Affordable Care Act (PPACA), the new healthcare law includes a reform provision that allows a plan member to request an External Independent (clinical) Review if the plan s Level I and Level II benefit determinations adversely impact the member. To request this review, the member must file a written request to ValueOptions within four (4) months of the final internal adverse benefit determination. Within five (5) business days after receiving the external review request, the plan must complete a preliminary review to determine claimant is or was covered under the plan at the time the healthcare service was requested, that the adverse benefit determination is not related to eligibility, that the claimant has exhausted the plan s internal appeal process, and that the claimant has provided all the information and forms required to process an external review. Within one (1) business day of the preliminary review, the plan will issue a written notice to the claimant as to the completeness of the request and/or to perfect the request within the four-month filing period or within 48 hours after receiving the notification, whichever is later. ValueOptions will assign a contracted rotating IRO to review the appeal de novo and will consider in the course of the review the claimant s medical record; the attending healthcare professional s recommendations, reports from the appropriate healthcare professionals and other documents submitted by the plan, the claimant or the treating provider; the terms of the claimant s plan, appropriate practice guidelines, any applicable clinical review material or criteria developed or used by the plan; and the opinion of the IRO clinical reviewer. The IRO must provide written notice to the member, provider, and facility within the determination timeframe. The notice must include the basis for the decision and a statement that the decision is binding. If the noncertification determination is upheld on appeal, ValueOptions will notify the provider of the patient in writing. The notification will include the information described under the Benefit Claims and Appeals Procedures section above. Hold harmless requirement ValueOptions in-network providers are contractually responsible to hold the patient harmless for any charges incurred until the entire appeals process is completed. If a patient wishes to continue treatment once the appeals process is completed, the participating provider must obtain the patient's written consent to be financially responsible for any care thereafter. The patient's consent must be signed and dated on or after the date that the appeals process is completed. ValueOptions may request a copy of this consent form. HRI-SUBS Rev. 23 Page 175 of 205

176 Claims and Appeals ValueOptions - Appeals Process Denial of claims for administrative reasons ValueOptions may also deny a claim for administrative reasons if it determines that the plan does not cover the care in question. There is one level of appeal of claims that are denied for administrative reasons. If a claim for benefits under the plan is partially or wholly denied for administrative reasons, you should receive written notice of the denial within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. Appeals Step Administrative Reasons Appeals Process Review Level I 1 If the Benefits Administrator (ValueOptions) denies a claim for administrative reasons, you must send a written request for review. 2 Submit your written appeal within 180 days of the date of the initial denial notice to: ValueOptions (for all plans except HDHP) 3800 Paramount Parkway, Suite 300 PO Box Morrisville, NC ValueOptions will re-examine the claim and consider any additional information supplied in support of the claim. ValueOptions will complete their review and notify you of their conclusions within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. HRI-SUBS Rev. 23 Page 176 of 205

177 Claims and Appeals BCBS/Magellan - MHSA Claims Filing BCBS/Magellan MHSA Claims Filing MHSA In-network providers file directly with BCBSNC. For out-of-network office providers, you will have to file claims with BCBSNC at the address on the back of your BCBSNC ID card. With in-network providers, you must satisfy the deductible before the plan pays at 100%. In-network providers may not bill you for the difference between their charges and the negotiated discounted rate. Filing a MHSA claim If you choose to use a non-network provider for outpatient care, you will be required to file your own claims with BCBSNC and after meeting the deductible will have to pay any charges above the allowed amount. Reimbursements are mailed to you and not the provider. To access a claim form, click on the following link Claim forms, contact BCBSNC at or call the Employee Service Center at VoiceNet or You must send the initial claim within 12 months of the date of service Note: A claim form will be treated by the plan as having been filed on the date it is received. To BCBSNC Claims Department PO Box 35 Durham, NC Questions If you have claim questions, you may call BCBSNC Customer Service at or Magellan at HRI-SUBS Rev. 23 Page 177 of 205

178 BCBS/Magellan Appeals Process AUTHORIZED COPY Claims and Appeals BCBS/Magellan - Appeals Process Appeal of a denied claim If your claim is denied, you may request that your claim be reviewed. There is one level of appeal for Urgent Care Claims, and there are two levels of appeal for Pre-Service Claims and Post-Service Claims (the first level of appeal is mandatory, but the second level of appeal is voluntary). The Benefits Administrator is responsible for making all appeal decisions. BCBSNC/ Magellan MHSA Appeals Review First Level (urgent care, pre-service, and postservice) Step Steps to follow in the MHSA Appeals Process 1 Request an Appeal Review form by visiting the BCBSNC website at or by calling BCBSNC Customer Service at You may request an expedited appeal of a denied Urgent Care Claim. Any request for review should include: Employee's ID number Patient's name Employee s name Nature of the appeal Any other information that may be helpful for the review In connection with an appeal, you have the right to review pertinent documents and other information relevant to your claim and to submit written comments, documents and other information relevant to your appeal. Copies of all information relevant to your claim will be provided free of charge upon request. 2 Submit your written appeal within 180 days of the date on your denial notice to: BCBSNC Appeals Department Customer Service PO Box Durham, NC If you do not appeal on time, you will lose your right to appeal. You will also lose your right to file suit in court, as you will have failed to exhaust your administrative appeal rights, which is generally a prerequisite to bringing suit. 3 You will be notified in clear written terms of the decision within a reasonable time but no later than the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. If it is determined that a claim is eligible for payment, it will be processed promptly. If you are dissatisfied with the first level appeal review decision for pre-service or post-service claims, you have the right to a voluntary second level appeal review. The pre-service claims appeals process does not apply to a decision that is based on the fact that the requested services are not covered or disputes regarding the dollar amount or number of covered visits that are limited under the plan. HRI-SUBS Rev. 23 Page 178 of 205

179 Claims and Appeals BCBS/Magellan - Appeals Process BCBSNC/ Magellan MHSA Appeals Review Second Level (pre-service & postservice only) Step Steps to follow in the MHSA Appeals Process 1 If your appeal is denied you may request a voluntary review of your denied claim. Your request should include any additional information you believe may affect the outcome of the review. You will have the right to examine all relevant documents and to submit written issues and comments about your claim. 2 Submit your written request for a voluntary second level appeal review within 180 days of the first level appeal review decision to: BCBSNC Appeals Department PO Box Durham, NC If your voluntary second level appeal is denied, you will receive written notice from the Benefits Administrator within 15 days of receipt of pre-service claims or within 30 days of receipt of post-service claims. The notice will generally include the same information that was included in your earlier denial notices. The second level appeal of a benefits dispute is voluntary under ERISA. It is not necessary to complete a second level appeal before bringing a civil action under Section 502(a) of ERISA. With respect to second level reviews of benefits disputes, The plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to a second level appeal; Any statute of limitations or other defense based on timeliness will be tolled during the time that any such voluntary appeal is pending; You may submit a benefits dispute to a second level appeal only after completing a first level appeal; The plan will provide you, upon request, sufficient information relating to a second level of appeal to enable you to make an informed judgment about whether to request a second level of appeal; and No fees or costs will be imposed on you as part of a second level of appeal. If the Benefits Administrator fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Benefits Administrator decides in its discretion that you are entitled to them. Appeals Step Independent Review Organization (IRO) Review External Review 1 Once you have exhausted the internal claims and appeals process described above, you may be able to file an appeal with an independent review organization (IRO) that is accredited to conduct external review. External review is available only after internal appeals are exhausted and is available only for certain types of adverse benefit determinations, as defined by federal regulations. If you wish to file a request for external review, refer to the Voluntary External Review Program under the Benefit Claims and Appeals Procedures section above. HRI-SUBS Rev. 23 Page 179 of 205

180 Claims and Appeals UMR - Dental Claims Filing UMR Dental Claims Filing Filing a dental claim A claim form is required when filing dental services with UMR. The Group Dental Claim Form (FRM-SUBS-00877) is available online through ProgressNet and from the Employee Service Center. You may also use the standard dental claim form available from your dentist. Retain a copy of the form and statement for your records. You must send the initial claim within 12 months of the date the expense was incurred. Note: You should hold claims until you have enough expenses to meet the deductible. After the deductible has been satisfied, you should wait until you have incurred $50 of additional expenses or the end of the calendar year to file additional claims. To UMR - Dental Claim Services PO Box Salt Lake City, UT You will receive an explanation of benefits indicating how your claim was processed and the amount of benefits, if any, that were paid. Your dentist will also receive a copy of the explanation of benefits if you elect to have the payment sent directly to the dentist. The plan and UMR reserve the right to require verification of any fact or assertion concerning any claim for covered dental expenses to ensure that benefits are paid appropriately. Submission of x-rays and other appropriate diagnostic materials may be requested. Failure to provide the requested information could result in the denial of the claims involved. Filing claims under more than one plan Original statements should be submitted to the primary plan first if two or more plans are involved. When the primary plan responds, send a copy of that plan s explanation of benefits and copies of the bills to the secondary plan for payment consideration. If this plan is secondary, it will not pay any benefit that would have been paid by the primary plan even if the claim was not filed with the primary plan. Claim questions Call UMR at if you have claim questions. Have available a copy of your charges, your explanation of benefits, and any other correspondence you may have received. HRI-SUBS Rev. 23 Page 180 of 205

181 UMR Dental Appeals Process AUTHORIZED COPY Claims and Appeals UMR - Dental Appeals Process Appeal of a denied claim If a claim for benefits under the plan is partially or wholly denied, you will receive written notice of the denial within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. UMR Appeals Step Steps to follow in the UMR Appeals Process Review First Level 1 To appeal the denial of a dental claim, you must send a written request to the Benefits Administrator. Any request for review should include: Employee's ID number Employee's name Any other information that may be helpful for the review Patient's name Nature of the appeal 2 Submit your written appeal within 180 days of the date of the initial denial notice to: UMR PO Box Salt Lake City, UT You will be informed in writing of the decision on review within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. If you are dissatisfied with the first level appeal review, you have the right to a voluntary second level appeal review. The plan waives any right to assert that you failed to exhaust administrative remedies if you do not elect this second, voluntary level of appeal, and the plan agrees that any statute of limitations or defense based on timeliness will be waived during the time that any voluntary appeal is pending. Second Level 1 Submit your written request for a voluntary, final, second level appeal review to the Plan Administrator within 180 days of receipt of the denial of your first level appeal to the address below. The letter should include any additional information you believe may affect the outcome of the review. Progress Energy Service Company, LLC PO Box 1551 Raleigh, NC You and your legal representative will have the right to examine all relevant documents and to submit written issues and comments about your claim. 2 The claim will be reviewed, including all information submitted with the original claim and review requests. A final decision will be made as soon as possible but no later than 30 days after the second review request is received, unless a 30-day extension is requested. HRI-SUBS Rev. 23 Page 181 of 205

182 Claims and Appeals UMR - Dental Appeals Process UMR Appeals Review Step Steps to follow in the UMR Appeals Process You will receive a written notice of the results of this review. The notice will include the reasons for the decision, will refer to the plan provisions on which the decision is based and will include the additional information included in your first notice of denial upon review described above. The second level appeal of a benefits dispute is voluntary under ERISA. It is not necessary to complete a second level appeal before bringing a civil action under Section 502(a) of ERISA. With respect to second-level reviews of benefits disputes: The plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to a second level appeal; Any statute of limitations or other defense based on timeliness will be tolled during the time that any such voluntary appeal is pending; You may submit a benefits dispute to a second level appeal only after completing a first level appeal; The plan will provide you, upon request, sufficient information relating to a second level of appeal to enable you to make an informed judgment about whether to request a second level of appeal; and No fees or costs will be imposed on you as part of a second level of appeal. If the Insurer fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Insurer decides in its discretion that you are entitled to them. HRI-SUBS Rev. 23 Page 182 of 205

183 Vision Service Plan Claims Filing AUTHORIZED COPY Claims and Appeals VSP - Claims Filing Filing a vision claim If you use an in-network provider, the in-network provider will submit the claim to VSP on your behalf. If you use an out-of-network provider, you must pay the entire bill when you receive services and file a claim to receive reimbursement (up to the out-of-network plan limit): You must send the initial out-of-network claim within Six months of the date the expense was incurred and include the following: Itemized bill listing the services you received Name, address, and phone number of the out-ofnetwork doctor Name of the group (Progress Energy) that provides the coverage Employee's name, Social Security number, address, and phone number Patient's name, date of birth, address, and phone number Patient's relationship to the covered member (self, spouse, child, etc.) To Vision Service Plan Attn: Out-of-Network Provider Claims PO Box Sacramento, CA You should keep a copy of the information for your records. HRI-SUBS Rev. 23 Page 183 of 205

184 Vision Service Plan Appeals Process AUTHORIZED COPY Claims and Appeals VSP - Appeals Process Appeal of a denied claim If a claim for benefits under the plan is partially or wholly denied, you will receive written notice of the denial within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. VSP Appeals Step Steps to follow in the VSP Appeals Process Review First Level 1 To appeal the denial of a vision claim, you must send a written request to the Insurer (Vision Service Plan). Any request for review should include: Employee's ID number Patient's name Employee's name Nature of the appeal Any other information that may be helpful for the review 2 Submit your written appeal within 180 days of the date of the initial denial notice to: Vision Service Plan PO Box 2350 Rancho Cordova, CA You will be informed in writing of the decision on review within the timeframes outlined under the Benefit Claims and Appeals Procedures section above, and such notification will include the information described under that same section. If your claim is denied on review, you also have the opportunity for a voluntary second level appeal review. The plan waives any right to assert that you failed to exhaust administrative remedies if you do not elect this second, voluntary level of appeal, and the plan agrees that any statute of limitations or defense based on timeliness will be waived during the time that any voluntary appeal is pending. Second Level 1 Your request for a voluntary, final, second level appeal must be submitted in writing to the Insurer (Vision Service Plan). This request should include any additional information you believe may affect the outcome of the review. You and your legal representative will have the right to examine all relevant documents and to submit written issues and comments about your claim. 2 Submit your written appeal within 180 days of the date of the initial denial notice to: Vision Service Plan PO Box 2350 Rancho Cordova, CA The claim will be reviewed, including all information submitted with the original claim and review requests. A final decision will be made as soon as possible but not later than within the timeframes outlined under the Benefit Claims and Appeals Procedures section above. HRI-SUBS Rev. 23 Page 184 of 205

185 VSP Appeals Review Step Steps to follow in the VSP Appeals Process AUTHORIZED COPY Claims and Appeals VSP - Appeals Process You will receive a written notice of the results of this review, and such notification will include the information described under the Benefit Claims and Appeals Procedures section above. The second level appeal of a benefits dispute is voluntary under ERISA. It is not necessary to complete a second level appeal before bringing a civil action under Section 502(a) of ERISA. With respect to second-level reviews of benefits disputes: The plan waives any right to assert that you have failed to exhaust administrative remedies because you did not elect to submit a benefit dispute to a second level appeal; Any statute of limitations or other defense based on timeliness will be tolled during the time that any such voluntary appeal is pending; You may submit a benefits dispute to a second level appeal only after completing a first level appeal; The plan will provide you, upon request, sufficient information relating to a second level of appeal to enable you to make an informed judgment about whether to request a second level of appeal; and No fees or costs will be imposed on you as part of a second level of appeal. If the Insurer fails to follow the procedures outlined above consistent with the requirements of ERISA with respect to your claim, you will be deemed to have exhausted all administrative remedies under the plan and will have the right to bring a civil action under Section 502(a) of ERISA. Benefits under the plan will be paid only if the Insurer decides in its discretion that you are entitled to them. HRI-SUBS Rev. 23 Page 185 of 205

186 When Coverage Ends When Coverage Ends Generally, coverage will continue as long as you make the necessary contributions and continue to meet the eligibility requirements under the Progress Energy-sponsored plans. When Eligibility Ends Eligibility for medical (includes prescription drug coverage, as well as mental health and substance abuse coverage under the EAP and MHSA Services Plan), EAP, dental and vision services will end if one of the following events occurs: Your employment status changes and you no longer meet the employee eligibility criteria and you are not reclassified as an LTD recipient or retired employee. You transfer to a non-participating subsidiary. Your employment status changes from an employee of a participating subsidiary to a Progress Energy Florida, Inc. bargaining unit employee. (Progress Energy Florida, Inc. bargaining unit employees are eligible for benefits under the FlexPower program.) You are an employee of a participating subsidiary that terminates its participation in the plan or leaves the controlled group of companies. The plan is terminated. (Eligibility for services will end on the date of such termination.) Your death. When Eligibility Ends for Dependents Coverage for your dependents continues as long as your coverage does, unless your dependents no longer meet the eligible dependent definition. When a dependent is no longer eligible for coverage, you should complete an employer-provided Choice Benefits Change Form (FRM-SUBS-00011) or retiree change form to drop the dependent from your coverage within 30 days of the loss of eligibility. Coverage will end on the date your dependent loses eligibility. Eligibility for dependent children ends at 11:59 p.m. on the day before their 26 th birthday. Employees who cover ineligible dependents are in violation of the company s Code of Ethics and may be subject to disciplinary action up to and including termination of employment. They may also be required to pay damages and costs to the company, including reimbursement of any benefit payments made with respect to an ineligible dependent. In addition, if a dependent becomes ineligible, you must notify the Employee Service Center within 60 days in order for the dependent to be eligible for COBRA coverage. When Coverage Ends Terminated Employees Coverage will end if you terminate employment. The coverage will terminate on the last day of the base pay period in which your employment terminates. Terminated employees and their dependents are not eligible to continue coverage, unless they qualify for COBRA coverage as described in the COBRA Coverage section. Surviving Dependents If you die as a regular, full-time non-bargaining employee, LTD recipient, or retired employee, your eligible dependents may be covered as surviving dependents. As an alternative, your covered dependents may elect coverage as COBRA participants. HRI-SUBS Rev. 23 Page 186 of 205

187 When Coverage Ends Eligible surviving dependents may continue their coverage without interruption, waive coverage or elect coverage if they apply within 30 days after the Employee Service Center is informed of your death and pay the required contributions (as described below) in a timely manner. If your surviving spouse or domestic partner is eligible for other employer-sponsored coverage, he or she will not be eligible to elect coverage as a surviving dependent. If your spouse or domestic partner is no longer eligible for other employer-sponsored coverage, he or she will be eligible to elect coverage as a surviving dependent within 30 days of the loss of coverage. Coverage on a surviving spouse or domestic partner will permanently terminate if he or she remarries or establishes a new domestic partner relationship. Coverage for a dependent child will terminate when the child no longer meets the eligible dependent definition. Surviving dependents who no longer meet the eligibility requirements of the plan may be eligible for COBRA coverage. Contributions for coverage of surviving dependents Plan participants of Progress Energy Carolinas, Inc., Progress Energy Service Company, LLC, and Progress Energy Ventures Inc. who become surviving dependents Surviving dependents of regular, full-time non-bargaining employees, LTD recipients, or retired employees of a participating subsidiary who are eligible for Progress Energy-sponsored medical, dental and vision coverage may continue or elect coverage at Progress Energy full cost rates. New dependents may not be added to the coverage. Plan participants of Progress Energy Florida, Inc. (non-bargaining employees), Progress Fuels (corporate employees), and Progress Telecom who became surviving dependents On or after January 1, Surviving dependents of active employees on or after January 1, 2002 or of retired employees who retired after January 1, 2002, who were plan participants or eligible to be a plan participant and who met the eligibility requirements to continue Progress Energy-sponsored medical, dental and vision coverage may continue Progress Energy-sponsored medical, dental and vision coverage or elect coverage at full-cost rates. New dependents may not be added to the coverage. Prior to January 1, Surviving dependents of retired non-bargaining employees who retired on or before January 1, 2002, and were eligible for coverage under the Employees Group Comprehensive of Florida Power Corporation at the time of retirement are eligible to continue or elect medical coverage under the Progress Energy-sponsored medical plan if the retiree had completed 15 years of continuous active service. The surviving dependent spouse s or domestic partner s medical contribution is based on the age/service matrix percent at retirement if retirement is on or after January 1, The matrix is available from the Employee Service Center. Retirements prior to January 1, 1993, have no spouse or domestic partner contribution. Dependent child coverage is paid 100% by the surviving spouse or domestic partner. New dependents may not be added to the coverage. These surviving dependents are not eligible for dental or vision. HIPAA Certificates of Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires employers to issue certificates of coverage to employees and their dependents when coverage is lost under the employer s plan due to termination of employment or loss of dependent eligibility. The certificate may be used to reduce or eliminate the length of time coverage may be excluded for pre-existing conditions under a new employer s plan. Certificates of coverage are automatically issued to employees and their dependents following their coverage termination. HRI-SUBS Rev. 23 Page 187 of 205

188 Cobra Coverage AUTHORIZED COPY Cobra Coverage If coverage under the health benefit plans terminates because of a qualifying event, you and your covered dependents may elect to continue participation in the plans under the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA). Domestic partners and their eligible dependents are eligible for COBRA-like continuation coverage under the same terms as those provided to employees and their eligible dependents. An individual who is eligible to continue coverage under the provisions of COBRA is known as a qualified beneficiary. Eligibility for COBRA You become eligible for COBRA coverage if you would otherwise lose coverage due to a qualifying event. A qualifying event is one of the events listed below, when the event causes a loss of eligibility under the plans. Both the event itself and the resulting loss of benefits must occur in order to create a qualifying event as defined by COBRA. Qualifying events include: For you: Termination of your employment with a participating subsidiary for any reason other than gross misconduct. Reduction in your hours of employment. For your spouse or domestic partner: Your death. Termination of your employment (for reasons other than gross misconduct) or a reduction in your hours of employment. Your entitlement to Medicare. Divorce or legal separation, or termination of your domestic partner relationship. For your dependent children: Your death. Termination of your employment (for reasons other than gross misconduct) or a reduction in your hours of employment. Your entitlement to Medicare. Divorce or legal separation, or termination of your domestic partner relationship. Loss of dependency status (including a child reaching age 26). For retirees and their dependents: Loss of your coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy) United States Code with respect to your employer (this is a qualifying change only for retired employees and dependents, including surviving dependents of retired employees). Plans Covered Under COBRA In accordance with COBRA, you have the opportunity to continue your participation in the employer-sponsored medical (including prescription drug coverage, as well as mental health and substance abuse services under the EAP and MHSA Services Plan), EAP, dental and vision plans under certain circumstances. These circumstances are called qualifying events. HRI-SUBS Rev. 23 Page 188 of 205

189 Cobra Coverage Responsibility of Employer to Provide Notice If health coverage (medical, dental, and/or vision) is lost because of termination of employment, reduction in work hours, death of the employee, employee becoming eligible for Medicare benefits, or commencement of a proceeding in bankruptcy with respect to your employer, you and your eligible dependents will automatically be notified of your COBRA rights. Your Responsibility to Notify Your Employer If you have a qualifying event due to a divorce, termination of domestic partner relationship, legal separation or a dependent no longer meets the dependent definition, a Choice Benefits Change Form (FRM-SUBS-00011) or retiree change form has to be completed by you, your spouse or your domestic partner and received within 30 days by the Employee Service Center to modify your coverage (see Changing Your Elections under Enrollment and Changes above). The Employee Service Center may be contacted at to request forms and assistance. If you do not notify your employer within 60 days from the date of the qualifying event, then your dependent will not be offered COBRA. After being notified within 60 days that a qualifying event has occurred, the employer will send notification of COBRA rights to the individuals for whom you completed a change form. You and/or your eligible dependents have 60 days from the date you would lose coverage because of one of the events described above, or 60 days from the date you are notified of your right to elect continuation coverage under COBRA, if later, to make an election under COBRA. If a COBRA election is not made during this 60-day election period, continuation of coverage will not be available. COBRA Elections Each qualified beneficiary may make a separate election to purchase COBRA coverage when a qualifying change occurs. For example, if you terminate employment and do not want to purchase COBRA coverage, your spouse, domestic partner and dependent children still have the opportunity to do so. Qualified beneficiaries who purchase coverage are eligible to participate in the plans annual benefits enrollment period. Cost of Cobra Coverage The cost of continuing coverage under COBRA is 102% of the plan s full cost rate (100% of the full cost of the coverage plus a 2% administrative fee). For example, if the total cost of employee medical coverage is $300 per month for employee and employer contributions combined, the cost for COBRA coverage would be $306 per month for medical. During the 11-month extension period for disabled qualified beneficiaries (discussed below), the cost increases to 150% of the total cost of the coverage beginning with the 19th month of COBRA coverage. Your first payment covering the notification and election period is due no later than 45 days after the election is made. Subsequent payments are due on a monthly basis. All subsequent payments will have a 30-day grace period. Premium amounts are subject to change, even during a COBRA coverage period. COBRA participants will be notified of any change. If your salary does not exceed 100% of the official poverty line and it is cost-effective, the state in which you live may be required to pay your COBRA premiums. Contact your state s Department of Human Services for more information. HRI-SUBS Rev. 23 Page 189 of 205

190 Cobra Coverage Partial Payments If a partial COBRA payment is received that is not significantly less than the amount required to be paid for the period of coverage, the qualified beneficiary will receive a notice regarding the underpayment. The qualified beneficiary will be allowed 30 days from the date of receipt of the notice to make the necessary payment. Under the regulations, an insignificant shortfall is defined as an underpayment that does not exceed the lesser of $50 or 10% of the full amount required to be paid for COBRA coverage. When a partial payment with a significant shortfall is received, COBRA coverage will be terminated as explained below in Termination of COBRA Coverage. Maximum Period of Coverage Your covered dependents may be eligible for COBRA coverage for up to 36 months if coverage is lost because of one of the following qualifying events: Your death. You become entitled to Medicare. Divorce or legal separation, or termination of your domestic partner relationship. Loss of dependency status by a dependent. You and your eligible dependents may be eligible for COBRA coverage for up to 18 months (except in certain cases of disability) if you lose coverage because of one of the following qualifying events: Termination of your employment with a participating subsidiary for any reason other than gross misconduct. Reduction of your work hours. The 18-month period may be extended to 36 months for your eligible dependents if divorce, legal separation, your death, your becoming entitled to Medicare benefits or loss of dependent status occurs during the initial 18-month period following either of the two qualifying events above. If a qualified beneficiary is eligible for the 18 months of coverage and is disabled (as determined by the Social Security Administration) on the date of the qualifying event, or at any time during the first 60 days of continued coverage, the 18-month coverage period may be extended by an additional 11 months for a total of up to 29 months of COBRA coverage from the date of the first qualifying event. This extension is designed to permit the individual to continue coverage until becoming entitled to Medicare. A disabled qualified beneficiary who becomes eligible for the special 11-month extension must notify the COBRA administrator within 60 days of the Social Security determination of disability and prior to the end of the 18-month continuation period. The employer can charge up to 150% of the applicable premium during the 11-month disability extension. If coverage is extended to 29 months, coverage will cease upon a final determination that the qualified beneficiary is no longer disabled. The disabled individual must notify the employer within 30 days of any final determination that he or she is no longer disabled. Termination of COBRA Coverage A qualified beneficiary s COBRA coverage will be terminated before the end of the applicable maximum period if: The qualified beneficiary becomes entitled to Medicare.* The qualified beneficiary becomes covered under another group health plan that does not contain any exclusion or limitation for a pre-existing condition of the beneficiary. The qualified beneficiary s contribution (premium payment) is not paid on time or is in an amount that demonstrates a significant shortfall. All Progress Energy-sponsored benefit plans are terminated. The qualified beneficiary, with coverage extended to 29 months, is determined by the Social Security Administration to be no longer disabled. HRI-SUBS Rev. 23 Page 190 of 205

191 Cobra Coverage *Note: If you become entitled to Medicare after you elect to continue coverage under COBRA, your continued coverage will end on the date of your Medicare entitlement. Your covered dependents, however, may be eligible for 36 months of continued coverage from the date of the original qualifying event. HIPAA restricts the extent to which group health plans may impose pre-existing condition limitations, as follows: If you become covered by another group health plan and that plan contains a pre-existing condition limitation that affects you, your COBRA coverage cannot be terminated. However, if the other plan s pre-existing condition does not apply to you by reason of HIPAA s restrictions on pre-existing condition clauses, the employer may terminate your COBRA coverage. The law also says that, at the end of the 18-month, 29-month or 36-month continuation coverage period, you must be allowed to enroll in an individual conversion health plan if such an individual conversion health plan is otherwise generally available under the plan. Conversion to an individual policy is not available under the Progress Energy health plans. If a qualified beneficiary's COBRA coverage is terminated for any of the above-referenced reasons, or the qualified beneficiary elects to discontinue coverage before the end of the applicable maximum period of coverage, the qualified beneficiary will not be eligible to re-elect coverage at a later date. If COBRA coverage is denied or terminated, qualified beneficiaries and eligible dependents will be notified in writing as to why coverage was denied or is being terminated. Other COBRA Information Multiple Qualifying Events Should your dependents experience more than one qualifying event while COBRA coverage is still active, they may be eligible for an additional period of continued coverage, not to exceed a total of 36 months from the date of the first qualifying event. For example, if you terminate employment, you and your dependents may be eligible for 18 months of continued coverage. During this 18-month period, if your dependent child ceases to be a dependent under the plan (a second qualifying event) your child may be eligible for an additional period of coverage not to exceed a total of 36 months from the date of your termination. To be eligible for extended coverage after a second qualifying event, you or your dependent must notify the employer within 60 days of the second qualifying event by calling the Employee Service Center. Changing Your COBRA Election While you are continuing coverage under COBRA, you and your covered dependents may change your health care elections during the annual enrollment period. You will have the same options available to active employees and any changes to the plans for active employees will automatically apply to your and your dependents COBRA coverage. The full cost rates for the coming year will also apply (plus the 2% administrative fee). If you did not elect COBRA during the 60-day election period, you may not elect it during a subsequent annual enrollment period. During the year, you may also make certain qualified status changes to your coverage, including: Add a new spouse or domestic partner or newborn or newly adopted child (or a child placed with you for adoption) to your health care coverage. Add an eligible dependent who loses other health care coverage. Add a dependent to your health care coverage if required by a Qualified Medical Child Support Order or other family relations judgment. Change your health plan if you move out of a plan s coverage area (applies to medical only). HRI-SUBS Rev. 23 Page 191 of 205

192 Cobra Coverage You must notify the employer within 60 days of the event to change your coverage under COBRA. If you provide notice within 30 days of the date of your status change, your change in coverage will be effective on the date of your status change. If you provide notice after 30 days but within 60 days, your change will be effective on the date you notify the employer. In the case of a domestic relations judgment, decree or order, the child will be covered from the date specified in the judgment, decree or order. If you are on a Family and Medical Leave (FMLA) If you have taken a leave of absence under the Family and Medical Leave Act (FMLA) and you do not return to work at the end of your FMLA leave, you may elect COBRA coverage. You will experience a qualifying event on the last day of your FMLA leave, which is the earliest of: When you inform the employer that you are not returning at the end of the leave. The end of the leave, assuming you do not return. When the FMLA entitlement ends. For the purpose of the FMLA leave, you will be eligible for COBRA, as described earlier, only if: You or your dependents are covered by the plan on the day before the leave begins (or become covered during the FMLA leave). You do not return to employment at the end of the FMLA leave. You or your dependents lose coverage under the plan before the end of what would be the maximum COBRA continuation period. Note: You do not have to show that you are insurable to choose continuation coverage. However, continuation coverage under COBRA is provided subject to your and your dependents eligibility for coverage under the plan. Progress Energy reserves the right to terminate your continuation coverage if you are determined to be ineligible. HRI-SUBS Rev. 23 Page 192 of 205

193 Other Important Information AUTHORIZED COPY Other Important Information Section Contents Plan Information Pgs Provider Compensation 194 Health Insurance Portability and 194 Accountability Act (HIPAA) Other Participant Notices 195 Plan Administration Pgs Plan Identification 196 Costs and Funding 196 Administration 196 Plan Administrator 196 Benefits Administrators 197 Prescription Drug Program Benefits 197 Administrators Mental Health and Substance Abuse 198 Services Benefits Administrators Dental Plan Benefits Administrators 198 Vision Plan Benefits Administrators 198 Participating Subsidiaries 198 Agent for Service of Legal Process 198 Continuation of the Plan and Plan 199 Amendments Your Rights Under ERISA Pgs Receiving Information About Your Plan 200 and Benefits Prudent Actions by Plan Fiduciaries 200 Enforcing Your Rights 200 HRI-SUBS Rev. 23 Page 193 of 205

194 Plan Information AUTHORIZED COPY Other Important Information Plan Information Provider Compensation The relationship between the plan s Benefits Administrators and participating providers is contractual. Compensation for participating providers is based on a variety of payment mechanisms. For example, some providers receive a fee each time they provide covered services to a plan participant; others are paid a global rate for a particular category of service; and others are paid a set dollar amount each month for each plan participant on their member panel whether or not the participants receive services. Payment methods for participating providers may also include financial incentive agreements such as withholds and bonuses which may be based on factors such as member satisfaction, quality of care, control of costs, and use of services. For additional information on participating provider compensation, contact the applicable Benefits Administrator. Health Insurance Portability and Accountability Act (HIPAA) HIPAA Privacy Rule The plans are required to handle protected health information ( PHI ) about you in keeping with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). HIPAA limits both the purposes for which the plans may use or disclose PHI and the persons who may have access to PHI. Further, as a result of HIPAA, both the plans and Progress Energy are required to take certain protective measures with respect to PHI. A description of how PHI about you may be used and disclosed and your rights under HIPAA s Privacy Rule may be found in the plans Notice of Privacy Practices ( NPP ) available from the plans Privacy Official. HIPAA Security Rule The Plan Sponsor shall reasonably and appropriately safeguard electronic protected health information created, received, maintained, or transmitted to or by Progress Energy on behalf of the plans. Progress Energy shall: (i) (ii) (iii) (iv) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the plans. Ensure that the adequate separation required by (f)(2)(iii) of the HIPAA Security Regulation is supported by reasonable and appropriate security measures. Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement reasonable and appropriate security measures to protect the information. Report to the plans any security incident of which it becomes aware. The Privacy and Security Officials may be contacted by phone at or [email protected]. HRI-SUBS Rev. 23 Page 194 of 205

195 Other Important Information Plan Information Other Participant Notices Genetic Information Nondiscrimination Act The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to any request for medical information. Genetic information as defined by GINA, includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Women's Health and Cancer Rights Act of 1998 The Women's Health and Cancer Rights Act of 1998 (WHCRA) requires group health plans that cover mastectomies to also cover reconstructive surgery and other related services following a mastectomy. The services to be covered include (1) reconstruction of the breast upon which the surgery was performed, (2) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (3) provision of prostheses and treatment of any complications at all stages of the mastectomy. The services are subject to the plan's annual deductible and coinsurance provisions. Newborns and Mothers Health Protection Act The Newborns and Mothers Health Protection Act (NMHPA) states that group health plans and health and insurance issuers offering group health insurance coverage 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 normal 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 and issuers may not, under Federal law, require that a provider obtain authorization from the plan or insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Mental Health Parity Law As of January 1, 2011, the company-sponsored medical plans are in full compliance with revised rules under the Mental Health Parity and Addiction Equity Act of Generally, this act prohibits more restrictive benefit limitations for mental health/substance abuse services than for other medical/surgical services. Choosing HMO Primary Care Providers AvMed HMO and BlueCare HMO generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in their network and who is available to accept you or your family members. Until you make this designation, AvMed or BlueCare designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact AvMed at or BlueCare at For children, you may designate a pediatrician as the primary care provider. Female HMO members do not need prior authorization from AvMed or BlueCare or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in their network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or following procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact AvMed at or BlueCare at HRI-SUBS Rev. 23 Page 195 of 205

196 Plan Administration AUTHORIZED COPY Other Important Information Plan Administration Plan Identification The Progress Energy, the Progress Energy Employee Assistance and Mental Health & Substance Abuse Services Plan, the Progress Energy Dental Plan and the Progress Energy Vision Plan are each separate component plans under the Progress Energy, Inc. Welfare Benefit Plan (the Plan ). The three-digit plan number for the plan is 526. The employer identification number (EIN) issued by the Internal Revenue Service for Progress Energy, Inc., the Plan s sponsor, is The Plan Sponsor s address is: Progress Energy, Inc. PO Box 1551 Raleigh, NC Costs and Funding Progress Energy (including MHSA), Progress Energy Dental Plan, Progress Energy Vision Plan Benefits and operating expenses are funded through contributions from participating subsidiaries of Progress Energy, Inc. and participating participants. Progress Energy Employee Assistance Program Benefits and operating expenses are funded from the general assets of the participating subsidiaries of Progress Energy, Inc. Administration The plan is a welfare plan as defined by the Employee Retirement Income Security Act of 1974 (ERISA), as amended. The plan year ends on December 31 of each year and the plan operates and maintains records on a calendar year basis. Plan Administrator A Plan Administrator has been appointed, as required by law, to be responsible for the operation of the plan. The Plan Administrator has overall responsibility for the operation of the plan and controls the administration of the plan. The Plan Administrator has the discretionary authority to interpret the plan and to decide any and all matters arising thereunder, including but not limited to matters related to eligibility for benefits, application of plan limitations, and the amount of any required contributions by or on behalf of any participants. The Plan Administrator has delegated to the Benefits Administrators the exclusive authority in their sole discretion to determine claims for benefits under the plan and to review denied claims for benefits on appeal, including the authority to interpret applicable provisions of the plan and to make factual determinations. Although the Plan Administrator and Benefits Administrators have the right to interpret the provisions of the plan and to decide all matters arising thereunder, the Plan Administrator and Benefits Administrators do not have the authority to deviate from the provisions of the plan, or to approve any exceptions to the plan. The Plan Administrator and Benefits Administrators have a fiduciary obligation under applicable law to apply the provisions of the plan as written. HRI-SUBS Rev. 23 Page 196 of 205

197 Other Important Information Plan Administration If it should become necessary to contact the Plan Administrator, call or write referring to the plan identification number. The Plan Administrator is: Progress Energy Service Company, LLC PO Box 1551 Raleigh, NC The Employee Service Center provides administrative services for plan participants and can be reached at the address above, by calling or by at Benefits Administrators The Plan Administrator has delegated authority to decide medical claims and appeals to the following Benefits Administrators: AvMed HMO Benefits Administrator AvMed HMO 1511 N. Westshore Blvd., Suite 700 Tampa, FL Telephone Number: BCBSF Benefits Administrator Blue Cross and Blue Shield of Florida PO Box Jacksonville, FL Telephone Number: BlueCare HMO Benefits Administrator BlueCare HMO PO Box Jacksonville, FL Telephone Number: UnitedHealthcare Benefits Administrator UnitedHealthcare 450 Columbus Blvd. Hartford, CT Telephone Number: BCBSNC Benefits Administrator Blue Cross Blue Shield of North Carolina PO Box 2291 Durham, NC Telephone Number: Prescription Drug Program Benefits Administrators The Plan Administrator has delegated authority to decide prescription drug claims and appeals for participants in a Progress Energy, Inc.-sponsored medical plan to the following Benefits Administrators: Retail (AvMed HMO) AvMed 1511 N. Westshore Blvd., Suite 700 Tampa, FL Retail (BlueCare HMO) BlueCare Pharmacy Network PO Box Jacksonville, FL Mail Order (AvMed HMO) Medco Health, Inc. PO Box Cincinnati, OH Mail Order (BlueCare HMO) Prim Pharmacy PO Box Dallas, TX Retail (all PPO plans except HDHP) Catalyst Rx 8601 Six Forks Road, Suite 400 Raleigh, NC Mail Order (all PPO plans except HDHP) Walgreens Mail Services PO Box Orlando, FL HRI-SUBS Rev. 23 Page 197 of 205

198 Other Important Information Plan Administration Retail (HDHP) Prime Therapeutics Mail Route: BCBSNC PO Box Lexington, KY Mail Order (HDHP) Prim PO Box Dallas, TX Mental Health and Substance Abuse Services Benefits Administrators The Plan Administrator has delegated authority to decide mental health and substance abuse claims and appeals to the following Benefits Administrators: ValueOptions (for all plans except HDHP) 3800 Paramount Parkway, Suite 300 PO Box Morrisville, NC BCBSNC (for HDHP only) Claims Department PO Box 35 Durham, NC Dental Plan Benefits Administrator The Plan Administrator has delegated authority to decide dental claims and appeals to the following Benefits Administrator: UMR PO Box Salt Lake City, UT Vision Plan Benefits Administrator The Plan Administrator has delegated authority to decide vision claims and appeals to the following Benefits Administrator: Vision Service Plan 3090 Governors Lake Drive, Suite 240 Norcross, GA Participating Subsidiaries Non-bargaining employees of the following participating subsidiaries of Progress Energy, Inc. may be covered by this plan subject to all eligibility requirements stated herein. Progress Energy Carolinas, Inc. Progress Energy Florida, Inc. Progress Energy Service Company, LLC Agent for Service of Legal Process Legal process may be served upon the Plan s Agent, Sponsor or Administrator. The Plan s Agent for service of legal process is: Vice President - Human Resources Progress Energy Service Company, LLC PO Box 1551 Raleigh, NC HRI-SUBS Rev. 23 Page 198 of 205

199 Other Important Information Plan Administration Continuation of the Plan and Plan Amendments The Plan Sponsor reserves the right to amend or terminate the plan or any plan benefit at any time based on the cost of the benefits or other considerations without prior approval of or notification to any party. HRI-SUBS Rev. 23 Page 199 of 205

200 Your Rights Under ERISA AUTHORIZED COPY Other Important Information Your Rights Under ERISA The following statement is provided in compliance with the requirements of the Employee Retirement Income Security Act of 1974 (ERISA), as amended. Receiving Information About Your Plan and Benefits As a participant in the Progress Energy, Inc. Welfare Benefit Plan (the Plan ), you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Examine without charge at the Plan Administrator's office and at other specified locations such as worksites, all plan documents governing the plan, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan descriptions. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue health plan coverage for yourself, spouse, domestic partner or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Enforcing Your Rights Under ERISA, there are steps that you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court once you have exhausted the internal administrative claims and appeals process under the plan. In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees (for example, if it finds your claim is frivolous). HRI-SUBS Rev. 23 Page 200 of 205

201 Other Important Information Your Rights Under ERISA If you have any questions about your plan, you should contact the Plan Administrator or the Employee Service Center. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue NW, Washington, DC You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. HRI-SUBS Rev. 23 Page 201 of 205

202 Contact Information AUTHORIZED COPY Contact Information Contact Information If you do not find the information you need in this SPD, turn to the resources below for additional information. Employee Service Center The Employee Service Center provides administrative services for plan participants and representatives can be reached by calling or by at Benefits Administrators The chart below and continued on the next several pages provides the contact information for the Progress Energy health benefit plans Benefits Administrators. Medical AvMed HMO Customer Service hour nurse line N. Westshore Blvd Suite 700 Tampa, FL Member Services PO Box 749 Gainesville, FL AvMed HMO Group # Medical Prescription Drugs Mental Health/Substance Abuse and EAP AvMed (retail) Medco (mail order) Customer Service Medco Health Solutions of Fairfield PO Box Cincinnati, OH ValueOptions Claims/Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Paramount Pkwy, Suite 300 Morrisville, NC Medical BlueCare HMO Group #570XX Medical Prescription Drugs Mental Health/Substance Abuse and EAP BlueCare HMO Customer Service PO Box Jacksonville, FL BCBSF (forms/retail) Prim Pharmacy (mail order) Customer Service Prim Pharmacy PO Box Dallas, TX CVS Caremark Specialty Pharmacy Fax Enrollment and order are located at under Physicians & Providers, Tools & Resources, Forms ValueOptions Claims/Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Paramount Pkwy, Suite 300 Morrisville, NC HRI-SUBS Rev. 23 Page 202 of 205

203 Contact Information Medical BCBSF Customer Service Pre-certification Condition Management TTY BCBSF Standard and Choice Plans Group #57040 Medical Prescription Drugs Mental Health/Substance Abuse and EAP Catalyst Rx (retail) Customer Service Catalyst Rx 800 King Farm Blvd Rockville, MD ValueOptions Claims/Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Jacksonville, FL Walgreens (mail order) Refills Customer Service Walgreens Mail Service PO Box Orlando, FL PO Box Paramount Pkwy, Suite 300 Morrisville, NC Medical BCBSNC Customer Service Condition Management Annual Enrollment Line (nonmembers) Transition of Care/ Case Mgmt Prenatal Services Pre-certification Claims BCBSNC Standard and Choice Plans Group # Medical Prescription Drugs Mental Health/Substance Abuse and EAP Catalyst Rx (retail) Customer Service Catalyst Rx 800 King Farm Blvd Rockville, MD Walgreens (mail order) Refills Customer Service Walgreens Mail Service PO Box Orlando, FL ValueOptions Claims/Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Paramount Pkwy, Suite 300 Morrisville, NC BCBSNC Claims Dept. PO Box 35 Durham, NC essenergy HRI-SUBS Rev. 23 Page 203 of 205

204 Contact Information Medical BCBSNC (HDHP) Customer Service Condition Management Annual Enrollment Line (nonmembers) BCBSNC HDHP Group # Medical Prescription Drugs Mental Health/Substance Abuse and EAP BCBS (retail) Customer Service Prime Therapeutics Mail Route: BCBSNC PO Box Lexington, KY Magellan Behavioral Health In- or out-patient facility services/ Customer Service Magellan Behavioral Health PO Box 1619 Alpharetta, GA Transition of Care/ Case Mgmt Prenatal Services Pre-certification Claims BCBSNC Claims Dept. PO Box 35 Durham, NC essenergy Prim (mail order) Customer Service CuraScript (specialty) BCBSNC Customer Service/Claims Annual Enrollment Line (nonmembers) BCBSNC Claims Dept. PO Box 35 Durham, NC ValueOptions (EAP only) Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Paramount Pkwy, Suite 300 Morrisville, NC Medical UHC Standard and Choice Plus Plans Group # UnitedHealthcare Customer Service/Claims/ Pre-certification Condition Management Medical Prescription Drugs Mental Health/Substance Abuse and EAP Catalyst Rx (retail) Customer Service PO Box Atlanta, GA (member) (general) Catalyst Rx 800 King Farm Blvd Rockville, MD Walgreens (mail order) Refills Customer Service Walgreens Mail Service PO Box Orlando, FL ValueOptions Claims/Customer Service Available 8:00 a.m. to 5:00 p.m. M-F Pre-certification Available 24/7/365 PO Box Paramount Pkwy, Suite 300 Morrisville, NC HRI-SUBS Rev. 23 Page 204 of 205

205 Contact Information HSA (associated with the HDHP) Mellon Dental UMR PO Box Salt Lake City, UT Vision Vision Service Plan Customer Service VSP Corporate PO Box Sacramento, CA Vision Service Plan Attn: Out-of-Network Provider Claims PO Box Sacramento, CA HRI-SUBS Rev. 23 Page 205 of 205