Flexible. The. benefits plan YOUR HEALTH CARE ADVANTAGE SPD. Summary Plan Description

Transcription

1 The Flexible benefits plan YOUR HEALTH CARE ADVANTAGE SPD Summary Plan Description

2 Table of Contents Overview of the Plan Eligibility Enrollment Life Events Medical Dental Vision Life Insurance and AD&D Spending Accounts Signature LegalCare Adoption Assistance LifeWorks Personal Lines Insurance Long-Term Care Insurance Cancer Expense Insurance Income Protection Plan If a Claim Is Denied Continuation of Coverage Under COBRA Plan Administration and ERISA Information Who To Call Back Cover

3 Overview of the Plan Concern for the security and well being of you and your family is the cornerstone of our benefits philosophy. We regard our benefits expenditures as an investment in your health and security. The Flexible Benefits Plan (the Plan) is designed to ensure that you receive value for the benefit dollars spent. The Plan is part of your total compensation package. The Plan offers you a variety of benefit opportunities, allowing you to customize your benefits package to meet your own unique needs. Because your needs will change over time, you can select new benefits annually. WHAT BENEFITS ARE INCLUDED IN THE PLAN? The following benefits are part of the Flexible Benefits Plan and are described in this summary plan description booklet: medical, including prescription drug coverage and mental health/substance abuse treatment dental vision employee, spouse s and children s basic life insurance* employee, spouse s and children s supplemental life insurance* employee basic accidental death and dismemberment (AD&D) insurance employee and family supplemental AD&D insurance short-term disability income long-term disability income health care spending account (HCSA) child/elder care spending account (C/ECSA) cancer expense insurance* legal* adoption assistance* personal lines insurance* long-term care* Additional important information about your coverage is described in your Insert. Keep your Insert with this booklet for reference. *Although these benefits are described in this booklet and are part of the Flexible Benefits Plan, they are not intended to be nor should they be construed to be part of the pre-tax cafeteria plan. HOW THE PLAN WORKS Each year, the Company will decide how much it will contribute toward your benefit costs. This dollar amount is provided as Flex Credits and is shown on your Enrollment Worksheet. You may use your Flex Credits to buy the benefits you want. The prices for each of the options are shown on your Enrollment Worksheet. If your choices cost less than your Flex Credits, you get the excess credits back as additional taxable income in each paycheck, prorated throughout the year. If your choices cost more than your Flex Credits, you pay the extra through payroll deductions. You can change your benefit choices each year during the annual enrollment period. The benefits you select at that time will be effective for the following calendar year, with certain exceptions for dental and vision. Overview of the Plan 1

4 The only time that you can change your benefit selections during the year is if you have a change in status, such as marriage, birth of a baby or adoption, or a significant change in your work hours that affects benefits eligibility of you, your spouse, or your dependents. See the Life Events section on page 9 for more information on changes in status. LEVELS OF COVERAGE Medical, Dental and Vision If you enroll for medical, dental or vision coverage, you ll be asked to choose one of the following levels of coverage: you only you plus spouse you plus children you plus family Cancer Expense Insurance and Legal If you enroll for legal coverage or cancer expense insurance, you can choose coverage for: you only you plus family single parent for you and your children (for cancer expense insurance only) TAXES AND YOUR BENEFITS One of the advantages of the Plan is that you can pay for many benefits on a beforetax basis. You re able to do this because the Plan falls under Section 125 of the Internal Revenue Code, which states that employees do not pay tax on the amount they pay for certain benefits. (The tax advantages for the child/elder care spending account are similar, but based on Section 129 of the Code.) You may also choose to waive coverage altogether. In order to receive credits, if applicable, you must certify that you have coverage elsewhere. The following chart shows which benefits are paid for before-tax and after-tax: Before-Tax After-Tax Medical Dental Vision Spending accounts AD&D Cancer expense insurance* Long-term disability* Supplemental employee life insurance Supplemental spouse s life insurance Supplemental children s life insurance Signature LegalCare Personal lines Long-term care *Cancer expense insurance benefits may be taxable. See page 102 for more information and consult your tax advisor for details. Long-term disability benefits are taxable. See page 113 for more information on LTD and taxes. 2 Overview of the Plan

5 PAYING FOR BENEFITS Using your Flex Credits from the Company, you can purchase the level of benefits coverage that best meets your needs. Credits are first used to purchase before-tax benefits medical, dental, vision, AD&D, spending accounts, cancer expense insurance and LTD. Leftover credits (if any) are then taxed, and you can use them to buy after-tax benefits or receive them as income. There are two types of Flex Credits: Base Credits Wellness Pledge Credits Base Credits Base Credits represent the Company s contribution to the cost of benefits. These amounts may change from year to year (as determined by the Company) and are shown on your Enrollment Worksheet. The Base Credits available to you depend on the level of coverage you select for medical coverage (i.e., you only, you plus spouse, you plus children, or you plus family). Wellness Pledge Credits Wellness Pledge Credits are added to your Base Credits if you pledge that you will maintain a healthy lifestyle. See your Enrollment Worksheet for details. Overview of the Plan 3

6 Eligibility You re eligible to participate in the Flexible Benefits Plan if you meet the eligibility requirements stated in the Insert under Eligibility. ELIGIBLE DEPENDENTS It s important that you know exactly what dependent means for each type of coverage. Medical, Dental, Vision, Life Insurance and Legal Coverage You may enroll your dependents for coverage if the dependent is: your legal spouse* an unmarried child who is: 1. a natural child; an adopted child (or a child placed for adoption); a stepchild living with you at least half of the time; a stepchild who is a full-time student away from home, provided that the stepchild lived with you at least one half of the time in the year immediately prior to the year the stepchild became a full-time student away from home; or a child for whom you are the courtappointed custodian or guardian, and 2. under age 19 and financially dependent on you, or up to age 25 if a full-time student and still financially dependent on you, or an incapacitated child (see below). *If your spouse is your legal spouse under the common law of the state in which you reside, you will be required to provide evidence of the state s law on common law marriages and evidence that you meet such legal requirements. For the Flexible Benefits Plan, placed for adoption means that you have become legally obligated to support the soon-to-beadopted child as a result of beginning the adoption process. A student is considered full time if he or she meets the requirements of full-time status for the school he or she attends. Your children s (and eligible stepchildren s) eligibility for coverage ends on December 31 of the calendar year in which they have their 19th birthday (or 25th birthday if full-time students). If your child graduates from or leaves school before the age limit is reached, coverage continues through December 31 of the year in which he or she graduates or leaves, or until he or she becomes covered through another plan, if earlier. If your dependent loses eligibility for any other reason, for example marriage, coverage ends on the date of the event. Incapacitated Children A child who becomes incapacitated before age 19 (or before age 25 if a full-time student) and becomes covered by the Plan prior to age 19 (or before age 25 if a full-time student) is eligible to continue dependent coverage as long as the incapacity exists. This continuing coverage is available as long as the child is unmarried and depends primarily on you for support and maintenance. 4 Eligibility

7 The child must have a mental or physical incapacity that renders the child unable to care for herself/himself, as determined by the network manager or claims administrator. For this purpose, the incapacity needs to be verified before coverage can be continued. In addition, periodic medical documentation of the continuing incapacity is required as determined by the network manager or claims administrator. Health Care Spending Account A dependent is a relative or anyone else whose primary residence is your home and who is a member of your household, as long as you provide more than one-half of the person s support. Child/Elder Care Spending Account A dependent includes any of the following if they reside with you: your children age 12 and under your spouse, if disabled any disabled relatives or household members who are dependent on you or your spouse for more than half of their support When Spouses Are UPSers If you and your spouse both work for the Company (or an affiliate) and are both eligible for the Flexible Benefits Plan, the following conditions apply: Each of you may select employee coverage under the medical, dental and vision options. Only one of you may elect coverage for your eligible children. Each of you can be covered only once; you may not be covered as both a spouse and as an employee. If you select coverage for your spouse as your dependent, and your spouse elects no medical coverage, he or she will not receive any Flex Credits. You and your spouse may each elect employee life insurance as an employee. Only one of you may select life insurance coverage for your eligible children. If you are eligible for the Flexible Benefits Plan and your spouse is covered by a UPSsponsored or UPS-affiliate plan other than the Flexible Benefits Plan, or a multi-employer health care plan to which UPS contributes: You may select any available level of coverage (you only, you plus spouse, you plus children, or you plus family). If you decide not to participate in the medical, dental and vision care options, your coverage may be provided by your spouse s plan, based on that plan s eligibility rules. If you do not select medical coverage, you will not receive any Flex Credits. However, you may select participation in the other Plan coverages: dental, vision, life insurance, AD&D, legal, spending accounts and personal lines insurance. If you enroll your spouse in the Flexible Benefits Plan, your spouse may also continue coverage through the UPSsponsored plan. QUALIFIED MEDICAL CHILD SUPPORT ORDERS (QMCSO) Medical, dental and vision coverage will comply with the terms of a Qualified Medical Child Support Order. A QMCSO is a judgment, decree or order (including approval of settlement agreement) issued by a court of competent jurisdiction or Eligibility 5

8 an administrative process established under state law which has the force and effect of law or a judgment from a state court directing a plan administrator to cover a child by a company s group health plans. Federal law requires that a QMCSO must meet certain form and content requirements in order to be valid. When an order is received, each affected participant and each child covered by the order will be notified of the implementation procedure to determine if the order is valid. If you have any questions or would like to receive a copy of the UPS written procedure for determining whether a QMCSO is valid, please contact your Human Resources department. WHEN COVERAGE STARTS If you re hired (or rehired in a new calendar year) or transferred into an eligible position, coverage based on the options you select begins on the first day of the first full pay period following 30 days from the date you re: hired or rehired, or transferred to an eligible position. Spending account coverage is effective on the latter of the date you enroll or the date your elected coverage begins. If you re rehired in the same calendar year in which you left the Company, the coverage you had prior to leaving the Company will automatically be reinstated effective on your return date. For information about the special rules that govern the effective date of life insurance and AD&D coverage, see the Life Insurance and AD&D section on page 77. TRANSITION COVERAGE If you re a newly hired full-time employee or a current employee moving to or from a Flex-eligible position, the Plan will provide you and your family with transition coverage while you re making your selections or until you become eligible under another plan. Newly Hired If you re a newly hired full-time employee, your transition coverage includes: Medical Option 3 (non-network) for you plus family Vision Option 0 for you plus family basic life insurance for you and your family basic AD&D for you only Aetna is the administrator of the transition medical benefits, including prescriptions. Mail order prescription service is not available.vision Service Plan administers vision services. Current Employees If you re a current employee who is new to a position that is eligible for the Flexible Benefits Plan, your transition coverage includes: Medical Option 2 (non-network) for you plus family Dental Option I for you plus family Vision Option 0 for you plus family basic life insurance for you and your family basic AD&D for you only 6 Eligibility

9 Aetna is the administrator of these transition medical benefits, including prescriptions. Mail order prescription service is not available. Vision Service Plan and Aetna administer vision and dental services, respectively. If you re a current employee transferring from the Flexible Benefits Plan to another plan sponsored or contributed to by the Company or its affiliates, certain coverages will be continued at no cost to you during the waiting period until you gain eligibility under the new plan. If there is a waiting period before benefits begin under the new plan, the following changes occur at the end of the payroll period in which the job change notification is received at the Benefits Service Center: your current medical, dental and vision options and family status levels continue basic employee life insurance and AD&D continue basic spouse s and children s life insurance continues all other coverage stops payroll deductions and/or credits stop Transition coverage continues only during the waiting period. Transition coverage ends: for you, when you become eligible under the new plan for your dependents, when they become eligible under the new plan, unless there is no dependent coverage available under your new plan. Then your dependents coverage ends when you become eligible under the new plan (see page 116 for information about COBRA coverage for your dependents) for you and your dependents if you terminate employment during the waiting period. In some cases, you may have a longer waiting period for certain coverages, for instance dental or vision. As an example, if you or your dependents gain eligibility under the medical plan, but not the dental plan, your transition coverage for dental will continue until your new dental coverage begins. Once eligibility under your new dental plan is reached, however, dental coverage under transition coverage ends, even if a particular dental benefit, for instance orthodontia, is not available under the new dental plan or is available at a later eligibility date. HOW LONG COVERAGE LASTS In general, your Flexible Benefits Plan coverage continues as long as you meet the Plan s eligibility requirements and make any required contributions. Your dependents coverage will continue as long as you remain eligible for the Plan and your dependents meet the eligibility requirements and make any required contributions. Please see the Life Events section on page 9 for additional details. Eligibility 7

10 Enrollment Enrollment occurs when you first become eligible for the Flexible Benefits Plan at any time during the year, and again each fall to allow you to make annual changes to your selections. IF YOU DO NOT ENROLL If you do not enroll for Plan coverage within your initial 45-day enrollment period, you re automatically assigned the following default coverages: Medical If you plus family credits are greater than you plus family Medical Option 3, you will be assigned Option 3. If not, No Coverage is assigned. Excess credits are waived. Dental no coverage Vision Option 0 exam only for you and your family basic life insurance for you and your family basic AD&D for you only If you fail to enroll, no credits, if applicable, are payable. At future annual enrollments, if you do not make new benefits selections you ll receive the same coverage for you and your dependents that you had in the prior year, except in the following situations: You wish to continue participation in the spending accounts. You must annually elect participation in the spending accounts. Your dependent child is a full-time student age 19 or older. You must certify fulltime students annually to maintain their coverage. If you do not certify student status, coverage will end on December 31 of that Plan year. Opting Into the Network If you live outside the network area (nonnetwork) but feel the network is convenient to you, you may elect to participate in the network. This is called overriding into the network. You may override into the network at any time during the year by calling the Benefits Service Center at However, you will be required to remain in the network for the rest of that Plan year. You will automatically remain in the network from year to year unless you call at annual enrollment to change back to your nonnetwork coverage. 8 Enrollment

11 Life Events Flexible benefit plans are regulated by the Internal Revenue Code, and changes during the year are restricted. However, the IRS realizes that certain life events do occur during the year that create the need for you to change your benefit choices. You re allowed to change certain benefit selections during the year depending on the type of change in status that occurs as long as the change in selection is consistent with the change in status. As a general rule, you will only be allowed to make coverage changes if the event results in you, your spouse, or your dependents gaining or losing coverage eligibility under an employersponsored plan. For example, if you have a baby, you can change your level of medical coverage from you plus spouse to you plus family, but you may not decrease your life insurance. 60-DAY TIME LIMIT You must call the Benefits Service Center ( ) within 60 days of the date of the event to request a change in coverage. You re not allowed to change coverage after the 60-day period until the next annual enrollment period. EFFECTIVE DATE OF REVISED COVERAGE Revised coverage is effective retroactive to the date of the event, with the following exceptions: life insurance* For life insurance requiring evidence of insurability, the requested level of coverage is effective when approved. Until then, the highest level of coverage (up to the level requested) not requiring evidence of insurability is effective. If you decrease your coverage for the cash accumulation fund, the effective date of that coverage change will be the first day of the next full pay period. spending accounts If you change your contribution to the spending accounts, the effective date of that coverage change is the date you notify the Benefits Service Center. *In certain circumstances, you or your dependents coverage could be delayed. Please see page 77 for further details. Life Events 9

12 SPENDING ACCOUNT CONTRIBUTIONS AND COVERAGE CHANGES If you change your contribution amount (HCSA or C/ECSA) because of a status change, for instance a marriage or birth of a child, the following occurs: If you increase your account balance, the amount of the increase is prorated throughout the remaining calendar year. For instance, if you increased your account from $1,200 to $1,500, then the additional $300 would be prorated over the remaining pay periods and added to your current per-pay-period contribution amount. If you decrease your account balance, your new per-pay-period contribution is calculated by taking any contributions already deducted from your paycheck and subtracting those from your new annual amount, and dividing that difference by the remaining pay periods in the year. For example, assume your original annual contribution was $1,200, and in May you decreased your annual contribution amount to $600. You would have paid for four months at $100 per month. Subtract the $400 you have already paid from your new annual contribution amount of $600. Then divide the remaining $200 by the number of remaining pay periods in the year. That would be your new per-pay-period contribution amount. You may not decrease your account to an amount that is less than what you have already contributed. In the example above, for instance, you could not decrease your account to less than $400, because you have already contributed $400. (Some changes in status, however, allow you to stop your account altogether.) 10 Life Events

13 ALLOWABLE COVERAGE CHANGES MATRIX (Only the changes that are listed are allowed.) Spending Accounts Event Medical or Cancer Expense Insurance Dental Vision AD&D Employee Life* Spouse s Life* Children s Life* Legal LTD Health Care Child/ Elder Care Marriage If covered, change family status. If opted out, start coverage. If now have outside coverage, can opt out. Increase family status Increase family status Change family status Increase coverage Add coverage Add coverage Start coverage; change family status Start, stop or change coverage Start or increase contributions Start, stop or change contributions Divorce; Legal Separation; Annulment If covered, change family status. If opted out, start coverage if lost under spouse s plan. If covered, change family status. If opted out, start coverage if lost under spouse s plan. Change family status. Increase coverage if lost under spouse s plan. Change family status Increase or decrease coverage Drop coverage No changes Start or drop coverage; change family status Start, stop or change coverage No changes Start, stop or change contributions Birth; Adoption or Placement for Adoption; Child Gains Eligibility If covered, increase family status. If opted out, start coverage Increase family status Increase family status Increase family status Increase coverage Add coverage Add or increase coverage Start coverage; change family status No changes Start or increase contributions Start, or increase contributions Death of Spouse If covered, change family status. If opted out, start coverage if lost under spouse s plan. If covered, change family status. If opted out, start coverage if lost under spouse s plan. Change family status. Increase coverage if lost under spouse s plan Change family status Increase or decrease coverage Drop coverage No changes Start or drop coverage; change family status Start, stop or change coverage Stop or decrease contributions Start, stop or change contributions Death of Child; Loss of Child s Eligibility; Termination of Adoption Proceedings Decrease family status Decrease family status Decrease family status Decrease family status No changes No changes Drop coverage No changes No changes Stop or decrease contributions Stop or decrease contributions Dependent Loses Eligibility for Spending Accounts No changes No changes No changes No changes No changes No changes No changes No changes No changes Stop or decrease contributions Stop or decrease contributions (continued on page13) Life Events 11

14 ALLOWABLE COVERAGE CHANGES MATRIX (continued) (Only the changes that are listed are allowed.) Spending Accounts Event Medical or Cancer Expense Insurance Dental Vision AD&D Employee Life* Spouse s Life* Children s Life* Legal LTD Health Care Child/ Elder Care Loss of Outside Medical Coverage Eligibility with Other Employment If opted out, start coverage. Increase family status if dependent lost coverage elsewhere If opted out, start coverage if lost elsewhere. Increase family status if dependent lost coverage elsewhere No changes No changes No changes No changes No changes No changes No changes Start or increase contributions if health coverage is lost due to employment change No changes Change in Spouse s Employment or Coverage; Open Enrollment Period Differs from Employee s If covered, change family status. If opted out, start coverage. If now have outside coverage, can opt out. If covered, change family status. If opted out, start coverage. Change family status Change family status No changes Add or increase coverage No changes Start, stop or change Start, stop or change coverage Start or increase contributions (Employment) No changes (Annual Enrollment, Coverage) Start, stop or change contributions Loss of DMO access No changes Change to Option 1 or 2 No changes No changes No changes No changes No changes No changes No changes No changes No changes Reduction in earnings due to leave of absence** No changes No changes No changes No changes Decrease coverage Stop or decrease coverage Stop or decrease coverage Start or drop coverage; change family status No changes No changes Stop or decrease coverage Change Full-time to Part-time No changes No changes No changes No changes Decrease coverage Stop or decrease coverage Stop or decrease coverage Start or drop coverage; change family status No changes No changes Stop or decrease coverage Change in Child/Elder Care Provider or Cost No changes No changes No changes No changes No changes No changes No changes No changes No changes No changes Start, stop, or change contributions (limited to four changes per year) Court- Ordered Coverage Change As dictated by court order As dictated by court order As dictated by court order As dictated by court order As dictated by court order As dictated by court order As dictated by court order As dictated by court order No changes As dictated by court order As dictated by court order Note: You may start, stop, or change your contributions to the Cash Accumulation Fund at any time. **See the Life Insurance section on page 77 for details about coverage maximums and evidence of insurability requirements. **Except military leave. 12 Life Events

15 What If If your employment status with the Company changes, that may affect Plan coverage for you and your eligible dependents. Additionally, your credits or deductions could be affected. This section answers the question What if? for the following circumstances. YOU LEAVE THE COMPANY? If you leave the Company, coverage for you and your eligible dependents ends: for an employee paid weekly, on the last day of the pay period following the pay period in which you became ineligible. for an employee paid monthly or bi-monthly, on the last day of the pay period in which you became ineligible. Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your eligible dependents can continue health coverage from the Flexible Benefits Plan for a period of time after your termination date. (Please see the COBRA section on page 116 for more information.) Also, you may convert your, your spouse s and your children s life insurance to individual policies. You cannot convert AD&D coverage to an individual policy. YOU RETIRE? If you retire from the Company and are eligible for retiree health coverage, your active coverage ends on the last day of the month following 30 days from your retirement date. If you do not retire from the Company, coverage ends as indicated under If you leave the Company. If you take early or normal retirement based on the provisions of the UPS Retirement Plan, you and your eligible dependents may be eligible for medical, dental and vision coverage from the Retired Employees Health Care Plan if you meet the eligibility rules of that Plan. You ll receive a separate summary plan description of your retiree health coverage when you retire. Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your eligible dependents can continue health coverage from the Flexible Benefits Plan for a period of time after your termination or retirement date. (Please see the COBRA section on page 116 for more information.) Also, you may convert your, your spouse s and your children s life insurance to individual policies. You cannot convert AD&D coverage to an individual policy. Life Insurance Because your life insurance can be continued without evidence of insurability, you may wish to evaluate your coverage during the last annual enrollment prior to your retirement date. At the time of retirement, you are not allowed to increase your life insurance coverage. It s a good idea to review the Life Insurance and AD&D section in detail, paying particular attention to the section entitled If You Leave. Life Events 13

16 YOU DIE? If you die while you re covered by the Flexible Benefits Plan as an active employee, the Company will continue your eligible dependents coverage at no cost to your dependents through the last day of the 13th calendar month following the date of your death. (For instance, if your death occurs on February 2, dependent coverage continues through March 31 of the following year.) Your covered dependents are automatically enrolled for this 13-month coverage period. When this Company-paid coverage ends, your dependents may extend health care coverage in accordance with COBRA provisions for up to an additional 23 months, for a total of 36 months of coverage. The full cost of this coverage will be billed to your dependents according to the COBRA provisions of this Plan. (Please see the COBRA section on page 116 for more information.) Spouse s and children s life insurance may be converted to individual policies. Your dependents are only eligible for this 13-month extension of coverage if you and your dependents were covered by the Flexible Benefits Plan at the time of your death. For example, if you are on military leave, or if you opted out of medical coverage for you or your dependents, your dependents would not be eligible. YOU RE LAID OFF? If you re laid off, your Flexible Benefits Plan coverage will continue until the last day of the month following the month in which your layoff begins. In addition, you can then continue your medical, dental, vision and health care spending account coverage through COBRA. (Please see the COBRA section on page 116 for more information.) You may convert your, your spouse s and your children s life insurance to individual policies. YOU HAVE JURY DUTY? If you have jury duty, your coverage continues. You will make contributions as if you were at work. YOU TAKE AN APPROVED LEAVE OF ABSENCE? FMLA Leave If you re on an approved leave of absence as provided by the Family and Medical Leave Act of 1993 or Company policy, full Plan coverage for you and your dependents will continue for up to 12 weeks. You are responsible for your share of the costs and may be billed if your leave extends beyond 20 days. If you fail to make timely payment of this bill, your coverage will be terminated. If you are billed, you must pay the billed amount; it will not be deducted from your paycheck when you return to work. If you do not receive a bill, deductions and credits will be applied to your first paycheck upon returning to work. If your leave is approved for extension beyond 12 weeks, your coverage from the Plan will continue provided you pay the full cost of coverage (see Personal Leave on page 15). You ll need to notify the Company in writing that you want to extend your leave. 14 Life Events

17 Military Leave Except for military leaves of less than 31 days (or as otherwise required by federal law), benefits cease and therefore deductions and/or credits also cease. Refer to page 116 for details about continuing coverage under COBRA. Personal Leave You are responsible for the full cost of coverage during a personal leave, and may be billed if your leave extends beyond 20 days. If you fail to make timely payment of this bill, your coverage will be terminated. If you are billed, you must pay the billed amount; it will not be deducted from your paycheck when you return to work. Deductions/Credits While on Leave (except military leave of more than 31 days) As long as you are receiving a paycheck from the Company, deductions or credits will continue to be applied to your paycheck while you are on leave. However, if you are not receiving a paycheck, deductions or credits that accumulate while you are on leave will be applied to your first paycheck when you return to work. If your leave extends beyond 20 days, you may be billed. If you fail to make timely payment of this bill, your coverage will be terminated. If you are billed, you must pay the billed amount; it will not be deducted from your paycheck when you return to work. To avoid an accumulation of deductions during your leave, you may request to be billed during your leave. Call the Benefits Service Center at Credits will not be issued during a leave, but will accumulate and be applied to your first paycheck upon return to work. Spending Accounts and Leaves C/ECSA Your C/ECSA contributions will stop during your leave until you return to work. Upon return to work, your per-pay-period contribution amount will automatically be reinstated. Only eligible expenses incurred prior to your date of leave and after your return to work will be eligible for reimbursement. HCSA During a leave, contributions to your HCSA may be continued on an after-tax basis (assuming you are on leave long enough to be billed for your share of the expenses), or stopped. If you choose to continue your contributions on an after-tax basis during your leave, any eligible expenses incurred during your leave will be eligible for reimbursement. If you stop your contributions during your leave, only expenses incurred prior to your leave or upon your return to work will be eligible. Expenses incurred during your leave will not be eligible for reimbursement. Upon return to work, your per-pay-period contribution amount will automatically be reinstated, (except for FMLA leaves, in which case you must notify the Benefits Service Center at to start your account again). Your annual contribution amount will be reduced by the amount not contributed during your leave. Life Events 15

18 If you move out of the network area until the effective date of your new coverage at your new address, you must continue to coordinate your care through your old network PCP or you will receive out-ofnetwork benefits. For instance, if your annual contribution amount is $1,200, and you are on leave for three months and do not continue your contributions on an after-tax basis during your leave, your revised annual contribution amount will be reduced to $900 (reduced by $300 the amount you didn t pay while on leave). YOU MOVE If you change your address, call ehr at UPS Your call will be transferred to the Employee Service Center and you will be prompted to update your new address. YOU BECOME DISABLED? You and your dependents still have protection if you become disabled. A full description of your short-term and long-term disability coverage, including health care coverage, begins on page 103, Income Protection Plan. In addition to the information in the Income Protection Plan section, please refer to Deductions/Credits While on Leave and Spending Accounts and Leaves in this section, both of which also apply to a disability leave. Depending on your move, several situations could then occur to your elected medical and/or dental coverage: If you: Stay in the same network area Move to a new network (from another network or from a non-network area) Move from a new network area to a non-network area Move out of your HMO network area Move into an HMO network area Move outside the DMO area Move into the DMO area Then No changes will occur to your coverage. If necessary, you may call the network manager to change your PCP. You will receive a letter from the Benefits Service Center asking you to select a PCP for each family member, and to select a coverage effective date (within 30 days of the date of the letter) for your new network. If you do not notify the Benefits Service Center within 30 days, you will automatically be moved to the new network without a PCP. You will receive a letter from the Benefits Service Center asking you to select a coverage effective date (within 30 days of the date of the letter) for your non-network coverage. If you do not notify the Benefits Service Center within 30 days, you will automatically be moved to non-network coverage. You will receive a letter from the Benefits Service Center asking you to make a new medical election (Option 1, 2, or 3, or a new HMO option if available). You will receive a letter from the Benefits Service Center allowing you to elect coverage for the HMO. If you do not elect the HMO, you must keep your current medical option. You will receive a letter from the Benefits Service Center asking you to elect a new dental option. You will receive a letter from the Benefits Service Center allowing you to elect the DMO. If you do not elect the DMO, you must keep your current dental option. In all cases, you are not allowed to change your coverage level (you only, you plus spouse, etc.) when you move. If you are a shareowner, you will also want to notify First Union National Bank in Philadelphia of your new address ( ). 16 Life Events

19 Medical Choice is a central part of the medical care provided through the Flexible Benefits Plan. The choices you have are based on your home ZIP code. If you live: in a network area, you may elect a point of service (POS) option. With POS, you select a Primary Care Physician (PCP) who coordinates your medical care. The costs to you are less when your services are provided and coordinated through your PCP. outside a network area (non-network), you have indemnity options to choose from. With an indemnity option, covered services and supplies may be provided by any doctor or health care provider you select. in an HMO network area, you may elect HMO coverage You can also choose not to have medical coverage. If you live outside the network area (non-network) but feel the network is convenient to you, you may elect to participate in the network. See page 8 for details. In describing the medical benefits provided by the Flexible Benefits Plan, this section explains: how the POS options work how the indemnity options work your expenses expenses covered by the Plan prescription drug benefits Solutions for mental health and substance abuse treatment how the HMO options work A GUIDE TO POINT OF SERVICE BENEFITS What Is Point of Service (POS)? In a point of service plan, in-network care is provided by Primary Care Physicians who provide or coordinate all of your care. However, you also have benefits if you choose to use a non-network physician. You can choose whether to go to a network provider or go outside the network each time you seek care; in other words, you choose the coverage you want at the point of service. The network managers for the POS options are Aetna U.S. Healthcare, Blue Cross/Blue Shield, CIGNA or United HealthCare, depending on where you live. Medical 17

20 Network manager means the company that establishes and maintains the network for the managed care options. The network manager is also responsible for processing claims for in- and out-of-network treatment. What Is a Network? A network is a group of doctors, hospitals and other health care providers who have agreed to provide their services to participants at contracted rates. When services are provided in-network: coverage is provided at a higher level for most eligible charges preventive care is covered no annual deductible must be met in-network care is always within reasonable and customary limits your care is coordinated through your Primary Care Physician you usually don t have to file claim forms If you go out-of-network for care: you pay a higher percentage of eligible charges you pay an annual deductible you are responsible for precertifying all hospitalizations preventive care is not usually covered you file claim forms you are responsible for charges above reasonable and customary limits you are responsible for ensuring that care is medically necessary YOUR PRIMARY CARE PHYSICIAN (PCP) When you use the network your Primary Care Physician will provide most of your care, refer you to a specialist when necessary and coordinate any hospital services you need. PCPs are general or family practitioners, internists and pediatricians. You must choose a PCP for each covered family member, but you can choose a different PCP for each. You must use your PCP to receive in-network benefits. If you go to a network doctor or hospital without your PCP s referral, your expenses will be paid on an out-of-network basis. There are five exceptions: Women do not need a referral from the PCP to visit a network obstetrician or gynecologist for OB/GYN-related care. Students away at school may receive non-preventive care without a referral from their PCP (see Special Situations on page 20). Solutions can be contacted directly by you or your covered dependents. Emergency care as described in Emergency Treatment on page 25. Selected network specialists in certain locations. Contact Member Services for details. Selecting Your PCP You select your PCP from your network manager s provider directory when you first enroll. A provider directory is included with your enrollment materials. Or you can call Member Services to learn more about a particular PCP. 18 Medical

21 A PCP must meet strict eligibility standards established and maintained by the network manager before admission to the network. For example, a PCP generally: has an appropriate professional degree and current, unrestricted state license is board certified or board eligible has adequate malpractice insurance has 24-hour office coverage has sufficient office hours to meet patient demand has admitting privileges to at least one network hospital Other providers in the network like hospitals, labs and X-ray facilities are also selected by the network manager based on reputation in the community, geographic location, efficiency in providing medical service, the quality of those services, and willingness to adhere to the network manager s guidelines and to provide appropriate, affordable care. The network manager regularly reviews all providers to make sure they continue to meet their standards. Changing your PCP You can change your PCP by calling Member Services, which will send you a new medical ID card. Certain network managers may have a waiting period for changing your PCP. Call Member Services for details. If Your PCP Leaves the Network Some doctors will occasionally be added to the network and some doctors will occasionally leave the network. If your PCP leaves the network, your network manager will notify you and ask you to select another PCP. Be sure to call Member Services with your new PCP selection prior to your first visit to the new PCP. REFERRAL TO A SPECIALIST When your PCP refers you to a network specialist, you receive in-network benefits for covered services. Because you may choose at any time to seek care outside the network, your PCP s referral to a network specialist notifies the network manager that your visit to the specialist has been authorized, and to pay your eligible claims in-network. Without the referral, your claims will be paid out-of-network, even if the specialist or hospital is a network provider. Usually, you will receive authorization for a prescribed number of visits to a specialist within a specific time for a specific course of treatment. Make sure you and your specialist know how many visits have been authorized. Your PCP is responsible for coordinating the care you receive from a network specialist. The network manager follows the same credentialing process for network specialists as for PCPs. In addition, the specialist must complete an approved residency program and be board certified or board eligible in her/his specialty area. Provider Directories You should have received a provider directory in your first enrollment kit. If you would like to access the most current list of doctors or dentists, however, log on to Your Benefits Resources and look under Other Sites for a full list of carriers. If you would like a hard copy mailed to your home free of charge, call Web addresses are also listed on the back of this booklet. Medical 19

22 Referral to an Out-of-Network Provider In the rare instance that you need to see a specialist who is not in the network, your PCP can request the network manager s approval of the referral. If the request is approved, in-network benefits will be paid. Except for emergencies, and urgent care when traveling away from your network area, the network manager must approve the use of out-of-network providers and facilities in advance, or out-of-network benefits will apply. Women Can Self-Refer to Network OB/GYN Women do not need a PCP referral to visit a network obstetrician or gynecologist for OB/GYN-related care. However, OB/GYN providers may not be selected as primary care physicians. If you go to a non-network OB/GYN for your routine check-up, only the laboratory fees are covered. The office visit itself is not covered. SPECIAL SITUATIONS If you re traveling and need urgent medical care when you re away from home, call your PCP to discuss treatment. If your doctor recommends that you be treated where you are, your expenses will be paid at the in-network level provided they are otherwise covered by the Plan. If you can t contact your PCP, get the treatment you think you need. If you call your PCP within 48 hours, you ll receive in-network benefits for the covered services. However, because treatment was provided out-ofnetwork, you ll have to file a claim form. If your eligible dependent child attends school away from home, select a PCP for your child in your home network. The PCP will provide and coordinate all care when your child is at home. When your child is at school, non-preventive care is covered in-network without a referral from the PCP, provided it is otherwise covered by the Plan. It is still a good idea to keep your child s PCP informed of any care received while away at school, so the PCP has a complete medical history on your child. Preventive care is only covered if provided by your child s PCP. If you have eligible dependent children or an eligible spouse who permanently lives outside your network area (nonresident dependents), their covered expenses will be paid as in-network benefits, even though services are provided out-of-network, provided they are otherwise covered by the Plan. In this situation, you re responsible for ensuring that the services are medically necessary; non-medically necessary treatment is not covered. In addition, you ll have to file claim forms to be reimbursed. You should not select a Primary Care Physician for these nonresident dependents. (See A Guide to Indemnity Benefits following.) To designate your dependent children or eligible spouse as non-resident dependents, call the Benefits Service Center at Medical

23 MEMBER SERVICES Member Services is your link to network care. You can call a Member Services representative to: ask questions about a network physician s credentials ask questions about your benefits change your PCP obtain information about a network provider or service replace an ID card Your medical ID card will show a toll-free number for Member Services or you can refer to the back page of this booklet. A GUIDE TO INDEMNITY BENEFITS If you live outside the network area, you participate in an option that provides indemnity benefits. Aetna U.S. Healthcare administers all the Flexible Benefits Plan indemnity options. With an indemnity option, covered services and supplies may be provided by any doctor or health care provider you select. Benefits are paid once the annual deductible is met. All covered expenses must be: medically necessary as determined by the claims administrator, not investigational or experimental as determined by the claims administrator, and within the reasonable and customary amount as determined by the claims administrator Choosing a Doctor In an indemnity option, you don t choose a primary care physician. However, you may want to consider choosing a primary doctor for yourself and your dependents to work with you in coordinating your care and the selection of any necessary specialists. By doing so, you ll have a doctor with full knowledge of your health history. WHAT MEDICAL EXPENSES YOU HAVE TO PAY UNDER OPTIONS 1, 2 AND 3 Medical Options 1, 2, and 3 pay a significant portion of the medical expenses you and your family may incur each year. You ll generally also pay a portion of the costs incurred. Here s a description of the types of charges for which you ll be responsible if you elect Option 1, 2, or 3. For information about the amount of these charges, please refer to the Summary of Medical Options at the end of this section. If you elect an HMO option, your covered expenses could be different. Refer to your HMO kit for details about HMO coverage, or call your HMO s Member Services. Copayment If you participate in a managed care option, you pay a flat dollar amount, called a copayment, for each in-network office visit. Your copayment amount will depend on the option you elect. The balance of the covered expense is paid in full by the Plan. The copayment is not included in determining if your costs have reached the out-ofpocket maximum. Non-network area means those ZIP codes which do not have network access. If your home ZIP code is in a non-network area, your medical benefits are provided through one of the indemnity options, unless you contact the Benefits Service Center and request inclusion in a network option. Claims administrator means the company that administers the indemnity options and is responsible for claims processing for those options. Medical 21

24 If you elect an HMO option, your covered expenses could be different. Refer to your HMO kit for details about HMO coverage, or call your HMO s Member Services. A copayment also applies to network care for mental health or substance abuse treatment provided through Solutions, to prescription drugs purchased through your prescription benefits and to emergency room services. Deductible The deductible is the amount you must pay before certain benefits begin each year if you participate in: a POS option and receive out-of-network care, or an indemnity option The amount of the deductible varies with the option you select. The individual deductible applies separately to each covered family member. However, if two or more family members expenses combine to reach the family deductible, then the deductible for each family member is considered to be met. This is true even if no single member reached the individual deductible. Expenses credited toward the deductible are also credited toward the out-of-pocket maximum that applies each year. The deductible must be met each year there is no carryover provision. The following chart shows several examples of how a family deductible might be met. Family Member Example 1 Example 2 Example 3 #1 $250 $250 $300 #2 $250 $125 $ 50 #3 $125 $ 50 #4 $100 Family deductible $500 $500 $ Medical

25 Coinsurance Coinsurance is the percentage of covered expenses paid by the medical option you select. The remaining percentage you pay is credited toward your out-of-pocket maximum for that year. This provision assures you that your annual out-of-pocket expenses for most covered charges will never be more than a certain amount. This feature can be particularly valuable if you or a dependent has a catastrophic illness or injury. Hospital Admission Fee The hospital admission fee is the amount that you pay each time you re admitted as a hospital inpatient. The hospital admission fee applies to all options, but does not apply to treatment as an outpatient. If you are readmitted to a hospital for the same or a related condition within 30 days after your stay as an inpatient ends, you will not have to pay another hospital admission fee. An additional hospital admission fee of $250 applies if a hospital admission is: not coordinated by your PCP, or not precertified by the network manager if care is provided out-of-network, or not precertified by the claims administrator if you participate in an indemnity option. Out-of-Pocket Maximum Each option limits the out-of-pocket expenses you pay. After you meet the outof-pocket maximum for the option you select, 100 percent of most covered charges are paid for the rest of the calendar year. In calculating your out-of-pocket expenses, the dollar amounts included are the deductible, coinsurance amount (except mental health/substance abuse expenses) and the hospital admission fee. If you are confined in the hospital from one calendar year to the next, your hospital charges for that stay will count toward the out-of-pocket maximum for the year that you are admitted, not the year you are discharged. This means that you do not have to start a new out-of-pocket maximum during your hospital stay. Physician and other charges related to the hospital stay begin a new out-of-pocket calculation on January 1. Dollar amounts not included in determining the out-of-pocket maximum are copayments, prescription drug expenses, mental health/substance abuse treatment expenses, the additional hospital admission fee (for failure to precertify), any amounts over reasonable and customary and expenses that are not covered expenses by the Plan. Medical 23

26 Reasonable and Customary (R&C) All eligible medical expenses received outof-network or in an indemnity option are subject to reasonable and customary (R&C) limits charges within the normal range of fees in your geographic area for similar services and similar supplies, as determined by the network manager or claims administrator. If your doctor charges more than the R&C limit, you re required to pay any amounts considered above the R&C limit. These charges do not count toward your deductible or out-ofpocket maximum. All benefits provided in-network through a managed care option are considered reasonable and customary. Lifetime Maximum Benefits Up to $1 million in lifetime medical benefits can be paid for each person covered by the Plan. The maximum is a combined amount that is the total of benefits paid even if you switch from one option to another from year to year. The lifetime maximum includes benefits payable through the medical option you select, including benefits you receive from Solutions. However, benefits from PAID Prescriptions or the Mail Order Prescription Program do not count toward the $1 million lifetime maximum. If you were a participant in the UPS Insurance Plan on March 31, 1994, the medical and dental benefits you received from that Plan count toward the $1 million lifetime maximum. Each January 1, up to $1,000 in individual benefits paid during the preceding year or years will automatically be restored. PREVENTIVE CARE Since it s often less painful and less expensive to keep people healthy than it is to treat them when they re ill, the medical options cover preventive services. In determining how frequently or at what ages certain preventive care services are covered, the medical options generally follow the guidelines of medical consultants (for adult frequency and protocols), the American Cancer Society (for mammograms) or the American Academy of Pediatrics (for wellbaby care). For information about the preventive care guidelines, refer to the Physical Evaluation Guidelines on page 58. You may also call Member Services or your claims administrator at the toll-free number on your ID card or on the back page of this booklet. The preventive benefits listed in the Guidelines represent suggested guidelines for physical evaluations. Actual care is determined by the primary care doctor as patient needs warrant. If you participate in a POS option, preventive care must be performed by your primary care physician (or a specialist when authorized). Women may see a network OB/GYN for an annual well-woman exam without a referral from the PCP. INDIVIDUAL CASE MANAGEMENT While none of us likes to think about a complicated, long-term illness or serious accident, sometimes it can happen. The Individual Case Management (ICM) program can offer you and your dependents help with: understanding treatment plans and alternatives, monitoring claims payments, and evaluating alternative treatment facilities and options Here are some medical conditions that may be appropriate for ICM: quadriplegia, paraplegia AIDS and certain associated symptoms brain injury, including traumatic brain injury newborn respiratory distress, newborn apnea spinal cord injury any complicated, chronic illness 24 Medical

27 The principles of ICM are an automatic feature of in-network care. If you receive out-of-network care or participate in an indemnity option, a nurse consultant contacts your doctor or a social worker at the hospital to begin case management. Or, you may call Member Services to discuss whether case management is appropriate for your situation. Early identification allows the patient, family, physician, social worker and case manager to work together to arrange appropriate care in a timely manner. EMERGENCY TREATMENT In an emergency, seek medical care as quickly as possible at the nearest appropriate facility. Contact your PCP or primary doctor so he or she can coordinate your care. Emergency rooms should only be used for true emergencies. An emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or the unborn child in the case of a pregnant woman) in serious jeopardy. Examples include an apparent heart attack, loss of consciousness, excessive bleeding, severe or multiple injuries or serious burns. You should contact your PCP or primary doctor if you have concerns about whether your illness or injury is consistent with the definition of an emergency. All PCPs have 24-hour availability. Your level of reimbursement will depend on whether the situation is a medical emergency as determined by the network manager or claims administrator using the standards defined above. If the network manager or claims administrator determines that the situation: meets the definition of an emergency the option you select will pay all related covered charges (such as charges for the emergency room, physician charges, laboratory fees, X-rays, etc.) after you pay the applicable emergency room copayment for the option you elected. This copayment will be waived if you are admitted to the hospital from the emergency room. does not meet the definition of an emergency the option you select will pay related covered charges, at the appropriate coinsurance level, after you pay a $100 emergency room copayment. Once you are discharged from the emergency room or admitted to the hospital from the emergency room, emergency coverage ends and benefits are covered as non-emergency treatment. If you participate in a POS option, emergency benefits are paid regardless of whether the facility or provider participates in the network. Contact your PCP within 48 hours so that she or he can coordinate any follow-up care. If you are admitted to the hospital from the emergency room, your PCP will certify your stay to ensure in-network benefits are paid for the hospitalization. Once you are discharged from the emergency room or admitted to the hospital from the emergency room, emergency coverage ends and benefits are covered as non-emergency treatment. Medical 25

28 If you do not contact your PCP within 48 hours, all treatment received after being discharged from the emergency room or admitted to the hospital from the emergency room will be covered at the out-ofnetwork level. An additional $250 hospital admission fee will apply if you are admitted to the hospital without notifying your PCP. (See Precertification of a Hospital Admission below.) PRECERTIFICATION OF A HOSPITAL ADMISSION Precertification is the approval of a nonemergency hospital admission before the hospital stay begins. Through the precertification process you and your doctor will be notified in advance when alternatives should be considered, and benefits payments may also be approved in advance. If your PCP sends you to the emergency room for treatment that does not meet the definition of an emergency, the option you select will pay all related covered charges after you pay the emergency room copayment. If you participate in a POS option and the hospitalization is under your PCP s direction (or that of a network specialist to whom you were referred by your PCP), the precertification is the doctor s responsibility. There is nothing further for you to do. If you participate in an indemnity option, and hospitalization occurs, you must contact your claims administrator within 48 hours to avoid a $250 additional hospital admission fee. (See Precertification of a Hospital Admission below.) Ambulance Coverage (Ground or Air) Emergency use of an ambulance is covered as an emergency benefit in all options. Non-emergency use of an ambulance is covered at the designated coinsurance level for each option, if it s medically necessary. If you do not use your network doctor or if you are covered by an indemnity option, you must have a non-emergency hospital admission precertified by your network manager or claims administrator or you ll have to pay an additional $250. This $250 fee does not count toward the deductible or the annual out-of-pocket maximum. The $250 fee is in addition to the hospital admission fee. To precertify, call the toll-free number shown on your medical ID card. Pursuant to federal law, precertification is not required for hospital stays in connection with childbirth for the mother or newborn child that are less than 48 hours after a normal vaginal delivery or less than 96 hours after a cesarean section. 26 Medical

29 Coordinating With Dental Coverage If you re enrolled in a POS option and need dental surgery that requires hospitalization, your PCP must be notified in advance of the hospitalization in order for you to receive in-network benefits. If you re enrolled in an indemnity option, you are responsible for precertifying your hospital stay. In all cases, if you re hospitalized for dental care, the dentist s charges are covered by dental benefits. Other eligible charges are covered by your medical benefits. COVERED EXPENSES Your medical benefits under Options 1, 2 and 3 cover the following types of medical services and supplies, but the amount you pay for each covered expense will vary with the option you select. Regardless of the option you select, the care must be: medically necessary, as determined by the network manager or claims administrator; neither investigational nor experimental, as determined by the network manager or claims administrator; within the standards for the reasonable and customary amount, as determined by the network manager or claims administrator, and not excluded by the Plan. Keep in mind that if you select an HMO option, coverage could be different. Refer to your HMO kit for details about your coverage, or call your HMO Member Services. Hospital Services Inpatient All options cover hospital charges for semiprivate room and board and related services and supplies. Other covered hospital services include: the use of operating, recovery and treatment rooms and their equipment the use of intensive care and cardiac care units dressings, splints and plaster casts inpatient laboratory and X-ray examinations physical therapy electrocardiograms oxygen and anesthesia and their administration the cost and administration of blood and blood plasma intravenous injections and solutions X-ray and radium therapy prescribed drugs Outpatient All medical options cover the following outpatient hospital services provided on an outpatient basis or by a licensed free-standing emergency care center, surgical center or birthing center: preadmission testing within seven days of a scheduled admission for nonemergency surgery chemotherapy infusion kidney dialysis performed either in the hospital or in your home hospital charges connected with outpatient surgery hospital emergency room care of an accidental injury or for emergency treatment of a life-threatening sudden and serious illness Medical 27

30 Keep in mind that if you select an HMO option, coverage could be different. Refer to your HMO kit for details about your coverage, or call your HMO Member Services. 28 Surgical Services Covered surgical services include preoperative and post-operative care within the 14-day period after surgery. These include: surgeon s services anesthesiologist s services assistant surgeon s services, when medically necessary or when required by the hospital s established policy Professional Services All options cover the following professional services: doctor s and osteopath s services second surgical opinions chiropractor s services (limited visits per calendar year) podiatrist s services (limited visits per calendar year) services by a registered graduate nurse, licensed practical nurse or licensed vocational nurse examinations and other services for the treatment of an illness or injury, including radiation therapy and chemotherapy medical consultations when requested by the physician in charge of the patient diagnostic examinations, X-rays and laboratory tests, including their reading and interpretation charges for hearing exams and an initial hearing aid per ear per lifetime age 19 or older or one hearing aid per ear every three years for children up to age 19 (must be prescribed by an otolaryngologist) ambulance service to the nearest appropriate facility to treat a patient s medical condition hemodialysis Medical Transplants Transplants are covered as any other medical procedure in all three options. Network managers and claims administrators develop nationwide transplant networks to coordinate available resources for transplant procedures. National transplant networks are created using a rigorous credentialing methodology. Facilities participating in the transplant networks have been evaluated for their surgical and medical capabilities as well as their clinical outcomes (how well they performed). While you are not required to, you are encouraged to consider using a facility in your network manager s national transplant network. If you do, transportation costs as outlined below will be covered. Reasonable and necessary transportation, lodging and meal expenses incurred by the recipient and a companion who travels the same day(s) as the recipient to and from the transplant center for pre-transplant evaluation, transplant surgery and necessary post-transplant services performed at the transplant center will be covered. If the recipient is a minor, transportation, lodging and meal expenses for two companions who travel with the minor will be covered. There is a daily maximum of $200 and an overall lifetime maximum of $15,000 for all transportation, lodging and meal expenses incurred for covered services per transplant. No benefits are payable for services rendered by a member of the recipient s, companion s or donor s immediate family. No benefits are payable for the purchase or shipment of home furnishings or personal belongings.

31 Maternity and Obstetrical Services If you participate in a POS option, benefits for in-network maternity care are as follows: A copayment applies to each visit to your PCP, if necessary, to diagnose that you are pregnant, and to your initial visit to a network obstetrician. After your initial visit to your network obstetrician, the balance of the cost for maternity care for that pregnancy will be paid consistent with the option you select, with no further office visit copayments applying. For example, in Option 2, you pay your initial $15 copayment and the remainder of your physician charges are paid at 85 percent. If you participate in an indemnity option, your maternity expenses are covered as any other medical expense. Covered services include: normal delivery or delivery by cesarean section prenatal and postnatal care initial sonogram per pregnancy (additional sonograms are only covered if medically necessary) amniocentesis if medically necessary treatment by an obstetrician for complications during pregnancy and delivery services in connection with a miscarriage or abortion (including a voluntary abortion) surgery related to an extrauterine or ectopic pregnancy Lamaze or other child-birth preparation classes (upon completion of the class) services of a registered midwife; in order for delivery services to be covered, delivery must be performed in a hospital, licensed free-standing emergency care center or birthing center Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Coverage for Reconstructive Surgery Following Mastectomies The following services are covered by all options. Benefits are paid like any other covered services under the option you select: reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and Contraceptive Coverage Prescription contraceptive devices, implants and injections are covered as preventive care. Refer to the summary charts beginning on page 51 for details on how these and oral contraceptives are covered. Medical 29

32 prostheses and physical complications of all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient. Medical Supplies All options cover the following medical supplies: rental or purchase of durable medical equipment required for therapeutic use and prescribed by a physician. Durable medical and surgical equipment is equipment that is made to withstand prolonged use, made for and mainly used in the treatment of a disease or injury, suited for use in the home, not normally of use to persons who do not have a disease or injury, not for use in altering air quality or temperature and not for exercise or training. In determining the maximum amount that will be paid for durable medical equipment, the network manager or claims administrator will consider the appropriateness of the equipment based on your medical needs and suitable alternatives. To determine whether rental or purchase is appropriate, call Member Services at the number on your medical ID card; the purchase of artificial limbs or other prosthetic appliances; medical supplies and dressings prescribed by a physician, for example, splints, trusses, braces, catheters, oxygen and equipment for its administration, blood and blood products, electronic pacemaker and colostomy bags and colostomy-related supplies; and PKU supplements. Call your network manager or claims administrator to determine if a certain medical supply is covered. Total Parenteral Nutrition and Enteral Nutrition Total parenteral nutrition (TPN) is required for patients with certain medical conditions that impair gastrointestinal function to a degree incompatible with life or with optimal recovery from interventional procedures, such as major surgery or cancer chemotherapy. These patients cannot be maintained through oral feeding and must rely on parenteral nutritional therapy for prolonged periods of time. Enteral nutrition (EN) is considered necessary for a patient with a functioning gastrointestinal tract who, because of dysfunction of surrounding structures that are necessary to permit food to reach the gastrointestinal tract, cannot maintain weight or strength commensurate with his or her general condition. Examples of these conditions are head and neck cancer with reconstructive surgery, and central nervous system disease leading to interference with the neuromuscular mechanisms of ingestion. TPN and EN covered expenses are: cost of nutrients/solutions, except baby food and other regular grocery items, including those that can be blended and used in enteral feeding systems cost of the infusion pump and Heparin lock supplies and equipment necessary for proper functioning and effective use of a TPN or EN system home visits by a physician or nurse in conjunction with TPN or EN 30 Medical

33 In order to qualify for this coverage, the patient must: require at least 75 percent of their total sustenance from EN or TPN have a long-term need for EN or TPN have a condition involving the GI tract which prevents adequate oral intake Coverage under this provision excludes: EN for patients with a normally functioning GI tract whose need for enteral nutrition is due to a lack of appetite or cognitive problems standard infant formulas and formula and food products modified to be low protein for people with inherited diseases of amino acid and organic acid metabolism (except PKU) baby food and other regular grocery items, including those that can be blended and used in enteral feeding systems Allergy Treatment For in-network allergy treatment, your PCP can refer you or your dependents for allergy testing by an allergist. For injections, you pay either the office visit copayment for the option you ve selected or the cost of the injection whichever is less. In all other circumstances, allergy treatment is covered like any other medical expense. Infertility Treatment All options cover the diagnosis of the cause of infertility and/or medical treatment to correct that cause (Viagra is not covered). Both men and women are covered for infertility treatment. However, all procedures and services, including lab and X-ray, intended to induce pregnancy (rather than to treat an underlying medical cause) are not covered. See the Prescription section for details on how infertility medications are covered. The following procedures are not covered because they do not correct the underlying medical causes of infertility: artificial insemination in vitro fertilization with embryo transfer intrafallopian transfer sperm banking/semen specimen storage artificially assisted fertilization infertility counseling for, or related to, artificially assisted fertilizations services for and costs of a surrogate mother Because of the variety of treatment approaches to infertility, you and your doctor may want to contact the network manager or claims administrator before treatment begins to determine if a particular treatment will be covered. Chiropractor and Podiatric Treatment The options cover a limited number of visits per calendar year to a chiropractor or podiatrist. If you participate in a POS option, you must have a referral from your PCP for treatment to be covered in-network. Medical 31

34 SPECIAL TYPES OF THERAPY The options cover short-term rehabilitation therapy and speech therapy. Here are the procedures for each type of coverage. If you participate in a POS option, rehabilitation and speech therapy benefits are covered in-network after your copayment for each visit. There is no limit for medically necessary visits. If you choose out-of-network care, you are limited to 60 visits (combined rehabilitation and speech therapy) per Plan year, and any in-network visits will be counted toward your out-of-network limit. If you participate in an indemnity option, you are limited to 90 combined visits per Plan year. In any case, you must show improvement within 60 calendar days from the beginning of treatment for coverage to continue. Rehabilitation Therapy Charges made by a physician or a licensed or certified physical or occupational therapist for furnishing short-term rehabilitation services for the treatment of acute conditions are covered by Options 1, 2 and 3. Rehabilitation is physical therapy or occupational therapy for the improvement of a body function that has been lost or impaired due to injury or illness. Charges are not covered for: services and supplies received while you or your dependent are confined in a hospital or other facility for medical care (these may be covered by other Plan provisions) services not performed by or under the direct supervision of a physician services that are not provided in line with a specific treatment plan that: details the treatment to be given and the frequency and duration of the treatment, and provides for ongoing reviews and is renewed only if therapy is still necessary Speech Therapy Benefits are paid only for speech therapy needed to restore speech lost as a result of an illness or injury. For example, children who have not fully developed their speech skills are not eligible for these restorative services. However, someone who loses speech capacity as a result of an accident could receive benefits under this provision. Speech problems can be unique, varying in severity from individual to individual, and frequently diagnoses can be subjective. To help determine if the condition is covered by the Plan, submit information to the network manager or claims administrator for advance review. This way, you ll know what benefits can be paid before treatment begins. Certain speech problems, such as stuttering in children, may be covered by Public Law , The Education for All Handicapped Children Act of This law provides public schools with language and speech services for all children between the ages of three and 21, including help in identifying and diagnosing speech and language disorders as well as rehabilitative and preventive treatment. As a result, treatment of these kinds of speech problems is not covered. 32 Medical

35 To be eligible for benefits, treatment of a speech problem must be prescribed, controlled and directed by a doctor and approved by the network manager or claims administrator. Besides the exclusions noted in the section What s Not Covered by Your Medical Benefits and situations covered by Public Law , there are other conditions and services not covered by the medical options. These include: certain speech problems in children that are classified as developmental delays that may correct themselves without treatment services rendered for the treatment of delays in speech development, unless resulting from injury or illness speech problems caused by learning disabilities or articulation disorders (if there is an underlying psychological reason for the condition, that underlying condition may be covered as a mental or nervous disorder) services or supplies that a school system is required by law to provide services of a speech therapist who lives in your home special education, including lessons in sign language, to teach a covered person whose ability to speak has been lost or impaired to function without that ability ALTERNATIVES TO A HOSPITAL STAY Rather than a stay as a hospital inpatient, an alternative course of medical care may be more appropriate, cost-effective and comfortable. Expenses are covered by each of the options for the following alternatives to a hospital stay. Skilled Nursing Facility Skilled nursing facilities provide intermediate care following a hospital stay, when a patient may still require 24-hour nursing care for a limited period, but not the level of care provided by a hospital. In these circumstances, benefits for a skilled nursing facility (or convalescent care facility) will be paid by all medical options. There are no limits to the number of days of skilled nursing facility care if provided in-network. Up to 60 days per calendar year are covered in an out-of-network skilled nursing facility or in an indemnity option. Any in-network days will be counted toward your out-of-network limit. Outpatient Private Duty Nursing Benefits may be paid for medically skilled private duty nursing at home if your doctor prescribes it. Benefits cover the home services of registered nurses, licensed practical nurses and licensed vocational nurses up to a maximum of 560 hours per calendar year (70 eight-hour shifts). The 560 hours are counted as they are used. For example, a two-hour visit will be counted as two hours, rather than an eight-hour shift. Medical 33

36 Call the toll-free number on your medical ID card before you make any arrangements for outpatient private duty nursing. 34 To be covered, outpatient private duty nursing services must: be medically necessary for treatment of a disease or injury require the medical training and technical skills of a registered nurse (RN), licensed practical nurse (LPN) or licensed vocational nurse (LVN) and be ordered by the attending physician as necessary treatment The charges of a private duty nurse in a hospital are not covered because the hospital provides a staff of registered nurses for care given during hospitalization. These charges are part of the room and board charges. Skilled nursing care is not the same as custodial care. Custodial care is not covered, even if given by an RN, LPN or LVN. Custodial care includes such things as meal preparation, bathing the patient, acting as a companion and other services that may be necessary for the normal activities of daily living, but that do not require the medical training and technical skills of a nurse. Daily nursing notes will be reviewed to determine the portion of the nursing care that qualifies for benefits. It s also important to understand that while skilled nursing care may be necessary initially, alternate caregivers may be encouraged to learn the skills necessary for ongoing medical care. Once alternate caregivers have demonstrated their proficiency in a particular procedure, skilled nursing coverage for that procedure may cease. No benefits are paid for services given by a nurse who lives with you. Medical Home Health Care Charges made by a home health agency for a covered family member in the home in accordance with a home health care plan are covered by this benefit. For these expenses to be eligible, the home health care plan must be outlined by your physician. Covered home health care expenses include: part-time or intermittent home health aide services, consisting primarily of caring for the patient in conjunction with skilled nursing care physical, occupational or speech therapy drugs and most medical supplies prescribed by a physician laboratory services Home health care benefits are calculated on a per-visit basis. Each visit by a nurse, therapist or aide is considered one visit; four hours is the maximum length of one visit. There are no limits on the number of home health care visits when the service is provided in-network. Up to 120 home health care visits per Plan year are covered when provided out-of-network or through an indemnity option. The following expenses are not covered by home health care: services or supplies not included in the home health care plan outlined by your physician services of a person who ordinarily lives in your home or who is a member of your or your spouse s family custodial care transportation

37 Hospice Care Hospice care provides terminally ill patients and their families with an alternative to hospital care while assuring them of a specialized program tailored to each individual. Terminally ill patients require specialized care, both medical and psychological, that may not be readily available from the regular hospital staff. For purposes of this program, a terminally ill patient has a medical prognosis of six months or less to live. Charges for room and board made by a hospice facility, hospital, convalescent facility or physician are allowable when furnished on a full-time inpatient basis for pain control and other acute and chronic symptom management. The following services and supplies are allowable when furnished to a person receiving outpatient hospice care coordinated by the hospice program administrator: part-time intermittent nursing care by an RN or LPN for up to eight hours in any one day medical social services under the direction of a physician, including: assessment of the person s social, emotional and medical needs and of the home and family situation identification of community resources needed to meet her or his assessed needs assisting the person to obtain the resources needed to meet her or his assessed needs psychological and dietary counseling consultation or case management services by a physician or nurse physical therapy part-time or intermittent home health aide services for up to eight hours in any one day. These consist mainly of caring for the person. Benefits are not provided for the following hospice care services and supplies: any charge for daily room and board in a private room in excess of the institution s semiprivate room rate charges made for the following services: bereavement counseling funeral arrangements pastoral counseling financial or legal counseling, including estate planning or the drafting of a will homemaker or caregiver services that are not solely related to care of the person (sitter or companion services for the patient or other members of the family, transportation, housecleaning and maintenance of the house) respite care Medical 35

38 WHAT S NOT COVERED BY YOUR MEDICAL BENEFITS Your medical benefits do not cover the following: charges that exceed the reasonable and customary limit, as determined by the network manager or the claims administrator services or supplies that are not medically necessary, as determined by the network manager or the claims administrator, even if prescribed, recommended or approved by the attending physician or dentist services or supplies the network manager or claims administrator determines to be unnecessary for the diagnosis, care or treatment of the condition involved care, treatment, services or supplies not prescribed, recommended and approved by the attending physician hospital care for diagnostic purposes unless the covered person s condition or type of test requires hospitalization services or supplies not provided in accordance with medical or professional standards and practice treatments or procedures and related materials that are investigational or experimental in nature, as determined by the network manager or the claims administrator. Investigational or experimental means that the medical use of a service or supply is still under study and the service or supply is not yet formally recognized throughout the medical profession in the U.S. as safe and effective for diagnosis or treatment. If a service or supply is furnished in connection with a service or supply that is investigational or experimental, as determined by the appropriate network manager or claims administrator, it is not covered. occupational conditions, ailments or injuries for which coverage is provided by Workers Compensation or by a similar law additional expenses for a private room in a hospital private duty nursing while confined custodial care, rest centers, nursing homes or assisted living centers treatment of a condition caused by war (declared or undeclared) or any act of war treatment of a condition caused by committing an unlawful act of aggression, including a misdemeanor or a felony services or supplies for which benefits are provided by any government law services or supplies that are provided by reason of past or present service in the armed forces of any government services provided before coverage becomes effective or for services given after coverage ends dietary supplements, including any supplement for newborn infants, except as described in Total Parenteral Nutrition and Enteral Nutrition and PKU supplements services or supplies related to any eye surgery mainly to correct refractive errors (for example, radial keratotomy) unless vision acuity cannot be corrected to 20/50 with corrective lenses services or supplies for or related to sex change surgery or any treatment of gender identity disorders reversal of a sterilization procedure services or supplies intended to induce pregnancy, such as artificial insemination, in vitro fertilization or embryo transfer procedures, including surrogate parenting 36 Medical

39 expenses related to the purchase of orthopedic shoes or related corrective devices and appliances, except where the shoes or devices are permanently fastened to an orthopedic brace and are medically necessary or used in the place of surgery personal hygiene or convenience items, such as air conditioners, humidifiers and physical fitness equipment items to accommodate your home, office or vehicle as a result of an injury or illness, such as wheelchair lifts, hand rails, or stair risers acupuncture therapy, except when acupuncture is performed by a physician as a form of anesthesia in connection with surgery that is covered by the medical option you select weight reduction programs, unless preapproved by the network manager or claims administrator treatment of an intentionally self-inflicted injury plastic surgery, reconstructive surgery or other services and supplies that improve, alter or enhance appearance, whether or not for psychological or emotional reasons. However, benefits are paid if cosmetic/ plastic surgery is needed to: improve the function of a body part that is not a tooth or structure that supports the teeth, or correct a severe birth defect, including harelip or webbed fingers or toes, provided the surgery is necessary to improve the functionality of the body part, or correct a malformation as a direct result of disease, surgery performed to treat a disease (including reconstructive surgery following a mastectomy), or an accidental injury charges for a missed or broken appointment charges for the doctor s travel administrative or office fees, such as copy and mailing expenses and state and local taxes claims received more than 12 months past the date of service charges for or related to services, treatment, educational testing or training related to learning disabilities or developmental delays items listed in the following sections as not covered expenses: Enteral Nutrition and Total Parenteral Nutrition Infertility Treatment Special Types of Therapy Home Health Care Hospice Care Prescription Drug Benefits Solutions Medical 37

40 HOW TO FILE A MEDICAL CLAIM For in-network care provided or coordinated by your PCP, you generally do not have to file a claim form. Simply pay your copayment when the service is received. The network manager handles all other paperwork. Claims must be received within 12 months after the date the service or treatment is given or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. In the rare case that you have to file a claim because you or a dependent needed care while away from home, follow the instructions below for filing an out-of-network claim. For out-of-network claims, or if you participate in an indemnity option, submit your invoice to the address on the back of your ID card. Be sure the invoice includes: patient s full name, date of birth and relationship to you your name and address your member number from your medical ID card dates of service diagnosis charge for each service your provider s full name, address and taxpayer identification number whether you want payment made to you or the provider Send the invoice to the network manager or claims administrator at the address shown on the back of your ID card. PRESCRIPTION DRUG BENEFITS Your medical coverage provides prescription drug benefits for all participants. Prescription drug benefits are provided through: PAID Prescriptions Program for your short-term and immediate prescription drug needs at retail pharmacies Mail Order Prescription Program for long-term and ongoing maintenance prescription drug needs PAID Prescriptions The PAID Prescriptions Program is designed to meet your short-term and immediate needs. You pay a copayment if you have your prescription filled with a generic drug, and a larger copayment if the prescription is filled with a brand name drug that has no equivalent generic. If the brand name drug has an equivalent generic, you will pay the larger copay plus the difference in cost between the generic and the brand name drug. You can receive up to a 34-day supply. Refills are also covered. 38 Medical

41 When you enroll, you receive a PAID Prescriptions ID card. Call PAID Prescriptions at to locate a participating pharmacy near you or to request any additional ID cards. At a Participating Pharmacy When you use a participating PAID Prescriptions pharmacy, simply present your ID card to the pharmacist along with your doctor s prescription. You don t have to file any claims. At a Non-Participating Pharmacy When using a non-participating pharmacy, you ll have to pay the full amount of each prescription and submit a completed claim form to be reimbursed. Your cost will equal the difference between the full retail price and the discounted amount (as if you had used a participating pharmacy) plus your copayment. Call PAID Prescriptions at for a claim form. Mail the completed claim form to: PAID Prescriptions P.O. Box 6121 Fairlawn, NJ Claims must be received within 12 months after the date the prescription is filled or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. (If your prescription is for a controlled substance, you ll receive only up to a 30-day supply. Also, a signature is necessary for the prescription when it s delivered to you.) The first time you order drugs through the mail order program, you must fill out a short questionnaire, called a patient profile. It is included with your ID card. Before leaving the doctor s office, check the prescription you ve been given to ensure that the doctor s name is legible, that the exact daily dosage, strength and quantity are indicated, and that the patient s first and last name are legible. To order drugs through the Mail Order Prescription Program, send the prescription to: Merck-Medco Rx Services, Inc. P.O. Box Dallas, TX Or order refills through the Internet or by phone. See the back page of this booklet for information. Your prescription will be immediately filled and sent to you. You will not be charged for shipping expenses. Generic vs. Brand Name Prescriptions When requesting an equivalent generic, keep in mind that only drug products that the FDA considers to be therapeutically equivalent are filled in place of a brand name drug. Therapeutically equivalent simply means the same active ingredients in the same strength and same absorption rate (and extent) into the bloodstream as the brandname drug it replaces. The FDA assures that all drugs, brand and generic, meet federal requirements for drug quality, strength, purity and potency. In fact, most generic drugs are made by the same companies that create brand-name drugs. Mail Order Prescription Program If medication is necessary on an ongoing basis, you can meet your long-term needs by getting up to a 90-day supply per prescription, plus refills, through the mail order program. This saves you several copayments. Medical 39

42 Voluntary Formulary A formulary is a list of commonly prescribed medications meant to be presented to your physician. By asking your doctor to prescribe drugs listed in the formulary, you can help control the rising costs of prescription medications to both you and the Company. A formulary list will be sent to you when you receive your PAID Prescriptions ID card. To obtain an additional formulary list, simply call Prior Authorization Program PAID Prescriptions and the Mail Order Prescription Program have a Prior Authorization Program that evaluates the medical necessity of using certain drugs in certain situations. Your pharmacist will tell you if your prescription requires prior authorization. Then you or your physician must call PAID Prescriptions to request authorization for coverage of these drugs. The list of drugs requiring prior authorization may change from time to time; contact PAID Prescriptions at for more information. What s Covered by Prescription Drug Benefits Prescription drug benefits cover (except as noted below): drugs approved by the federal government state-restricted drugs insulin by prescription only insulin needles, syringes and chem strips by prescription only over-the-counter diabetic supplies compounded medications smoking deterrents (limited to one 90-day supply per lifetime) oral contraceptives What s Not Covered by Prescription Drug Benefits Prescription drug benefits do not cover: contraceptive devices drugs not approved by the federal government drugs used for cosmetic purposes infertility drugs without prior authorization (see above) Viagra therapeutic devices or appliances drugs labeled Caution limited by federal law to investigational use, or experimental drugs, even though a charge is made to the individual medication for which the cost is recoverable by Workers Compensation, occupational disease law, any state or governmental agency, or medication furnished by any other drug or medical service for which no charge is made to the participant any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician s original order dietary supplements, including any supplement for newborn infants growth hormones without prior authorization (see above) over-the-counter medications (other than diabetic supplies) 40 Medical

43 SOLUTIONS FOR MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT Medically necessary treatment for mental health and substance abuse (drug and alcohol abuse) is provided through Solutions, a program administered by ValueOptions. Solutions complements, but does not replace, the current Employee Assistance Plan (EAP). For Solutions, medically necessary means care that, as determined by ValueOptions: is appropriate and necessary to evaluate or treat a disease, condition or illness as defined by standard diagnostic nomenclatures (the American Psychiatric Association s Diagnostic and Statistical Manual IV, as revised or updated in the future); can reasonably be expected to improve an individual s condition or level of functioning; is in keeping with national standards of mental health professional practice as defined by standard clinical references and valid empirical experience for efficacy of therapies; and is provided at the most appropriate and cost effective level of care How Solutions Works Solutions operates separately from other parts of the medical option you select, but is an integral part of the health care benefits you receive. Your out-of-pocket costs for mental health or substance abuse treatment are not credited toward your annual out-of-pocket maximum. However, benefits provided by Solutions count toward your lifetime maximum benefit. ValueOptions maintains a national network of mental health providers therapists, treatment programs and hospitals. Like PCPs in the POS options,valueoptions providers meet strict membership requirements, have proper credentials and are regularly reviewed by ValueOptions to ensure that standards are met. You will receive maximum benefits if you call Solutions for a referral. You and your covered dependents can contact Solutions 24 hours a day, 365 days a year by calling If you seek emergency treatment, you must contact Solutions within 48 hours. You can call Solutions directly, or your PCP, another doctor or the EAP may refer you to Solutions. When you first call Solutions, you ll talk with a trained professional who will discuss your situation confidentially with you. You may then be referred to an appropriate provider for a more complete evaluation and development of a treatment plan. After a treatment plan is developed, Solutions will monitor the care to ensure the treatment you receive is appropriate and medically necessary. All medically necessary outpatient visits to a ValueOptions network provider will be covered. Mental Health Mental health treatment is covered as follows: All inpatient mental health treatment must be provided through the Solutions network If you participate in Network Blue New England or Humana HMO, your mental health and substance abuse coverage is administered by Solutions. You have the same coverage as Option 1. Medical 41

44 Outpatient mental health treatment may be provided through Solutions or a provider who is not part of the Solutions network. If you seek treatment within the Solutions network, you are eligible to receive treatment for up to five visits per Plan year for marital, parent/child, partner-relational, sibling-relational and bereavement counseling. In addition, the Solutions network in certain states includes Licensed Professional Counselors (LPC) and Licensed Marriage and Family Counselors (MFCC and/or LMFT).These services and providers are not covered if you use a non-network provider. If you seek treatment outside the Solutions network, Solutions will pay benefits only if treatment is provided by one of these core providers: psychiatrist (MD, DO) licensed clinical psychologist (doctoral level) licensed masters-level clinical social worker (e.g., licensed MSW) masters-prepared psychiatric registered nurse (e.g., MA, MS, MSN) The core provider must hold the highest level of licensure or certification that the state in which they are practicing offers. In addition, all providers must have a current state license. Because licensing requirements vary from state to state, call Solutions before you start treatment to verify that you re seeing an appropriate provider. ValueOptions must always precertify the following services, regardless of whether or not you use a Solutions provider: psychological testing electroconvulsive therapy (ECT) biofeedback hypnotherapy aversion therapy individual therapy for chemical dependency (only available through Solutions network) Substance Abuse Substance abuse treatment whether inpatient or outpatient is covered only through Solutions. Substance abuse treatment not approved by ValueOptions before the treatment is provided is not covered. For substance abuse treatment arranged through Solutions, you are responsible for one fee or copayment per course of treatment (as well as any applicable coinsurance amount), regardless of the setting (or settings) for the treatment.this is called a Treatment Plan Fee. Confidentiality Information regarding your or an eligible dependent s participation in Solutions will be kept confidential, except with your written consent or where disclosure is required by law or specific company policy with regard to safety-sensitive positions. In the latter instance, disclosure will be made only to designated persons and will be limited to information for which there is a need to know. Outside the Solutions network, benefits are payable at 50 percent of reasonable and customary for up to 20 visits per calendar year, with no deductible applying. 42 Medical

45 What s Not Covered The following mental health and substance abuse services and treatments are not covered in Options 1, 2 and 3: treatment not provided by one of the core providers or a Solutions network provider court-ordered treatment, unless assessed and certified by ValueOptions to be in accordance with medically necessary standards services and treatment for the purpose of maintaining employment or insurance, unless assessed and certified by ValueOptions to be in accordance with medically necessary standards services and treatments which are: educational or vocational in nature required by law to be provided by a school system for a child (e.g., evaluation for attention deficit disorder) for personal growth and development for adjudication of marital, child support and custody cases services and treatment that are experimental, investigational, mainly for research or not in keeping with national standards of practice as determined by ValueOptions, for example, treatment of sexual addiction, codependency, or any other behavior that does not have a psychiatric diagnosis (except in-network treatment up to five visits per Plan year for marital, parent/child, partnerrelational, sibling-relational and bereavement counseling) regressive therapy, megavitamin therapy, nutritionally based therapies for chemical dependency treatment, and non-abstinence based chemical dependency treatment custodial care, including, but not limited to, treatment not expected to reduce the disability to the extent necessary to enable the patient to function outside a protected, monitored or controlled environment services and treatment for mental retardation (except initial diagnosis), autism (which may be covered by the medical plan), pervasive developmental disorders, chronic organic brain syndrome, learning disability treatment for transsexualism treatment for smoking cessation treatment for obesity and/or weight reduction treatment for stammering or stuttering treatment for chronic pain except for psychotherapy, biofeedback or hypnotherapy rendered in connection with a psychiatric disorder In addition to this list, certain medical services or supplies are not covered (for a general list of what s not covered, see pages 36-37). To determine if specific mental health or substance abuse treatment will be covered, call Solutions at Medical 43

46 How to File a Solutions Claim If your provider does not file a claim for you, send your invoice to ValueOptions, P.O. Box , Irving, TX If you have a question about a claim, you may call Types of HMOs There are several types, or models, of HMOs. The three most widely used are the independent practice association (IPA), staff model and group model. Here are the differences among the three: Claims must be received within 12 months after the date the service or treatment is given or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. The IPA is the most common type of HMO. It looks very much like a POS plan. Most of the doctors are in private practice and also see patients who don t participate in the HMO. They can make referrals to other network specialists as necessary. HEALTH MAINTENANCE ORGANIZATIONS (HMOS) To help you choose the coverage that s best for you and your family, you need to understand the differences between an HMO and the POS options.this section will help you do that. Also, refer to the materials sent directly to you from the designated HMO in your area for important information about how coverage works under that particular HMO. A staff model employs doctors who often work solely for the HMO and work out of central facilities that house other services, such as a pharmacy, lab and specialty care. These doctors see only HMO members. Referrals can be made to other network specialists. These specialists may be on staff, or they may be in private practice and contract with the HMO. The HMO may own its own hospitals or contract with local hospitals. How an HMO Works An HMO provides coverage only within its own network. There is usually no outof-network benefit. In return, the HMO can be an easier, less complicated system to use. A group model contracts with doctors who have formed a group practice. There can be many group practices in an HMO, but each group acts as its own network because referrals are made within that group practice to the extent possible. A group practice doctor may see patients from other health plans, or the group may have an exclusive arrangement with the HMO. 44 Medical

47 The following chart highlights some of the differences between the HMO and POS options: When You Receive care See your PCP first Go in-network Go out-of-network In a POS You have two options: You can receive care through your Primary Care Physician (PCP) for in-network benefits. Or, you can see any doctor and receive out-of-network benefits, which are generally more costly to you. You receive in-network benefits. Your PCP will treat you or refer you to a specialist. However, in-network OB/GYN care does not require a PCP referral. You ll pay only a small copayment. If you re admitted to a hospital, you ll pay an extra admission fee. You file no claim forms and pay no deductibles. Your benefits will be lower. You must first meet an annual deductible. You must file claims to get reimbursed. You ll need to coordinate your own care, as your PCP won t be involved to handle this for you. You ll have to coordinate hospital precertification (as required by the Plan). In an HMO You must use an HMO provider or facility to receive coverage. With few exceptions, if you don t use an HMO provider or facility, benefits will not be paid. In most HMOs, you must select and see your PCP to coordinate your care. However, OB/GYN care usually doesn t require a PCP referral. You ll pay only a small copayment. There is usually no hospital admission fee to pay. You file no claim forms and pay no deductibles. You ll have no benefits, except for emergency care, unless the outof-network care is preauthorized by the HMO. Your Care Is Coordinated When you select an HMO, you agree to receive care only from doctors who are affiliated with the HMO or to whom the HMO refers you. You may find it necessary to change doctors when you join the HMO if your doctor is not part of the network. But you receive higher benefits and may save money by paying lower out-of-pocket expenses for most HMO network care. It s All Handled for You In most HMOs, you choose a Primary Care Physician (PCP) to coordinate care for you and each covered member of your family. Your PCP provides for your health care, orders tests, prescribes medicine and refers you to specialists. If you require hospitalization, your PCP arranges for admission and coordinates your hospital care. Refer to your HMO materials for coverage details and health care services, supplies, and educational programs available through the Flexible Benefits Plan HMO networks. Medical 45

48 To Be Covered by the HMO,Your Care Must Be In-Network There are no out-ofnetwork benefits. If you do not see a network doctor or provider, you will not receive benefits. However, exceptions are allowed for emergencies. Network Referrals HMO network doctors have well-developed referral systems and highly integrated relationships with other providers. The doctors and other providers in HMOs talk to each other and work together for your benefit. In most cases, when you need specialty care, your PCP must refer you to another in-network doctor. However, selected HMOs allow you to see certain network specialists without a referral. Some Flexible Benefits Plan HMOs offer the convenience of one-stop shopping by providing primary and specialty care as well as pharmacy, lab and diagnostic services in one facility. Centralized and on-line medical records also ensure that your doctor and other network providers you re seeing have access to test results and other information regardless of when or where you seek network-based care. A Small Copay Per Doctor Visit Each time you visit your PCP or receive other network treatment, you pay a small copayment. You don t pay annual deductibles. Choosing a PCP In most HMOs, you select your PCP from the provider directory mailed to you by the HMO. However, in some staff model HMOs, you simply make an appointment with that PCP and he or she will become your regular doctor. If you want to change your PCP, call the HMO s Member Services to learn the guidelines. 24-Hour Care You have 24-hour medical care with an HMO doctor on call around the clock, seven days a week. You re always covered for emergencies and urgent care no matter where you travel. Many HMOs also have after-hour appointment times and urgent care centers as well as special Medical Advice telephone lines that you can call to receive guidance any time, day or night. When You Need Mental Health or Substance Abuse Care If you select an HMO, you may have coverage for mental health and substance abuse care administered by the HMO, or you may have Solutions coverage, as described on page 41. Because HMO plans vary, refer to the materials provided by the selected HMO in your area for details about how mental health and substance abuse care are covered. 46 Medical

49 Prescription Drugs Your HMO will administer the prescription drug program. Although you ll no longer participate in the existing PAID Prescriptions Program, you ll find the HMO coverage to be quite similar. Check your HMO materials for coverage details. No Claim Forms The HMO processes most paperwork for you and pays the doctors and specialists who treat you. All the administrative operations are handled internally by the HMO, which makes it convenient and easy for you to use. Special Situations Because only care received through the HMO is covered, special rules apply when you must seek care outside the HMO, for instance when you have an emergency or are traveling.to learn about your HMO s policies in these circumstances, refer to the HMO literature or call Member Services. If Your Dependent Doesn t Live With You Except for an emergency, HMO coverage is usually available only if you or your dependents receive care through the network. If your eligible dependents live outside the HMO network area (such as away at college or with a divorced spouse living outside of the HMO area), coverage is usually only available if those individuals come to the network area for care. If emergency care is provided out of the network area, the HMO usually limits followup care benefits outside the network area. Refer to your HMO materials for details, or call Member Services for more information. Make sure you know the rules before selecting the HMO option. GENERAL MEDICAL PROVISIONS Measuring Network Quality Most network managers seek accreditation by the National Committee on Quality Assurance (NCQA), an independent, nonprofit organization that validates managed care activities and gives network managers an accreditation or quality rating similar to a Malcolm Baldrige Quality or ISO 9000 award. NCQA accreditation means that network managers use the policies, procedures and programs approved by NCQA that are necessary to manage and arrange for the delivery of needed medical care and measure the quality of the care received. Medical 47

50 NCQA documents and accredits network managers in the following areas: quality management and improvement measuring the quality of care and the continuous improvement in delivery of care physician qualifications and evaluation ensuring that each participating provider has the credentials that meet standard practice guidelines preventive health services the levels of care that emphasize prevention, early detection, and treatment of disease access to care geographic care, comprehensive specialties, appropriate appointment access, and waiting times utilization management how the network manager reviews and ensures the appropriate level of care medical records the completeness and accuracy of medical records kept by network physicians member s rights and responsibilities how the network manager communicates the rights and responsibilities of each member of the HMO Maintenance of Benefits Your medical coverage has a maintenance of benefits (MOB) provision that ensures you will not receive duplicate benefits from two plans. That means that coverage will not exceed the amount that would have been paid by the Flexible Benefits Plan option you elect. However, maintenance of benefits does not apply to prescription drug benefits. If a person is covered by two plans, one of the plans is considered primary, and the other is considered secondary. When a claim is made, the primary plan pays benefits first. A plan without a maintenance of benefits provision is always the primary plan. If all plans have this provision, the primary plan will be determined in this order: The plan covering the person as an employee rather than the plan covering the person as a dependent is primary If a person is covered as an employee by two plans, the plan covering the person the longest is the primary plan Typically, HMO and POS plans offered through the Plan are either currently accredited or in the process of obtaining accreditation by NCQA. NCQA has a Web site at 48 Medical

51 If a child is covered by both parents plans, the plan of the parent whose birthday falls first in the calendar year is considered the primary plan In the case of a divorce or separation: First, the plan covering the child as a dependent of the parent legally declared financially responsible by court decree is primary Second, the plan covering the parent who has custody of the child (if there is not a court decree) is primary Third, in the event there is not a court decree and the parent who has custody has remarried, the order of priority is: The plan covering the parent who has custody is primary The plan covering the spouse of the parent who has custody is primary The plan covering the parent without custody is primary When a determination cannot be made, the plan covering the eligible dependent longer is considered primary. Any other situations will be handled in accordance with guidelines established for coordination of benefits by the National Association of Insurance Commissioners. An Example When the Flexible Benefits Plan is secondary, the combined benefits from both plans will equal what the Plan would have paid if it were the only plan. See the table below. The table below shows how the Plan pays when it is secondary. The examples assume that required deductibles have been met. Maintenance of Benefits Between Two Managed Care Plans Remember that when the Flexible Benefits Plan is the secondary plan, the Plan benefits will be paid at the outof-network level if services are provided by a provider that doesn t participate in the Flexible Benefits network, even if that provider participates in the other (primary) plan s network. How Flexible Benefits Are Coordinated Example 1 Example 2 Eligible expenses $1,000 $1,000 Flexible Benefits pays x 80% x 70% Flexible Benefits would pay if no other coverage $ 800 $ 700 Other plan paid $ 700 $ 800 Flexible Benefits will pay $ 100 $ 0 Medical 49

52 Coordination With Medicare Medicare benefits will be primary to the extent permitted under applicable law. Covered individuals who are covered under the Plan based on criteria other than current employment status e.g. COBRA continuees, certain disabled employees will have Medicare as their primary coverage. Individuals with End Stage Renal Disease (ESRD) may be subject to a coordination period, after which Medicare will become primary. As a general rule, if you or your covered dependent becomes eligible for Medicare benefits, there are rules that determine whether the Flexible Benefits Plan pays benefits first, or whether Medicare is primary. If you are an active employee covered by the Flexible Benefits Plan, the Plan would be primary for you and your covered dependent who is eligible for Medicare (for example, due to a disability or being age 65 or older). If you are disabled and not actively working, the Flexible Benefits Plan would be primary for you and any covered dependents who may be eligible for Medicare for the first six calendar months of your disability period. After the six-month period, if you are not actively working at the Company, Medicare pays benefits first for you and any covered dependents (if they are also eligible for Medicare). In the event an individual is eligible for Medicare due to end stage renal disease (ESRD) and is covered by this Plan, the Flexible Benefits Plan will be primary during the coordination period (currently the first 30 months of ESRD). Thereafter, Medicare will be primary. Notwithstanding the foregoing, this Plan will coordinate against Medicare to the extent permitted under applicable law. During the time the Flexible Benefits Plan pays benefits first, you should submit a claim for any remaining expenses not covered by the Plan to Medicare. (Incidentally, you should apply for Social Security disability income benefits during the fifth month of disability to make sure you have no gaps in income protection.) During the time Medicare pays benefits first, you should first submit claims to Medicare for payment. Right of Recovery Provision In some situations, you or your covered dependents may be entitled to certain payments from another source following an injury or illness. See page 122 for details on the Plan s right of recovery provisions. 50 Medical

53 These charts represent a summary of the actual benefits available under the Plan. Please refer to the appropriate section for more detailed information about coverage. IF YOU LIVE IN A NETWORK AREA: Benefit Option 1 Option 2 Option 3 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Plan Deductible The deductible applies only once to each individual in a calendar year. There is no endof-the-year deductible carryover provision. none $250/person $500/family All out-of-network benefits except emergency room, prescriptions, and mental health/substance abuse are subject to the deductible. none $350/person $700/family All out-of-network benefits except emergency room, prescriptions, and mental health/substance abuse are subject to the deductible. none $500/person $1000/family All out-of-network benefits except emergency room, prescriptions, and mental health/substance abuse are subject to the deductible. Coinsurance This is the amount the Plan pays after you have met the deductible or paid the hospital admission fee. 100% Applies to hospital, surgical, diagnostic X-ray/lab and other non-office visit services. 80% Applies to all services except emergency room and ambulance. 85% Applies to hospital, surgical, diagnostic X-ray/lab and other non-office visit services. 70% Applies to all services except emergency room and ambulance. 70% Applies to hospital, surgical, diagnostic X-ray/lab and other non-office visit services. 60% Applies to all services except emergency room and ambulance. Out-of-Pocket Maximum Once the out-ofpocket maximum is reached, covered expenses incurred during the rest of the calendar year are covered at 100%. $1,000/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. $3,000/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. $1,000/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. $4,500/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. $1,500/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. $6,000/person All out-of-pocket expenses count toward the maximum except copays, prescription copays, mental health/ substance abuse expenses, fees for failure to precertify hospital admission, amounts over R&C, and expenses not covered by the Plan. Lifetime Maximum $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected PHYSICIAN SERVICES Physician Office Visit $10/visit 80% $15/visit 70% $15/visit 60% Specialist Office Visit $10/visit 80% $15/visit 70% $15/visit 60% In-Hospital Physician Services 100% 80% 85% 70% 70% 60% Allergy Testing and Treatment Services The lesser of the $10 office visit copayment or the cost of the serum 80% The lesser of the $15 office visit copayment or the cost of the serum 70% The lesser of the $15 office visit copayment or the cost of the serum 60% Diagnostic X-Ray and Laboratory (including preadmission testing) 100% 80% 85% 70% 70% 60% Routine Physical Evaluation $10/visit Refer to Physical Evaluation Guidelines not covered $15/visit Refer to Physical Evaluation Guidelines not covered $15/visit Refer to Physical Evaluation Guidelines not covered Medical 51

54 IF YOU LIVE IN A NETWORK AREA: Benefit Option 1 Option 2 Option 3 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Well-Baby Care $10/visit Refer to Physical Evaluation Guidelines not covered $15/visit Refer to Physical Evaluation Guidelines not covered $15/visit Refer to Physical Evaluation Guidelines not covered Mammograms 100% Refer to Physical Evaluation Guidelines 80% for medically necessary procedures only 85% Refer to Physical Evaluation Guidelines 70% for medically necessary procedures only 70% Refer to Physical Evaluation Guidelines 60% for medically necessary procedures only Routine OB/GYN Exam $10/visit Self-referral for all OB/GYN services 80% Covers Pap smear and related lab fees only $15/visit Self-referral for all OB/GYN services 70% Covers Pap smear and related lab fees only $15/visit Self-referral for all OB/GYN services 60% Covers Pap smear and related lab fees only Contraceptives Oral Covered as prescription drug Covered as prescription drug Covered as prescription drug Covered as prescription drug Covered as prescription drug Covered as prescription drug Contraceptive devices, implants and injections $10 office visit copay Not covered $15 office visit copay Not covered $15 office visit copay Not covered Surgery Surgeon/Surgical Assistant/ Anesthesiologist 100% 80% 85% 70% 70% 60% Maternity Initial OB/GYN visit Hospital admission fee $10 $100 Then 100% of all hospital and maternity charges 80% of all charges $15 $150 Then 85% of all hospital and maternity charges 70% of all charges $15 $250 Then 70% of all hospital and maternity charges 60% of all charges HOSPITAL SERVICES Hospital Admission Fee. This is paid each time a covered individual is admitted to the hospital. $100 $250 $150 $350 $250 $500 Inpatient 100% 80% Precertification required* 85% 70% Precertification required* 70% 60% Precertification required* Outpatient 100% 80% 85% 70% 70% 60% Emergency Room An emergency is a sudden and unexpected illness or injury which requires immediate medical attention. 100% after $25 100% after $25 100% after $25 100% after $25 100% after $50 100% after $50 Non-Emergency Use of Emergency Room 100% after $100 80% after $100 85% after $100 70% after $100 70% after $100 60% after $100 PRESCRIPTION DRUGS Generic Retail/Mail Order $5/$5 Retail/Mail Order $5/$5 Retail/Mail Order $10/$10 Retail/Mail Order $10/$10 Retail/Mail Order $15/$30 Retail/Mail Order $15/$30 Brand name $10/$5 $10/$5 $20/$10 $20/$10 $30/$30 $30/$30 Brand name with equivalent generic $10/$5 + difference in cost between brand and generic $10/$5 + difference in cost between brand and generic $20/$10 + difference in cost between brand and generic $20/$10 + difference in cost between brand and generic $30/$30 + difference in cost between brand and generic $30/$30 + difference in cost between brand and generic *Failure to precertify hospital admissions will result in an additional $250 fee. 52 Medical

55 IF YOU LIVE IN A NETWORK AREA: Benefit Option 1 Option 2 Option 3 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network MENTAL HEALTH Call Solutions at: PCP referral not required Inpatient Admission Fee Coinsurance Outpatient Copayment Coinsurance Solutions Provider $ % $10 100% Other Provider not covered none 50% limited to 20 visits/year Solutions Provider $ % $15 100% Other Provider not covered none 50% limited to 20 visits/year Solutions Provider $250 80% $15 100% Other Provider not covered none 50% limited to 20 visits/year SUBSTANCE ABUSE Call Solutions at: PCP referral not required Treatment Plan Fee Coinsurance $ % not covered $ % not covered $250 80% not covered OTHER COVERED EXPENSES Hospice Care Inpatient 100% 80% limited to 30 days 85% 70% limited to 30 days 70% 60% limited to 30 days Hospice Care Outpatient 100% 80% limited to $5,000 85% 70% limited to $5,000 70% 60% limited to $5,000 Skilled Nursing Facility 100% 80% limited to 60 days/year 85% 70% limited to 60 days/year 70% 60% limited to 60 days/year Outpatient Private Duty Nursing Maximum 560 hours per calendar year of private duty nursing care provided by an RN or LPN. 100% 80% 85% 70% 70% 60% Ambulance- Emergency 100% 100% 100% 100% 100% 100% Ambulance- Non-Emergency if medically necessary 100% 80% 85% 70% 70% 60% Medical 53

56 IF YOU LIVE IN A NETWORK AREA: Benefit Option 1 Option 2 Option 3 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Home Health Care One visit equals up to four hours of care by an RN, LPN, or therapist to provide physical, occupational or speech therapy, or services from a home health aide. 100% 80% limited to 120 visits/year 85% 70% limited to 120 visits/year 70% 60% limited to 120 visits/year Durable Medical Equipment 100% 80% 85% 70% 70% 60% Chiropractors $10/visit limited to 60 visits per year 80% limited to 60 visits per year $15/visit limited to 60 visits per year 70% limited to 60 visits per year $15/visit limited to 25 visits per year 60% limited to 25 visits per year Podiatrists $10/visit limited to 60 visits per year 80% limited to 60 visits per year $15/visit limited to 60 visits per year 70% limited to 60 visits per year $15/visit limited to 25 visits per year 60% limited to 25 visits per year Rehabilitation Defined as services consisting of physical, occupational or speech therapy that are expected to improve a body function lost or impaired due to an injury, disease or congenital defect. $10/visit 80% limited to 60 visits/year combined inpatient and outpatient, combined physical, occupational and speech. $15/visit 70% limited to 60 visits/year combined inpatient and outpatient, combined physical, occupational and speech. $15/visit 60% limited to 60 visits/year combined inpatient and outpatient, combined physical, occupational and speech. Medical 54

57 IF YOU LIVE OUTSIDE OF A NETWORK AREA: Benefit Option 1 Option 2 Option 3 Plan Deductible The deductible applies only once to each individual in a calendar year. There is no end-of-the-year deductible carryover provision. The deductible does not apply to inpatient services, maternity, outpatient surgery, diagnostic X-ray/lab services, prescriptions, mental health/substance abuse or preventive services. $50/person $100/family $150/person $300/family $300/person $600/family Coinsurance This is the amount the Plan pays after you have met the deductible or paid the hospital admission fee. 100% hospital, maternity, diagnostic X-ray and lab, preventive services, and emergency; 80% all other services 85% 70% Out-of-Pocket Maximum Once the out-of-pocket maximum is reached, covered expenses incurred during the rest of the calendar year are covered at 100%. All out-of-pocket expenses count toward the maximum except prescription copays, mental health/substance abuse expenses, fees for failure to precertify hospital admission, emergency room copays, amounts over R&C, and expenses not covered by the Plan. $1,500/person $3,000/person $4,500/person Lifetime Maximum $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected $1,000,000/person regardless of option selected PHYSICIAN SERVICES Physician Office Visit 80% 85% 70% Specialist Office Visit 80% 85% 70% In-Hospital Physician Services 100% 85% 70% Allergy Testing and Treatment Services 80% 85% 70% Maternity 100% 85% 70% Diagnostic X-Ray and Laboratory (including pre-admission testing) 100% 85% 70% Routine Physical Evaluation Refer to Physical Evaluation Guidelines 100% 85% 70% Well-Baby Care Refer to Physical Evaluation Guidelines 100% 85% 70% Medical 55

58 IF YOU LIVE OUTSIDE OF A NETWORK AREA: Benefit Option 1 Option 2 Option 3 Mammograms Refer to Physical Evaluation Guidelines 100% 85% 70% Routine OB/GYN Exam Refer to Physical Evaluation Guidelines 100% 85% 70% Contraceptives Oral Covered as prescription drug Covered as prescription drug Covered as prescription drug Contraceptive devices, implants and injections 100% 85% 70% Surgery Surgeon/Surgical Assistant/ Anesthesiologist 100% 85% 70% HOSPITAL SERVICES Hospital Admission Fee. This is paid each time a covered individual is admitted to the hospital. $100 $150 $250 Inpatient Precertification required* 100% 85% 70% Outpatient 100% 85% 70% Emergency Room An emergency is a sudden and unexpected illness or injury which requires immediate medical attention. 100% after $25 100% after $25 100% after $50 Non-Emergency Use of Emergency Room 100% after $100 85% after $100 70% after $100 PRESCRIPTION DRUGS Generic Retail/Mail Order $5/$5 Retail/Mail Order $10/$10 Retail/Mail Order $15/$30 Brand name $10/$5 $20/$10 $30/$30 Brand name with equivalent generic $10/$5 + difference in cost between brand and generic $20/$10 + difference in cost between brand and generic $30/$30 + difference in cost between brand and generic MENTAL HEALTH Call Solutions at: Inpatient Admission Fee Coinsurance Outpatient Copayment Coinsurance Solutions Provider Other Provider $100 not covered 100% $10 none 100% 50% limited to 20 visits/year Solutions Provider Other Provider $150 not covered 100% $15 none 100% 50% limited to 20 visits/year Solutions Provider Other Provider $250 not covered 80% $15 none 100% 50% limited to 20 visits/year SUBSTANCE ABUSE Call Solutions at: Treatment Plan Fee Coinsurance $100 not covered 100% $150 not covered 100% $250 not covered 80% *Failure to precertify hospital admissions will result in an additional $250 fee. 56 Medical

59 IF YOU LIVE OUTSIDE OF A NETWORK AREA: Benefit Option 1 Option 2 Option 3 OTHER COVERED EXPENSES Hospice Care Inpatient Limited to 30 days 80% 85% 70% Hospice Care Outpatient Limited to $5,000 80% 85% 70% Skilled Nursing Facility Limited to 60 days/year 80% 85% 70% Outpatient Private Duty Nursing Maximum 560 hours per calendar year of private duty nursing care provided by an RN or LPN. 80% 85% 70% Ambulance Emergency 100% 100% 100% Ambulance Non-Emergency If medically necessary 100% 85% 70% Home Health Care One visit equals up to four hours of care by an RN, LPN, or therapist to provide physical, occupational or speech therapy, or services from a home health aide. Limited to 120 visits per year. 80% 85% 70% Durable Medical Equipment 80% 85% 70% Chiropractors 80% limited to 60 visits per year 85% limited to 60 visits per year 70% limited to 25 visits per year Podiatrists 80% limited to 60 visits per year 85% limited to 60 visits per year 70% limited to 25 visits per year Rehabilitation Defined as services consisting of physical, occupational or speech therapy that are expected to improve a body function lost or impaired due to an injury, disease or congenital defect. 80% limited to 90 visits/year combined inpatient and outpatient services, combined physical, occupational and speech therapy. 85% limited to 90 visits/year combined inpatient and outpatient services, combined physical, occupational and speech therapy. 70% limited to 90 visits/year combined inpatient and outpatient services, combined physical, occupational and speech therapy. Medical 57

60 PHYSICAL EVALUATION GUIDELINES Age Birth-12 Months Months 2-6 Years 7-19 Years Visits Well Baby Visit 1 Well Baby Visit 1 Well Baby Visit 2 Physical Evaluation 3 Exam Frequency 6 Exams 2 Exams Every Year Every Other Year Immunizations DPT 6 OPV 9 HIB 10 Hepatitis B 12 Tetramune 13 Varicella 5 DPT or DTaP 7 OPV 9 MMR 11 Hepatitis B 12 Tetramune 13 Varicella 5 DPT or DTaP 7 OPV 9 MMR 11 Hepatitis B 12 Varicella 5 Tetanus-diphtheria 8 MMR 11 Hepatitis B 12 Tests (same frequency as exams unless otherwise noted) Urinalysis 14 Hemoglobin & Hematocrit 15 Tuberculin skin test 16 PKU 17 Urinalysis 14 Hemoglobin & Hematocrit 15 Tuberculin skin test 16 Urinalysis 14 Hemoglobin & Hematocrit 15 Tuberculin skin test 16 Hearing Screening 18 Urinalysis 14 Hemoglobin & Hematocrit 15 Tuberculin skin test 16 If female: Gyn. Exam 19 Pap smear 19 Breast Exam If male: Testicular Exam This chart is intended as a physical evaluation guideline for your physician. It is not a complete listing of preventive services covered by the Plan, as some preventive services are only administered in high-risk situations. For more information, call the Member Services number listed on your medical ID card. Visits 1 Clinical screening, height and weight; physical/developmental assessment 2 Clinical screening, blood pressure, height and weight, physical/psychosocial/ developmental assessment 3 Clinical screening, blood pressure, height and weight, physical/psychosocial/ developmental/mental assessment. For years, scoliosis check, clinical testicular exam or breast exam 4 Basic Evaluation includes a comprehensive history and physical examination: History: Chief complaint (if present) History of present illness (if present) Past medical history (medications, allergies, prior operations and hospitalizations, immunization status) Family history Social history (marital status, use of drugs, alcohol and tobacco, education, current employment, occupational history) Review of systems (constitutional symptoms, eyes, ears, nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, breast, neurological, psychiatric, endocrine, hematologic, allergic/ immunologic) Physical Examination: General, vital signs, head, eyes, ears, nose, mouth, throat, neck, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, hematologic/lymphatic Immunizations 5 Varicella: chickenpox vaccine: one dose given between 12 months and two years, or between 2-6 years if not done earlier, or between 7-12 years if not done earlier 6 DPT: Diphtheria-Pertussis-Tetanus vaccine: given at ages 2, 4, and 6 months (see footnote 13) 7 DPT or DTaP: Diphtheria-Tetanus-acellular Pertussis vaccine: once between months and once between 4-6 years 8 Tetanus-diphtheria: given once between years and once every 10 years after age 18 9 OPV: oral polio vaccine: given at ages 2 and 4 months and between 6-18 months and between 4-6 years 58 Medical

61 20-29 Years Years Years 50 Years and up Basic Evaluation 4 Basic Evaluation 4 Basic Evaluation 4 Basic Evaluation 4 Every 5 years Every 3 years Every other year Every year Tetanus-diphtheria 8 MMR 11 Tetanus-diphtheria 8 MMR 11 Tetanus-diphtheria 8 MMR 11 Tetanus-diphtheria 8 MMR 11 Urinalysis 12 Lead EKG Chest XRay SMA 18/22 CBC Lipid Profile Urinalysis 12 Lead EKG Chest XRay SMA 18/22 CBC Lipid Profile Urinalysis 12 Lead EKG 20 Chest XRay 21 SMA 18/22 CBC Lipid Profile Occult Blood 22 Urinalysis 12 Lead EKG Chest XRay 21 SMA 18/22 CBC Lipid Profile Occult Blood 22 Exercise stress test 23 Sigmoidoscopy 24 Gyn. Exam 19 Pap smear 19 Breast Exam Gyn. Exam 19 Pap smear 19 Breast Exam Mammogram 25 Gyn. Exam 19 Pap smear 19 Breast Exam Mammogram 25 Gyn. Exam 19 Pap smear 19 Breast Exam Mammogram 25 Testicular Exam Testicular Exam Testicular Exam PSA 26 Testicular Exam PSA HIB: Haemophilus influenza type B (see footnote 13): Age at start (months) Number of doses * or over 1 *HIB at 60 months or older only for children with chronic illness known to be associated with increased risk for H-Influenza disease. 11 MMR: Mumps, measles and rubella virus vaccine: this two-dose series is given between months, and between 4-6 years. It may also be obtained between 7-12 years if not previously administered, or later if born after 1956 with no prior booster. 12 Hepatitis B virus vaccine series is now recommended for all infants.the series can be obtained through age 19 if not previously completed. 13 Tetramune is a combination of the DPT and HIB vaccines and may be substituted. Given at ages 2, 4, and 6 months and between months Tests 14 Urinalysis: once during first two years, once between 2-6 years, once between 7-12 years, once between years 15 Hemoglobin and Hematocrit: once during first two years, once between 2-6 years, once between 7-12 years, once between years 16 Tuberculin Skin Test:Tine or intradermal Mantoux skin tests: once during first two years. If not done earlier: once between 2-6 years (or if mandated for entry into school), or once between 7-12 years, or once between years 17 PKU: Phenylketonuria: up to two PKU tests during first three weeks of life 18 Hearing screening: once between 2-6 years 19 Gynecological Exam, including Pap smear: for females only, annually from age 18, or earlier if sexually active. 20 EKG: 12 lead EKG every 3 years, unless indicated 21 Chest Xray: 2 views, every 3 years, unless indicated 22 Occult Blood: For blood in stool: three cards 23 Exercise stress test: Can be performed every 3-5 years if high risk (multiple risk factors, and/or strong family history) 24 Sigmoidoscopy: For colorectal cancer: every 3-5 years 25 Mammogram: Baseline at age 35, every other year age 40-49, every year age 50 and up 26 PSA: Prostate Specific Antigen:Annually beginning at age 45 if high risk (African American or prostate cancer in first degree relative) Medical 59

62 Dental The Flexible Benefits Plan offers you a choice of three dental options administered by Aetna. You can also choose no dental coverage. All three dental options cover the same services, but the level of benefits varies from option to option. The dental options cover four categories of necessary dental care: preventive services basic services major restorative services orthodontia for children Options 1 and 2 are traditional dental plans that allow you to see the dental provider of your choice. You can participate in the Dental Preferred Provider Organization (PPO), a network of participating dentists who have agreed to negotiated rates. Or, you can see a provider who doesn t participate in the network. The choice is yours each time you seek care. Option 3 is Aetna s Dental Maintenance Organization (DMO ), which is also a network of dental providers. In Option 3, however, you must use a DMO provider in order to receive benefits. DMO benefits are provided through an insurance contract with Aetna. If you enroll in the DMO, you will be provided with a Certificate of Coverage. If there is any conflict between the certificate and the insurance contract, the contract will apply. AETNA MEMBER SERVICES Member Services is your link to the PPO and DMO. You can call Member Services at to: ask questions about your benefits obtain information about a network provider or service obtain help in filing claims, and change your DMO personal dentist 60 Dental

63 IMPORTANT DENTAL COVERAGE FEATURES Two-Year Rule Once you choose a dental option, you must keep dental coverage at the same coverage level you only, you plus spouse, you plus children or you plus family for two years. You may, however, change your option the following year for instance, from Option 1 to Option 3. The only exception to this is if you have a change in status (see pages 11 and 12). If you elect no coverage for dental, there will be a two-year waiting period before you can be covered by a dental option. If you fail to enroll during your initial enrollment period, and therefore have no coverage, you will be allowed to elect coverage at the first annual enrollment following your initial enrollment period. If you fail to elect dental coverage at the first annual enrollment, you will be locked out of dental coverage for a two-year period beginning on January 1 following the first annual enrollment (not a two-year period beginning with your initial enrollment period.) OPTIONS 1 AND 2 THE AETNA DENTAL PPO A central feature of Options 1 and 2 is access to the Aetna Dental PPO, a national network of preferred dental care providers who have agreed to a discounted fee schedule. This means your out-of-pocket costs will generally be less when you see a participating dentist rather than a dentist who does not participate in the Dental PPO. Each time you need dental care, you can choose to use a participating dentist or a non-participating dentist. While there is no penalty if you decide not to use a Dental PPO provider, your out-of-pocket expenses may be greater if you use a nonparticipating dentist. You can obtain a list of local participating dentists by calling the Benefits Service Center at Every dentist selected to participate in the PPO must meet Aetna s selection criteria, which includes an appropriate professional degree; a current, unrestricted state license; adequate malpractice insurance; and sufficient office hours to meet patient demand. Provider Directories You should have received a provider directory in your first enrollment kit. If you would like to access the most current list of doctors or dentists, however, log on to Your Benefits Resources and look under Other Sites for a full list of carriers. If you would like a hard copy mailed to your home free of charge, call Web addresses are also listed on the back of this booklet. Dental 61

64 Schedule your appointment as you would with any dentist, but be sure to identify yourself as an Aetna Dental PPO participant, and show your ID card when you visit the dentist s office. If you need specialty care, the Dental PPO includes a national listing of specialty dentists. You may also select a non-participating specialist, although your out-of-pocket expenses may be greater. The Deductible The deductible is the amount you pay for covered basic and major restorative services before Options 1 and 2 pay benefits. The deductible does not apply to preventive services or orthodontia. You must meet a new deductible every calendar year. The individual deductible equals $50 and the family deductible equals $100. The individual deductible applies separately to each covered family member. However, if two or more family members expenses combine to reach the family deductible, then the deductible for each family member is considered to be met. This is true even if no single member reached the individual deductible. The following chart shows two examples of how a family deductible might be met. Family Member Example 1 Example 2 #1 $ 50 $ 20 #2 $ 50 $ 40 #3 $25 #4 $15 Family deductible $100 $ Dental

65 Annual Maximum Benefits An annual maximum applies under Options 1 and 2. The portion of your claim paid by the Plan counts toward the individual annual dental maximum.the Plan s cost of preventive services also counts toward your annual maximum. See Summary of Dental Benefits on page 72 for the maximum annual benefit amount for the option you select. Reasonable and Customary All eligible dental expenses from a nonparticipating dentist under Options 1 and 2 are subject to reasonable and customary limits charges within the normal range of fees in your geographic area for similar services and similar supplies, as determined by Aetna. If your non-participating dentist charges more than the reasonable and customary limit, you re required to pay any amounts considered above the reasonable and customary limit. Reasonable and customary does not apply to services provided through a participating Dental PPO dentist. Predetermination of Benefits Options 1 and 2 Options 1 and 2 have a provision that lets you know in advance what benefits will be paid. If you anticipate that charges for a course of dental treatment will be more than $300, you should submit an itemization of the proposed treatment (including recent pretreatment X-rays) to Aetna before work is begun. A dental consultant will review the proposed treatment, and Aetna will inform you and your dentist of the amount of covered charges. This way, you ll understand the benefits that will be paid and have the opportunity to discuss possible treatment options with your dentist before treatment begins. While predetermination is not required, unless it s an emergency, you may not wish to begin the course of treatment until you know what amount your dental option will pay. Preauthorization of Benefits Options 1 and 2 You will not need to seek pre-authorization from Aetna for covered services, except in the case of dental implants, which must be preauthorized in advance by Aetna. Your dentist will be required to provide all necessary or requested documentation for review. If implants are not approved in advance, no expenses or related expenses will be covered. Dental implants must be preauthorized in advance by Aetna or no benefits will be paid. Dental 63

66 How to File a Claim Options 1 and 2 If you select Options 1 or 2, you have to file a claim whether you use a participating dentist or a non-participating dentist. Some dentists will file the claim on your behalf. Send the completed claim form to Aetna at the address shown on the form. You may obtain a claim form by calling Aetna. Claims must be received within 12 months after the date the service or treatment is given or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. COVERED EXPENSES OPTIONS 1 AND 2 This section describes the types of services and supplies covered by the Dental PPO dental options. The exact amount paid for services and supplies depends on the dental option you select, whether or not you go to a participating dentist and if it is necessary dental care, as determined by Aetna. Preventive Services Covered preventive services are: oral exams (twice a year*) prophylaxis any type (twice a year*) topical fluoride applications for children, until the end of the year in which the child turns 15 (twice a year) X-rays: full-mouth or panoramic (once every three years) bitewing (twice a year) sealants for children, until the end of the year in which the child turns 14: one application per tooth per 36-month period permanent first and second molars only *If additional examinations and scaling are necessary each year, your dentist should submit a letter to Aetna explaining the request.aetna will respond directly to your dentist. No more than four examinations will be covered per calendar year. Basic Services Covered basic services are: visits and exams professional visit after hours special consultation by a specialist emergency palliative treatment X-ray and pathology single films (up to 13) intra-oral, occlusal view, maxillary or mandibular upper or lower jaw, extra-oral biopsy and examination of oral tissue study models microscopic examination oral surgery includes local anesthetics and routine postoperative care extractions uncomplicated surgical removal of erupted tooth postoperative visit (sutures and complications) after multiple extractions and impaction impacted teeth removal of tooth 64 Dental

67 alveolar or gingival reconstructions alveolectomy (edentulous) per quadrant alveolectomy (in addition to removal of teeth) per quadrant alveoplasty with ridge extension, per arch removal of exostosis excision of hyperplastic tissue, per arch excision of pericoronal gingiva odontogenic cysts and neoplasms incision and drainage of abscess removal of odontogenic cyst or tumor other surgical procedures sialolithotomy removal of salivary calculus closure of salivary fistula dilation of salivary duct transplantation of tooth or tooth bud removal of foreign body from bone (independent procedure) maxillary sinusotomy for removal of tooth fragment or foreign body closure of oral fistula of maxillary sinus sequestrectomy for osteomyelitis or bone abscess, superficial condylectomy of temporomandibular joint meniscectomy of temporomandibular joint radical resection of mandible with bone graft crown exposure to aid eruption removal of foreign body from soft tissue frenectomy suture of soft tissue injury injection of sclerosing agent into temporomandibular joint treatment of trigeminal neualgia by injection into second and third divisions anesthetics general, only when provided in conjunction with an eligible surgical procedure periodontics emergency treatment (periodontal abscess, acute periodontitis, etc.) subgingival curettage or root planing and scaling, per quadrant (not prophylaxis), limited to four quadrants per year correction of occlusion related to periodontal surgery, per quadrant gingivectomy (including post-surgical visits) per quadrant gingivectomy, treatment per tooth (fewer than five teeth) osseous or muco-gingival surgery (including post-surgical visits) crown lengthening reviewed on a per claim basis. Predeterminations are suggested. endodontics pulp capping therapeutic pulpotomy (in addition to restoration) vital pulpotomy remineralization (Calcium Hydroxide, temporary restoration) as a separate procedure only Dental 65

68 root canals (devitalized teeth only), including necessary X-rays and cultures but excluding final restoration canal therapy (traditional or Sargenti method) single rooted bi-rooted tri-rooted apicoectomy (separate procedure) basic restorative excludes inlays, crowns (other than stainless steel and bridges). Multiple restorations in one surface will be considered as a single restoration. restorations (involving one, two or three or more surfaces) amalgam filling silicate cement filling plastic filling composite filling the alternate benefit of an amalgam filling will be given when placed on posterior teeth pins pin (retention) when part of the restoration used instead of gold or crown restoration crowns stainless steel (when tooth cannot be restored with a filling material) crown build-up will be reviewed by a dental consultant for necessity full and partial denture repairs broken dentures, no teeth involved partial denture repairs (metal) replacing missing or broken teeth except congenitally missing teeth adding teeth to partial denture to replace extracted natural teeth teeth and clasps recementation inlay crown bridge repairs crowns and bridges space maintainers includes all adjustments within six months after installation fixed space maintainer (band type) removable acrylic with round wire rest only removable inhibiting appliance to correct thumbsucking fixed or cemented inhibiting appliance to correct thumbsucking Major Services Covered major services are: major restorative gold restorations, inlays, onlays and crowns are covered only as treatment for decay or traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an abutment to a fixed bridge or partial denture. Only restorations needed for severe attrition, abrasion or erosion are covered. inlays and onlays one or more surfaces crowns acrylic acrylic with gold acrylic with non-precious metal porcelain porcelain with gold porcelain with non-precious metal non-precious metal (full cast) gold (full cast) gold (3/4 cast) gold dowel pin 66 Dental

69 prosthondontics bridge abutments (see inlays and crowns) pontics cast gold (sanitary) cast non-precious metal slotted facing slotted pontic porcelain fused to gold porcelain fused to non-precious metal plastic processed to gold plastic processed to nonprecious metal removable bridge (unilateral) one piece casting, chrome cobalt alloy clasp attachment (all types), including pontics dentures and partials (Fees for dentures, partial dentures and relining include adjustments within six months after installation. Specialized techniques and characterizations are not eligible.) complete upper denture complete lower denture partial acrylic upper or lower with chrome cobalt alloy clasps, base, all teeth and two clasps partial lower or upper with chrome cobalt alloy lingual or palatal bar and acrylic saddles, base, all teeth and two clasps additional clasps stress breakers stayplate, base additional clasps office reline, cold cure, acrylic laboratory reline special tissue conditioning, per denture denture duplication (jump case), per denture adjustment to denture more than six months after installation other services precision attachments (eligible with dentures if they are functionally necessary) implants (if specifically approved in advance and the teeth are extracted or missing while covered under the Plan) Alternate Benefit Provision In some circumstances, an alternate service or supply may be suitable to treat or restore a dental condition, other than the service or supply recommended by your dentist. In this case, the Plan will pay only for the alternate service or supply. If you choose the recommended course of treatment, you will be responsible for the difference between the recommended course and the alternate benefit. For example: Your dentist may recommend a composite (white) filling for a posterior tooth. An appropriate alternate treatment is an amalgam filling. The Plan will only pay for the amalgam filling. If you wish to have the composite filling, you will pay the difference between the composite and the amalgam filling. While predetermination is not required, you may wish to submit your course of treatment in advance so you know what amount your dental option will pay (See page 63, Predetermination of Benefits ). Dental 67

70 If you are new to Company dental coverage and your child is involved in a course of orthodontic treatment when your coverage becomes effective, your Flexible Benefits dental option will not pay benefits toward that treatment. Orthodontia Dental Options 1 and 2 allow benefits for teeth straightening for your dependent children under 19 years of age. Services provided by December 31 of the year in which your child turns 19 are covered, as long as the treatment began before the child s 19th birthday. Options 1 and 2 pay 50 percent of the reasonable and customary charges for orthodontia, up to a $2,000 lifetime maximum for each child. Orthodontia benefits are not subject to the annual deductible. Orthodontic payments are made on a monthly basis.the first payment is equal to 50 percent of the member s down payment plus 50 percent of the fee for the diagnostic records. The monthly installments are released automatically each month on or after the same day of the month in which the bands are placed. However, quarterly certification is required to verify that treatment is continuing. Payments begin when an active appliance is installed in your child s mouth. Covered orthodontic services are: initial consultation moldings and impressions installation of braces regular visits Before treatment begins, the orthodontist should submit a total treatment plan to Aetna for approval. In this way, you and the orthodontist will know what treatment will be covered. Temporomandibular Joint (TMJ) Therapy Temporomandibular joint dysfunction is covered for adults and dependent children. This coverage is for TMJ appliance therapy (bite splints), adjustments and diagnostic materials (including impressions) only. Options 1 and 2 cover 50 percent of the reasonable and customary cost of TMJ therapy up to a $2,000 lifetime maximum. The $2,000 lifetime maximum limit for children s TMJ benefits is combined with the orthodontia maximum. Accidental Injury Coverage Under Options 1 and 2, coverage for treatment and repair of sound teeth and gums damaged by an accidental injury will be covered as a regular dental expense (see Summary of Dental Benefits, page 72). For this treatment and repair of accidental injuries only, the deductible and the annual maximum will be waived for 36 months from the date of the injury. (Under certain circumstances this waiver could be extended for dependent children.) Additionally, orthodontic treatment required for repair will be covered at 50 percent for up to 36 months from the date of the injury with the lifetime orthodontic maximum waived during this treatment period. This benefit includes all eligible participants of the Plan regardless of age. The treatment must be medically necessary to restore the teeth to their condition prior to the accident. Cosmetic treatment beyond restoration is not covered under this benefit. 68 Dental All other dental care will continue to be subject to the annual deductible and annual maximum during these treatment periods.

71 WHAT S NOT COVERED BY YOUR DENTAL BENEFITS OPTIONS 1 AND 2 In addition to services not specifically listed in the Covered Expenses section, the following expenses are not covered by the dental options: services not required for the treatment of a specific condition or to maintain good dental hygiene, as determined by Aetna services not reasonably necessary or customarily performed, as determined by Aetna charges for services not furnished by a licensed dentist, except services provided by a licensed hygienist under the direction of a dentist or X-rays ordered by a dentist services for which you would not be required to pay in the absence of dental coverage charges covered by the medical options treatment of a work-related injury a charge for a service furnished by or for the United States government or for any other government, including a service that may be covered under a governmental plan charges for your missed or broken appointment charges for the dentist s travel occlusal adjustment (unless following periodontal surgery) or retainers if charged separately from orthodontic treatment claims received more than 12 months past the date of service IV sedation, except in certain circumstances. Call Aetna at appliances, restoration or procedures needed to alter vertical dimensions or restore occlusion or for the purpose of splinting or correcting non-severe attrition or abrasion dentures and bridgework when they are for the replacement of teeth that were extracted before the patient was covered by a Company dental option orthodontic treatment begun before covered by a Company dental plan root canal therapy, if the pulp chamber was opened before the patient was covered by a Company dental option relines and adjustments of dentures and partial dentures within six months after installation cosmetic dental services and supplies, including personalization or characterization of dentures prosthetic devices and appliances, including bridges and crowns, and expenses for fitting or modifying them, if the patient is not covered by a Flexible Benefits Plan dental option when they are ordered, when an impression was made or when a tooth was prepared.the above are also not covered if installed or delivered more than 30 days after the patient s coverage ends replacement of lost, stolen or broken appliances replacement of congenitally missing teeth dental implants (unless specifically approved in advance) education programs, such as plaque control or oral hygiene instruction Dental 69

72 The DMO is available only in selected locations you must determine if a DMO dentist is available in your area. You may obtain a DMO provider listing by calling the Benefits Service Center at a charge for a replacement or modification of a partial or fully removable denture, a removable bridge or fixed bridgework, or for adding teeth to any of these, or for a replacement or modification of an inlay, onlay, crown or cast processed restoration, within five years after installation Actisite local anesthesia or nitrous oxide, as a separate charge any prescription drug full mouth debridement guided tissue regeneration desensitization treatment precision attachments except as noted under Major Services infection control behavior management canal preparation, if submitted as a separate charge rubber dam THE AETNA DENTAL MAINTENANCE ORGANIZATION (DMO) When you select Option 3, dental benefits are paid if services are provided by participating Aetna DMO dentists. You do not have any annual deductibles. There are generally no claim forms to complete. In addition, you may have higher benefit levels and lower out-of-pocket expenses than through Option 1 or 2. Please refer to your DMO Certificate of Coverage for specific benefit levels in your area. If you enroll in Option 3, you must choose a personal dentist from the DMO network. In order to receive the highest level of dental benefits, you must go to the DMO personal dentist you ve selected. Option 3 provides very limited benefits for services provided by a dentist who is not your DMO personal dentist. Once enrolled, you and your dependents will receive DMO ID cards with your DMO personal dentist s name and phone number printed on the front. Selecting a DMO Personal Dentist You may choose a different DMO personal dentist for each member of your family and you can change your DMO personal dentist at any time. Simply call the DMO at , prior to visiting your new DMO personal dentist. A new ID card will be sent to you. By calling this number, you can receive assistance in selecting a new DMO personal dentist who best meets your needs. To be selected for the DMO network, dentists must meet the American Dental Association s licensing and treatment standards, and participate in ongoing evaluations by the DMO. Aetna also monitors DMO dentists to make sure they meet the following criteria: appropriate professional degree current, unrestricted state license infection control procedures adequate malpractice insurance emergency care within 24 hours sufficient office hours to meet patient demand 70 Dental

73 Scheduling an Appointment Once you ve selected your DMO personal dentist, schedule your appointment as you would with any dentist, but be sure to identify yourself as an Aetna DMO participant, and show your ID card when you visit the dentist s office. If Your Dentist Leaves the Network If your DMO personal dentist leaves the DMO network, you will receive written notification of your assignment to a new DMO personal dentist. However, you may select another DMO personal dentist by simply contacting the DMO. Specialty Treatment If you need specialty care, your DMO personal dentist will refer you to a DMO dentist in your area who specializes in the services you need. If you don t get a referral, the specialist s services will not be covered by the DMO, even if the specialist is a DMO participant. Emergency Coverage If you have a dental emergency, call your DMO personal dentist. Your DMO personal dentist should respond to you within 24 hours to schedule needed treatment or refer you to the appropriate network specialist. If you cannot reach your DMO personal dentist, you must call the DMO at for a referral to another DMO dentist. If you do not seek DMO approval for emergency treatment, it will not be covered. If you need emergency dental care while away from home, call your DMO personal dentist. If you are unable to reach your DMO personal dentist, call the DMO at for treatment options and coverage levels. If you do not seek DMO approval for emergency treatment while away from home, it will not be covered. If another DMO dentist is not participating in your area, you may switch coverage to Option 1 or 2. You must select a new option within the 60-day period following notification to you. To make a change, contact the Benefits Service Center at Covered Expenses Under the DMO Option 3 In general, the DMO covers preventive, basic, major and orthodontia services if the services are determined to be necessary by your DMO personal dentist and approved by Aetna. Specific coverage levels vary depending on where you live. Your Certificate of Coverage contains detailed information on what is and what is not covered. You will receive a Certificate of Coverage for the area in which you live after enrolling in the DMO. You can also obtain the appropriate Certificate of Coverage for your area by calling the Benefits Service Center at How to File a Claim Option 3 If you select Option 3 and receive services from a DMO provider, you do not have to file claim forms. You pay your portion of the bill at the time you receive the dental services. Dental 71

74 SUMMARY OF DENTAL BENEFITS Option 1 Option 2 Option 3** Annual Deductible * $50/$100 $50/$100 None The option will pay: Preventive 100% 100% 100% Basic 80% 50% 100% Major 80% 50% 80% Orthodontia 50% 50% 50% Maximum benefits: Annual maximum $2,500 $1,000 No limit per individual (excluding orthodontia) Combined lifetime maximum for orthodontia $2,000 $2,000 Orthodontia and TMJ treatment for each dependent child no limit, under age 19 TMJ $2,000 Lifetime maximum for TMJ treatment $2,000 $2,000 $2,000 for adults (age 19 and over) **Preventive and orthodontic services are not subject to the Options 1 and 2 deductibles. **Benefits are shown as if services are performed by your personal DMO dentist. If there is a conflict between this chart or this booklet and the Certificate of Coverage, then the certificate controls. If you choose a dentist who does not participate in the PPO network, reasonable and customary limits will apply for Options 1 and 2. GENERAL DENTAL PROVISIONS Maintenance of Benefits Your dental coverage has a maintenance of benefits (MOB) provision. This means that benefits from the dental option you select, when added to the benefits paid by another group plan for the same services, will not exceed the amounts that would have been paid by the Flexible Benefits Plan dental option you select. If you are enrolled in Option 3, your DMO personal dentist is responsible for pursuing maintenance of benefits if a person is primary under another plan. If a person is covered by two plans, one of the plans is considered primary, and the other is considered secondary. When a claim is made, the primary plan pays benefits first. A plan without a maintenance of benefits provision is always the primary plan. If all plans have this provision, the primary plan will be determined in this order: The plan covering the person as an employee rather than the plan covering the person as a dependent is primary. If a person is covered as an employee by two plans, the plan covering the person the longest is the primary plan. If a child is covered by both parents plans, the plan of the parent whose birthday falls first in the calendar year is considered the primary plan. 72 Dental

75 In the case of a divorce or separation: First, the plan covering the child as a dependent of the parent legally declared financially responsible by court decree is primary Second, the plan covering the parent who has custody of the child (if there is not a court decree) is primary Third, in the event there is not a court decree and the parent who has custody has remarried, the order of priority is: The plan covering the parent who has custody is primary The plan covering the spouse of the parent who has custody is primary The plan covering the parent without custody is primary When a determination cannot be made, the plan covering the eligible dependent longer is considered primary. Any other situations will be handled in accordance with guidelines established for coordination of benefits by the National Association of Insurance Commissioners. An Example When the Flexible Benefits Plan is secondary, the combined benefits from both plans will equal what the Plan would have paid if it were the only plan. Coordinating with HMO Coverage If you participate in an HMO, additional coordination issues may exist for dental surgery. Call your HMO in advance of any dental surgery outside your dentist s office to ensure appropriate coverage. The following table shows how the Plan pays when it is secondary. The examples assume required deductibles have been met. How Flexible Benefits Are Coordinated Example 1 Example 2 Eligible expenses $100 $100 Flexible Benefits pays x 80% x 50% Flexible Benefits would pay if no other coverage $ 80 $ 50 Other plan paid $70 $50 Flexible Benefits will pay $ 10 $ 0 COORDINATING WITH MEDICAL COVERAGE If you re enrolled in a POS medical option and need dental surgery that requires hospitalization, your PCP must coordinate your hospitalization in order for you to receive in-network benefits. If you re enrolled in an indemnity medical option, you should follow the required steps to precertify your hospital admission. (See page 26, Precertification of a Hospital Admission, for additional information.) In all cases, if you re hospitalized for dental care, the dentist s charges are covered by dental benefits. Other eligible charges are covered by your medical benefits. Right of Recovery Provision In some situations, you or your covered dependents may be entitled to certain payments from another source following an injury or illness. See page 122 for details on the Plan s right of recovery provisions. Dental 73

76 Vision The Company automatically provides you and your eligible dependents with coverage for one vision exam each calendar year (Option 0). Additionally, you may elect coverage for lenses and frames for those family members who need eyeglasses or contacts (Option 1).Vision provisions only cover routine eye care. If you experience a medical problem with your eyes, you should consult your PCP or primary doctor. (See the Medical section for coverage of services.) If You Don t Use a VSP Provider You and your covered dependents can receive vision care services from a non-vsp provider, and be reimbursed up to the limits of the fee schedule listed in this section. You can use a non-vsp provider for an eye examination, and then use a VSP provider for frames and lenses if that VSP provider agrees to fill the prescription without an exam. You have the choice of using a Vision Service Plan (VSP) network provider or any provider you choose. However, higher benefits may be paid if you use a VSP provider. HOW YOUR VISION BENEFITS WORK VSP has more than 22,000 member doctor locations that provide professional eye care, including eye examinations and the necessary corrective lenses. Two-Year Rule If you select Option 1, lenses and frames, you must keep vision coverage at the same coverage level you only, you plus spouse, you plus children or you plus family for two years. However, if you choose Option 0, exam only, you can change your selection during the next annual enrollment period. To use these services, call VSP at for a current list of member doctors in your area or log on to their Web site at Simply make an appointment with your VSP provider. Be sure to tell her or him that you are covered by the Flexible Benefits Plan and give the employee s Social Security number. Your VSP provider will verify your eligibility and plan coverage before your appointment. 74 Vision

77 A SUMMARY OF YOUR VISION OPTIONS Option 0 Option 1 (Exam only) (Frames and Lenses) Exam performed by any doctor* 100% 100% (once each calendar year) VSP Provider Standard lenses and frames Contact lenses** Contact lenses required after cataract surgery or for special medical conditions Not covered 100% (up to VSP limits) $100 allowance (includes contact exam) 100% with prior authorization Non-VSP provider Not covered Lenses and frames Single vision lenses up to $30 Bifocal lenses up to $40 Trifocal lenses up to $50 Lenticular lenses up to $60 Frames up to $30 Contact lenses** up to $60 (includes contact exam) Contact lenses required $250 maximum with prior authorization after cataract surgery or for special medical conditions **Non-VSP providers subject to R&C limits **In lieu of glasses COVERED EXPENSES Option 0, exam only, pays 100 percent of the reasonable and customary (R&C) cost of a vision exam once each calendar year, whether or not you use a VSP provider. The Company pays the full cost of Option 0. Lenses and frames are not covered under Option 0. Disposable contact lenses are covered under Option 1. However, the entire benefit amount ($100 if using a VSP provider or $60 if a non-vsp provider) must be used at one time. VISION BENEFIT LIMITATIONS The following limitations are in addition to the general guidelines previously described. Option 1, lenses and frames, covers vision exams exactly as Option 0. In addition, Option 1 will also pay for either a new pair of glasses and frames or contact lenses (but not both) once each calendar year. Vision 75

78 Available at an Additional Cost Vision benefits are designed to cover your corrective vision needs and not cosmetic materials. If you select any of the following items, you ll be responsible for additional charges (at reduced prices if you use a VSP provider): frames costing more than the plan allows coated lenses contact lenses (except as noted earlier) no-line, blended bifocal lenses You can also get a 20 percent discount on additional pairs of glasses and a 15 percent discount on contact lens professional services fitting, evaluation and follow-up from your VSP provider, if purchased within 12 months of your examination. Discounts on Laser Vision Correction Surgery As a VSP member, laser vision correction surgery is available at discounted prices through VSP s Laser VisionCare SM network of doctors. Visit VSP s web site at to learn more about laser vision correction and participating doctors. Or, call VSP at for more information. Not Covered by Vision Benefits The vision options will not pay benefits for professional services or materials connected with: visual analysis that does not include a complete eye refraction orthoptics or vision training subnormal vision aids aniseikonic lenses two pairs of glasses instead of bifocals replacement of lost or broken lenses or frames (unless you have not already received a pair of lenses or frames that year) services or materials provided as a result of Workers Compensation or similar legislation or provided through a government agency or program eye exams, glasses or contacts provided by any other vision care plan duplicate or spare glasses vision care services, materials or procedures covered by other provisions of the Flexible Benefits Plan. For example, vision therapy after cataract surgery is covered by the medical benefits HOW TO FILE A CLAIM If you use a VSP provider, your provider will file all necessary claim forms. To use a non-vsp provider, follow these steps to submit your claim: 1. Pay the provider the full amount of the bill and request a copy of the bill that shows the amount of the eye examination, lens type and frame. Write in the member s name and Social Security number and employer; and the patient s name, relationship to the member and date of birth. 2. Send a copy of the itemized bill to: Vision Service Plan P.O. Box Sacramento, CA Claims must be received within 12 months after the date the service or treatment is given or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. 76 Vision

79 Life Insurance and AD&D Life insurance is primarily a benefit for your family or anyone who depends on you for support. Its purpose is to help provide your beneficiary with some measure of financial security in the event of your death. Accidental death and dismemberment (AD&D) insurance provides financial protection if you re seriously injured or die in an accident. The Flexible Benefits Plan provides life insurance benefits through the following programs: employee life insurance spouse s life insurance children s life insurance employee accidental death and dismemberment insurance family accidental death and dismemberment insurance Life insurance and AD&D benefits are provided through an insurance contract with Prudential Insurance Company of America. If there is any conflict between the Prudential Insurance Group Contract- Certificate and this description or the Prudential Group Universal Life Brochure, the Contract-Certificate provisions apply. The terms of the Prudential Group Universal Life brochure are incorporated in and become part of this Summary Plan Description.You can obtain a copy of the Contract-Certificate by calling the Benefits Service Center at When Is Coverage Effective? Coverage based on your initial enrollment elections begins at the same time your other elected Flexible Benefits Plan coverage begins. For annual enrollment elections, your coverage begins on January 1 of the following calendar year. All changes in status elections are retroactive to the date of the event, except decreases in your cash accumulation fund which are effective on the first day of the next full pay period. In all cases, the following exceptions apply: If you re ill or injured and absent from work on the date your coverage should start, coverage starts on the first day after you return to work for at least one full day. You are considered absent from work for these purposes even if you perform limited work from home while you are ill or injured. Your dependents coverage is also delayed until your coverage starts. If you increase your coverage for any reason and are ill or injured and absent from work on the date the increased coverage should start, the incremental amount of the increased coverage will not be effective until after you return to work for at least one full day. You are considered absent from work for these purposes even if you perform limited work from home while you are ill or injured. If the increased coverage never becomes effective because you do not return to work, you will continue to be covered at the lower level of coverage that was in effect prior to the requested increase. Life Insurance and AD&D 77

80 If evidence of insurability is required, any amounts requiring approval will be delayed until approval is granted. See Evidence of Insurability later in this section. If your dependent has had treatment for disease or injury within the 90-day period preceding the date coverage should start, coverage will not be effective until the dependent has been free from treatment for 90 days or evidence of good health has been approved by Prudential, if earlier. This does not apply to newborns. However, stillborn deliveries are not covered. Basic Life Insurance The Company pays the full cost of basic life insurance: For you: 12 times your monthly salary For your spouse $2,000 For your children $2,000 Your coverage amount is automatically updated with any changes to your monthly salary. Basic life insurance is group term life coverage. It can be converted to an individual policy if you leave or retire from the Company. If you are unsure of your basic coverage amount, contact the Benefits Service Center. Imputed Income The value (as defined by the Internal Revenue Service) of your basic employee life insurance coverage over $50,000 is taxable and is reported to the federal government on your W-2 form. This value is called imputed income. For example, if you had $70,000 in basic employee life insurance, you would be taxed on the value of $20,000 of insurance. For most people this amount is nominal. Supplemental Group Universal Life Insurance If you want more insurance than your basic coverage, you can purchase additional amounts in $1,000 increments up to a maximum of $1,000,000. This supplemental insurance is called Group Universal Life (GUL). For more details about this coverage, see the Prudential Group Universal Life brochure. Evidence of Insurability (Good Health) For life insurance that requires evidence of insurability, Prudential will ask you to complete a form showing evidence of insurability (good health) before approving you for coverage. For life insurance that requires evidence of insurability, coverage will not be effective until the insurance is approved by Prudential and you meet the active at work requirements. Coverage and payroll deductions will be set at the highest level available without evidence of insurability. Once approved, the coverage level and payroll deduction increase retroactive to the date of approval. Refer to your Prudential Group Universal Life brochure for details about when evidence of insurability is required. 78 Life Insurance and AD&D

81 Premium Rates Your annual premium rate is based upon your age and smoking status. The premium rate for your spouse is based upon his or her age and smoking status. This rate per $1,000 of coverage is multiplied by the amount of coverage you elect. Please refer to your Prudential Group Universal Life brochure. Children s Life Insurance You may purchase children s term life coverage in increments of $1,000 up to a maximum of $30,000.The cost per $1,000 of coverage is the same regardless of how many children are covered. Please see the Prudential Group Universal Life brochure for the current premium rate. Features of Group Universal Life The following features are included in GUL coverage. For complete details about each, refer to your Prudential Group Universal Life brochure. Portability Cash Accumulation Fund Living Benefit Option Paid-Up Life Insurance Spouse s Life Insurance You may purchase spouse s Group Universal Life insurance in $1,000 increments up to a maximum of $500,000. This coverage includes all the same features as the employee Group Universal Life coverage (see above). Please refer to the Prudential Group Universal Life brochure for premium rates and coverage details. You are always the beneficiary of this insurance. This coverage ends when coverage under the Flexible Benefits Plan ends for your child. You may continue your child s coverage by converting it to a Prudential individual policy. Accidental Death and Dismemberment (AD&D) Insurance Accidental death and dismemberment insurance (also called Personal Accident Insurance in the Prudential contractcertificate) pays a benefit for certain injuries resulting from a covered accident. If you die, your beneficiary receives the full amount. If you are injured, you receive all or a portion of the benefit, depending on the nature of the injury. You are always the beneficiary of this insurance. This coverage ends when coverage under the Flexible Benefits Plan ends for your spouse. You may continue your spouse s coverage by converting it to a Prudential individual policy or by exercising the GUL portability option. Life Insurance and AD&D 79

82 Monthly Salary If you are a salaried employee, monthly salary means your base pay, excluding bonuses or other incentive compensation. If you are paid weekly, monthly salary means: Full-time your hourly rate times 40 hours times 52 weeks divided by 12 months. Part-time your hourly rate times 20 hours times 52 weeks divided by 12 months. Basic AD&D Insurance Supplemental AD&D Insurance The Company pays the full cost of basic You may purchase additional amounts employee AD&D coverage (12 times your of AD&D coverage in $1,000 increments monthly salary), up to a maximum up to a maximum of $1,000,000. Evidence of $1,000,000. Your coverage amount of insurability is not required. You may is automatically updated with any changes elect AD&D coverage for either you to your monthly salary. If you are unsure only or you plus family. about your Basic AD&D coverage amount, contact the Benefits Service Center. Your supplemental AD&D coverage ends when your Flexible Benefits Plan coverage ends. It cannot be converted to an individual policy. Family Coverage Benefit With Family AD&D, the coverage amount for your family is predetermined by your elected coverage amount. The chart below shows the coverage amount for your family members should they be injured or die in a covered accident. If your family is you plus: Benefit Amount Spouse only 70% of your coverage amount Children only 50% of your coverage amount for each child (maximum $50,000) Spouse and children 60% of your coverage amount for your spouse and 25% of your coverage amount for each child (maximum $50,000) For example, if you elect $100,000 of AD&D for you plus family and your spouse dies in a covered accident, you would receive $70,000 if your family consists of only you and your spouse. If your family consists of you, your spouse and your children, you would receive $60,000. In determining how to pay a benefit (Spouse only, Children only or Spouse and children), Prudential will rely on the Benefits Service Center s record of your eligible dependents on file at the time of the covered accident. Each covered family member is an insured. 80 Life Insurance and AD&D

83 Standard AD&D Benefits Benefits are paid at certain percentages of your coverage amount for specific accidental losses. Not more than 100 percent of the coverage amount for the Standard AD&D benefit is payable for all losses due to the same accident. The loss must be incurred within 90 days of the accident (paralysis within 365 days of the accident). Standard benefits apply to basic and supplemental coverage for you only and you plus family. For more information, see your Prudential Group Universal Life brochure. Additional AD&D Benefits If you are injured or die as a result of a covered accident, the plan pays the following benefits in addition to the Standard AD&D benefits. Please refer to your Prudential Group Universal Life brochure. These additional benefits apply to basic and supplemental coverage for you only and you plus family. Seat Belt Benefit Air Bag Benefit Rehabilitation Benefit Home Modification Benefit Emergency Medical Evacuation/Return of Remains Service Continuation of Medical Funding Benefit Additional Family AD&D Benefits If you are injured or die as a result of a covered accident, the plan pays the following benefits in addition to the amounts noted in the Standard and the Additional AD&D Benefits sections. These additional benefits only apply if you elect supplemental Family AD&D coverage. Spouse Tuition Reimbursement Benefit Child Tuition Reimbursement Benefit Day Care Expense Benefit Common Accident Benefit Exclusions AD&D benefits (Basic and Supplemental) do not cover a loss if it results from any of these: suicide or attempted suicide, while sane or insane intentionally self-inflicted injuries or any attempt to inflict such injuries while sane or insane sickness, whether the loss results directly or indirectly from the sickness medical or surgical treatment of sickness, whether the loss results directly or indirectly from the treatment any infection, unless pyogenic and occurring at the same time as the accident, cut or wound; or bacterial infection unless it results from accidental ingestion of a contaminated substance Life Insurance and AD&D 81

84 war or any act of war, declared or undeclared, including resistance to armed aggression an accident occurring while serving on full-time active duty for more than 30 days in any armed forces (does not include Reserves or National Guard active duty for training) commission of, or attempt to commit, a felony legal intoxication use of narcotics (unless administered or consumed on a doctor s advice) GENERAL PROVISIONS LIFE AND AD&D Your Beneficiary You may name anyone you choose as beneficiary for your life insurance and AD&D benefits. (AD&D benefits for your family or for an injury to you are payable directly to you.) To name a beneficiary or change your current beneficiary at any time, call the Benefits Service Center at for instructions. Your beneficiary designation is not effective until the Benefits Service Center receives your Beneficiary Designation form. If you do not name a beneficiary, or if the beneficiary(ies) you name is not living at your death, payments will be made to the following surviving people in the following order: your spouse your child(ren) your parent(s) your sibling(s) the executor(s) or administrator(s) or your estate You are automatically the beneficiary for your spouse s and children s life insurance and AD&D coverage. 82 Life Insurance and AD&D

85 If You Leave The Company or Retire If you leave the Company or retire, you have the opportunity to continue your, your spouse s and your children s basic term life insurance coverage by converting them to self-paid individual policies, without providing evidence of insurability. To obtain a Conversion Kit, call the Prudential Group Conversion Office at The conversion application must be returned within 31 days of your termination date. You also have the opportunity to either convert or to continue your and/or your spouse s GUL coverage through the portability option. For more information regarding portability, call Prudential Group Life Services at AD&D insurance ends when you leave the company; it cannot be converted to an individual policy. If You Become Disabled... Permanent and Total Disability (PTD) Coverage If you are not eligible for long-term disability coverage and you become permanently and totally disabled while you are a participant in the Flexible Benefits Plan, you may be eligible to have your basic employee life insurance paid to you as a lump-sum benefit. In order to qualify for this benefit, you must be permanently and totally disabled from engaging in any occupation which could be considered reasonable taking into account your age, education, and prior work experience as determined by Prudential. If you have questions or would like a claim form, call Prudential at and request the lumpsum Total Disability Benefit option. How To File A Claim Contact your Human Resources department for information about filing life insurance and AD&D claims. Claims must be received within 12 months of the date of the death or accident, or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. Life Insurance and AD&D 83

86 Spending Accounts Spending accounts let you set aside a portion of your annual earnings on a before-tax basis to pay for many of your out-of-pocket health, child and elder care expenses. You can use the Health Care Spending Account for expenses not covered by the medical, dental or vision options, including: your deductibles and copayments charges that exceed reasonable and customary levels expenses not covered by the Plan such as adult orthodontia, as long as these expenses meet the IRS guidelines The Child/Elder Care Spending Account lets you save on the cost of care for your dependents so you and your spouse, if you re married can work or attend school. HOW THE SPENDING ACCOUNTS WORK First, you estimate the amount of eligible expenses you will incur in the coming year. Based on your estimate, you decide how much to contribute to each account.then you enroll in each account independently of the other. Your elections will be in effect during the entire calendar year. The amount you choose to deposit in your account will be deducted, before-tax, from your regular pay in equal amounts throughout the year. Finally, once you have paid for eligible expenses, you submit a claim form for reimbursement from your account. All eligible health, child or elder care expenses must be incurred during the year for which you make your account deposits. An expense is considered incurred when the service is provided, not when you are billed or when you pay for it. Use It or Lose It Rule It s important that you carefully estimate your expenses before you enroll in either the Health Care or Child/Elder Care Spending Accounts because the Internal Revenue Service requires that you forfeit any account balance not used to pay eligible expenses incurred during the year. This is often called the use it or lose it rule. In addition, you cannot: receive a refund of any unused balances transfer your funds from one account to the other carry funds over from one year to the next stop making deposits until the following January 1 unless an eligible change in status occurs Any forfeited amounts in the spending accounts are used by the Plan to offset administrative costs of the Plan. Spending Account Tax Advantages You don t pay federal or Social Security (FICA) taxes and in most locations, state or local income taxes on the portion of your pay that you deposit into a spending account. 84 Spending Accounts

87 Certain states and localities include spending account deposits as taxable income. Please contact Human Resources to find out whether spending accounts are taxed in your area. If you re a highly compensated employee (as that term is defined by the IRS), the maximum amount you can contribute to the Health Care Spending Account and/or the Child/Elder Care Spending Account may be limited. You ll be notified if these limits apply to you and your maximum contribution may be reduced. HEALTH CARE SPENDING ACCOUNT (HCSA) The Health Care Spending Account lets you pay for eligible expenses with before-tax dollars, thereby reducing your taxable income. How Much Can You Deposit? You may deposit up to $3,500 a year into your HCSA. The amount will be taken in equal amounts from each paycheck you receive during the year. If you choose to participate, your minimum contribution amount is $50 annually. Eligible Dependents For the Health Care Spending Account, a dependent for whom you may claim eligible health care expenses is anyone you claim as a dependent on your federal income tax return (e.g., dependent children or elderly parents). These dependents do not have to be covered by the Flexible Benefits Plan. How the Health Care Spending Account Works You can use your HCSA to pay for health care expenses incurred by you and your eligible dependents if the expenses are not covered by a medical, dental or vision option. The IRS specifies the kinds of expenses that may be paid through a health care spending account. You cannot take a deduction on your federal income tax return for any health care expenses for which you have been reimbursed through your Health Care Spending Account. The following eligible and ineligible health care expenses are based on Internal Revenue Service Publication 502, Medical and Dental Expenses. To order a copy of the entire list, call the IRS at , or visit the IRS Web site at Eligible Health Care Expenses Here are some examples of eligible health care expenses: your deductibles and copayments (including those from other employers plans) fees for doctors, dentists and hospital services not covered by a medical, dental or vision option (e.g., adult orthodontia) charges that exceed reasonable and customary amounts (see the medical or dental care section for an explanation of the term reasonable and customary) medical equipment and supplies (must be prescribed and not available over the counter) equipment and materials required for using contact lenses, such as saline solution and enzyme cleaners Eligible health care expenses are discussed in IRS Publication 502, Medical and Dental Expenses. To order a copy of the entire list, visit the IRS Web site at or call Spending Accounts 85

88 reconstructive cosmetic surgery (surgery that is medically necessary to correct a deformity from a hereditary abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease) birth control pills or other birth control items prescribed by your doctor infertility treatment capital expenses to install special equipment or make home improvements if the main purpose is medical care (such as installing entrance and exit ramps) How Much Can You Deposit? You may deposit up to $5,000* a year to your C/ECSA. The amount will be taken in equal amounts from each paycheck you receive during the year. If you choose to participate, your minimum contribution amount is $50 annually. If you re married and you and your spouse file separate tax returns, the maximum each of you can set aside for child/elder care reimbursement is $2,500. Ineligible Health Care Expenses You may not receive reimbursement from your HCSA for expenses that are not considered deductible for income tax purposes. Following are some examples of ineligible expenses: premiums for your or your spouse s medical or dental coverage athletic club expenses to keep physically fit (even if suggested by doctor) cosmetic surgery of a non-reconstructive nature (i.e., not necessary to correct a deformity arising from, or directly related to, a hereditary abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease) transportation costs of a disabled person to and from work medical/dental expenses of a former spouse CHILD/ELDER CARE SPENDING ACCOUNT (C/ECSA) The C/ECSA lets you deduct money from your pay before taxes to cover your eligible child or elder care expenses. If you file a joint tax return, the amount you can deposit to a C/ECSA cannot exceed the lesser of your earned income or your spouse s earned income. Earned income means your annual gross earnings less your annual deposit to the C/ECSA. Your earned income (plus your spouse s earned income) must be greater than the C/ECSA contribution. If your spouse doesn t work, you cannot use the C/ECSA unless your spouse is disabled or a full-time student for at least five months of the year, or is looking for work. In these cases, the law assumes that your spouse has a monthly income of $200 if you have one dependent, or $400 if you have two or more dependents. If your spouse works part time, you can be reimbursed for child/elder care expenses but only for work-related time, such as the time he or she spends at work and in commuting to and from work. If your spouse is a full-time student or disabled, her or his monthly assumed income (i.e., $200 or $400) can be deposited into the account. *Combined total for all dependent care flexible spending account plans to which you and/or your spouse contribute. 86 Spending Accounts

89 Eligible Dependents Eligible dependents for the C/ECSA include the following if they reside with you: children age 12 and under your spouse who is physically or mentally incapable of caring for herself/himself dependent of any age (including a parent) residing in your home for at least eight hours a day, who is physically or mentally incapable of self-care and dependent on you for at least 50 percent of her/his financial support How the Child/Elder Care Spending Account Works You can use the C/ECSA to pay for eligible dependent care expenses necessary for you and your spouse, if married to work. Child/elder care expenses are often regular, budgeted expenses the cost of day care while you and your spouse work, for example. By being reimbursed for these expenses through the C/ECSA, you can increase your take-home pay. Eligible Child/Elder Care Expenses The following information is based on Internal Revenue Service Publication 503, Child and Dependent Care Expenses. Expenses eligible for payment through your C/ECSA include expenses for: wages or salary paid to a care provider (whether inside or outside your home) who is not a dependent and who is age 19 or older household services (such as preparing meals) related to the care of an eligible dependent FICA and other taxes you pay on behalf of the care/service provider nursery schools, day camps and day care and elder care centers that meet state or local regulations, provide care for more than six non-residents and receive fees for services provided Ineligible Child/Elder Care Expenses Services that do not qualify for reimbursement through your C/ECSA include: dependent care provided by a spouse, by a dependent under age 19, or by anyone you list as a dependent on your federal income tax return dependent care for non-work-related reasons dependent care provided if your spouse does not work or works different hours than you, unless your spouse is disabled or a full-time student any expense you plan to take as a credit on your income tax return transportation to and from a dependent care location care provided in a full-time residential institution Spending Accounts 87

90 Refer to IRS Publication 503 for a complete discussion of the tax credit. To order a copy, visit the IRS Web site at or call overnight care expenses (unless the parents work nights) late payment fees expenses for a provider s food, clothing and entertainment expenses to care for dependents that do not live with you at least eight hours per day To receive reimbursements from the C/ECSA, you must provide written receipts showing the caregiver s name and taxpayer ID number or Social Security number. (However, if the provider is a charitable organization such as the YMCA, a church or similar organization it is not necessary to provide the organization s taxpayer ID number.) Tax Credit vs. Child/Elder Care Spending Account Your participation in the spending accounts can affect the way you calculate your federal income tax return at the end of the year. For every dollar of reimbursement you receive through the C/ECSA, your dependent care tax credit is reduced by a dollar. So if you elect to participate in the C/ECSA, you are making a decision not to take the federal dependent care tax credit for those expenses. In most cases, the C/ECSA will offer you the greater tax savings. However, it is important to note that in some cases, your tax savings may be greater if you use the dependent care tax credit rather than the spending account for part or all of your dependent care expenses. The following table compares the C/ECSA and the federal income tax credit. You may want to consult your personal tax advisor to see which method makes the most sense for you. Using the Child/Elder Care Spending Account Minimum annual contribution is $50 Using the Federal Income Tax Credit No minimum annual expenses for using the tax credit Maximum annual contribution is $5,000 Maximum annual expense applicable toward tax ($2,500 each if married filing separately) credit is $2,400 for one child; $4,800 for two or more children Contributions are excluded from taxable income Contributions are free from Social Security taxes You must decide contribution amount before expenses are incurred and you forfeit the unused amount A percentage of expense is applied as credit against taxes owed Tax credit doesn t affect Social Security taxes You determine tax credit at the end of the year after all expenses are incurred; there s no risk of foreiture 88 Spending Accounts

91 IMPACT ON OTHER BENEFITS While your spending account contributions reduce your taxable income, Companysponsored benefit amounts, like life insurance and disability, are based on your earnings before spending account contributions have been withheld. Please keep in mind that if you pay less Social Security (FICA) taxes because of your participation in spending accounts, then your Social Security benefits at retirement, death or disability may also be lower. You will pay less FICA tax if your pay is at or below the wage base for Social Security taxes. However, whether your Social Security benefits will actually be lower depends on a number of factors, such as your current age, your earnings before participation in the accounts and future pay levels. If You Take a Leave of Absence... refer to the Life Events section. HOW TO FILE A CLAIM Claim forms are available by calling Aetna at HCSA Send a completed claim form and proof of payment (including an Explanation of Benefits form for non-reimbursed expenses) to Aetna. Reimbursements from the HCSA will equal the lesser of: the actual amount of your claim, or the total amount you ve elected to put in the account for the year, less any reimbursement you ve already received If you submit claims for less than $50, Aetna will hold them until they total $50 before making a payment (except at the end of the year, when you can submit smaller claims in order to clear the funds in your account). HCSA reimbursement checks are sent twice monthly. If You Have a Status Change... refer to the Life Events section. Spending Accounts 89

92 Account Statements To help you keep track of spending account balances, you ll receive a statement about 45 days after the end of each calendar quarter. The statements will show deposits, payments made and account balances as of the end of the quarter. C/ECSA Reimbursements from the C/ECSA will equal the lesser of: the actual amount of your claim, or the amount of your account balance at the time the reimbursement is made If you submit claims for less than $50, Aetna U.S. Healthcare will hold them until they total $50 before making a payment (except at the end of the year, when you can submit smaller claims in order to clear the funds in your account). C/ECSA reimbursement checks are sent weekly. End-of-the-Year Claims You ll have 90 days following the end of the calendar year to file a claim for expenses incurred during the prior year. After that date, any amount left in your account will be forfeited. This money will be used to offset future costs of administering the accounts. If You Leave the Company you will have 90 days from your termination date to submit expenses that were incurred prior to the termination date. You may elect, through COBRA, to continue your HCSA on an after-tax basis through the end of that calendar year. If you do so, you will have 90 days from the termination of your HCSA COBRA coverage to submit expenses that were incurred prior to the termination of your HCSA COBRA coverage. Reimbursement checks that are not cashed within 12 months from the date of the check are void. By January 31 of each year after you participate in the C/ECSA, you ll receive a statement showing the amount of assistance during the prior calendar year. Reimbursement checks that are not cashed within 12 months from the date of the check are void. 90 Spending Accounts

93 Signature LegalCare The legal option helps protect you from the financial expenses that may arise if you need legal services. The option offers a range of commonly needed legal services as well as access to a legal hotline and individual consultation administered by Signature LegalCare. You and your covered family members can use an attorney who participates in the Signature network of attorneys. You will then receive full coverage for most covered services from a Signature network attorney. You may also use any attorney of your choice; however, benefits are limited if you use a non-participating attorney. HOW THE LEGAL BENEFITS WORK If you enroll for legal coverage, you have access to legal services from three sources: Telephone Service You have unlimited access to advice, consultation and direction regarding personal legal matters that are not specifically excluded under the plan. There s no cost for this service. Signature LegalCare Attorneys If you need an attorney, you can choose one from Signature s national network of attorneys throughout the United States who have agreed to provide covered services to LegalCare participants. If you use a Signature LegalCare network attorney, you will receive benefits for most covered matters. Non-Participating Attorneys You can also receive legal counsel from an attorney who does not participate in the Signature LegalCare attorney network. When you use a non-participating attorney, you are reimbursed for covered legal services up to a scheduled maximum amount. You ll be responsible for any costs in excess of the scheduled benefit amount. COVERED LEGAL SERVICES Examples of covered services include*: administrative hearings adoptions debt collection defense defendant civil action document review and preparation estate administration and estate closings guardianship/conservatorship lawyer office work matrimonial matters preparation of a will, living will real estate matters telephone advice EXCLUDED LEGAL SERVICES Examples of excluded services* include services related to: participation in business ventures preparing or filing income tax returns estate planning matters Workers Compensation Law, unemployment matters *Which services are covered and which services are excluded are governed by the contract with Signature LegalCare. Covered and non-covered services are subject to change. To obtain a complete copy of covered and excluded services, call Signature LegalCare at Signature LegalCare 91

94 judicial appeal proceedings, group or class actions civil actions pursued in court where covered person is plaintiff consultations, civil or criminal legal actions which involve the Company or its affiliates legal services which began before coverage under LegalCare began services performed by attorney related to the covered person services provided outside the United States SIGNATURE LEGALCARE SERVICE CENTER You may call the Signature LegalCare Service Center from 5:00 a.m.-11:00 p.m. (Eastern time), Monday-Saturday and 5:00 a.m.-4:00 p.m. on Sundays by dialing when a legal issue or concern arises. Your call will be handled by the Interactive Customer Assistance System, which offers the following options: verify your membership in the plan order a Participating Attorney Directory order a claim form check the status on your claim During your call, you may choose to speak directly with a customer service representative between the hours of 8:00 a.m. and 9:00 p.m. Monday-Friday (except holidays) to obtain answers to other questions or to speak with a Signature LegalCare attorney. SIGNATURE LEGALCARE BENEFITS FOR ADOPTION ASSISTANCE You may use Signature LegalCare to cover any legal service related to adoption of a child, if the adoption is eligible for reimbursement under the Adoption Assistance Program (see next page). Legal services will be covered up to the LegalCare Plan s benefit levels, even if you did not elect coverage through Signature LegalCare. Any legal expenses for adoption provided through the LegalCare plan do not count toward, nor are they reimbursable from, the Adoption Assistance Program s $3,500 benefit limit. If you re interested in using Signature LegalCare for adoption assistance, contact the Adoption Assistance Program at for instructions on accessing the legal network. HOW TO FILE A CLAIM After legal services have been provided, you must file a claim form. When completing the claim form, indicate whether you want Signature to pay the attorney directly or reimburse you. Claim forms are available by calling the Signature LegalCare Service Center at You may also visit the Signature LegalCare Web site at You ll be asked to enter your company name and this password: Signature LegalCare

95 Adoption Assistance To help employees realize the dream of having a family, the Company offers eligible employees financial assistance through its Adoption Assistance Program. BENEFIT AMOUNT The Company will reimburse 100 percent of reasonable and customary costs, up to $3,500 per child, associated with the adoption of a child less than age 18. If both parents are employees, expenses are reimbursed only one time per child, up to $3,500. Children with Special Needs If you adopt a child with a special need, the program will reimburse an additional $1,500 in eligible expenses. A child with special needs often has a physical or emotional disability. As a result, the child is often difficult to place and may be more costly to raise. For the Adoption Assistance Program, documentation is required from the state in which the child is adopted certifying that the child qualifies for a special needs adoption in that state. Check with the applicable state social services division for information on that state s definition of special needs. International adoptions cannot be considered for the special needs benefit. ELIGIBLE EXPENSES The Adoption Assistance Program covers the following adoption-related expenses, to a maximum of $3,500 per child ($5,000 per special needs child): legal/court fees (in excess of those covered through any legal program) adoption agency fees (public or private, foreign or domestic) medical expenses (when not covered by another source), including the following: newborn expenses maternity expenses for the birth mother charges for temporary foster care before placement state-required home study program and other required adoptive parental counseling expenses to transport the child to the home Contact the Adoption Assistance Program at if you have any questions about what the program covers. SIGNATURE LEGALCARE BENEFITS FOR ADOPTION ASSISTANCE You may use Signature LegalCare to cover any legal service related to adoption of a child if the adoption is eligible for reimbursement under the Adoption Assistance Program. Legal services will be covered up to the LegalCare plan s benefit levels, even if you did not elect coverage through Signature LegalCare. Any legal expenses for adoption provided through the Legal- Care plan do not count toward, nor are they reimbursable from, the Adoption Assistance Program s $3,500 benefit limit. If you re interested in using Signature LegalCare for adoption assistance, contact the Adoption Assistance Program at for instructions on accessing the legal network. Adoption Assistance 93

96 WHAT S NOT COVERED BY THE PROGRAM The following expenses are not covered by the Adoption Assistance Program: expenses incurred prior to the effective date of this plan or your eligibility for this plan any costs when an adopting parent is related to or a stepparent of the child being adopted adoptions that are not legally recognized personal items for the parents or child (food, clothing, etc.) charges associated with legal guardianship expenses related to the adoption of a person 18 years of age or older donations or contributions consultant fees any costs for or expenses of a surrogate mother (woman who is acting solely as a host of a fertilized egg) ADOPTION ASSISTANCE AND TAXES Adoption assistance benefits incurred on or after January 1, 1997 are not subject to federal income tax withholding, but are subject to withholding of FICA taxes. Additionally, state or local income tax withholding may be required if the state or municipality does not treat adoption assistance as nontaxable. Adoption assistance is excluded from income for taxpayers with adjusted gross income of less than $75,000. This exclusion is phased out for those with adjusted gross income between $75,000 and $115,000. Employees receiving adoption assistance benefits should consult their tax advisor to determine what portion, if any, of the benefit is taxable. Taxable amounts are not grossed up to offset the tax liability. Employees may be eligible for a tax credit for expenses not reimbursed by the Company. Employees with unreimbursed adoption expenses should consult their tax advisor to determine the availability of tax credits. HOW TO FILE A CLAIM Eligible expenses are reimbursed after legal custody is obtained from a court of law. Follow these steps to file for reimbursement: Contact the Benefits Service Center at to request an Adoption Assistance Reimbursement form Complete the form and attach all itemized bills and legal documentation (must be translated into English if necessary) Send the form and documentation to: Adoption Assistance Program 55 Glenlake Parkway, NE Atlanta, GA Once reimbursement is approved, you will receive a check from your local Human Resources department with applicable taxes deducted. Allow three weeks for processing your reimbursement request. Claims must be received within 12 months after the date of legal custody or no benefits will be paid. Reimbursement checks that are not cashed within 12 months of the date of the check are void. 94 Adoption Assistance

97 LifeWorks To help you balance your responsibilities at work and in your personal life, LifeWorks offers free and confidential assistance with many of the challenges you face each day. LifeWorks, administered by Ceridian Performance Partners, provides practical solutions, information, advice and support for a wide range of work-life issues such as child care, senior care, education, and parenting. You do not have to enroll for this program, it is provided to you at no cost by the Company. LifeWorks offers 24-hour access to master s level consultants who manage your case from start to finish. Specialty teams and expert researchers for adoption, education and financial issues are also available to offer solutions. Customized research/reports are available on topics such as mortgage, auto insurance, school and college, medical information and consumer information. Materials include tip sheets, booklets, kits, Library by Mail Ș M tapes and Tips-on-Tape ṢM LifeWorks Online offers hundreds of resource rooms, topical newsletters, locators, links, live events and interactive tools. Important:The information services provided through LifeWorks should not be construed as tax, legal, or medical advise. Ceridian Performance Partners (and not the Company) is solely responsible for the content, advise, and informational material provided through LifeWorks. CONTACTING LIFEWORKS You can contact LifeWorks by phone at or online at At the Web site, enter the user name: ups, and the password: help. LifeWorks 95

98 Personal Lines Insurance To help employees purchase auto and homeowners insurance at discounted group rates and pay for coverage through convenient payroll deductions, the Company offers Liberty Mutual s Liberty For All program of personal lines insurance. Coverage is available through a program of individual policies for employees who are eligible to participate in the Flexible Benefits Plan. For more information about the Liberty For All program, contact the Liberty Mutual Insurance Group at and identify yourself as a Flexible Benefits Plan employee. Current policyholders should call ENROLLMENT You can enroll in Liberty For All at any time of the year by contacting Liberty Mutual directly. The program is voluntary. Enrollment in any Liberty For All coverage is separate from enrollment in the Flexible Benefits Plan. AVAILABLE COVERAGE The program offers you a variety of personal insurance coverages: automobile insurance (discounts available*) homeowners insurance (discounts available*) personal catastrophe liability insurance (local laws may affect the availability of this coverage in some states. Check with your Liberty Mutual representative for availability in your specific area.) valuable possessions protection yacht and motorboat insurance protection for seasonal dwellings and recreational vehicles *Group discounts, other discounts and credits are available where state laws and regulations allow and may vary by state.to the extent permitted by law, applicants are individually underwritten and not all applicants may qualify. 96 Personal Lines Insurance

99 HOW TO PURCHASE INSURANCE To obtain a quote from Liberty Mutual, call the company directly at Liberty Mutual s voice response system will give you a choice of speaking with a representative located in your community or a representative in Liberty Mutual s Insurance Counseling and Service Center. This service is available 7 a.m. to 7 p.m. local time, Monday through Saturday. The Liberty Mutual representative will provide a quote, reflecting all available discounts, no later than 72 hours after the call. Keep in mind that the rates quoted by Liberty Mutual may not be the lowest in your area. You are encouraged to shop around and compare prices and services before making a selection. If you elect to purchase a policy, the paperwork is also handled by Liberty Mutual, including notification of the appropriate payroll deductions. Liberty For All payroll deductions are on an after-tax basis. IF YOU HAVE CONCERNS If you have concerns about any aspect of your relationship with Liberty Mutual, you should contact your local Liberty Mutual office, or call The Company does not interpret Liberty Mutual s insurance policies, claims payment procedures, or any other administrative procedures. Questions and claim inquiries about personal lines insurance are between you and Liberty Mutual. Although summarized in this booklet, Personal Lines coverage is not part of the Flexible Benefits Plan. HOW TO FILE A CLAIM If you need to file a claim, contact your Liberty Mutual representative for instructions or call Personal Lines Insurance 97

100 Long-Term Care Insurance Long-Term Care Insurance, underwritten by Metropolitan Life Insurance Company (MetLife), protects you and your family from the high cost associated with longterm care. It s the type of care you need when you ve had an accident or illness and are unable to care for yourself over an extended period of time. It provides assistance with daily activities like eating, bathing and dressing. Most health care plans, including those offered by the Company, are not designed to cover long-term care and do not cover custodial care at all. Although Long-Term Care Insurance is summarized in this booklet, it is not intended to be nor should it be construed to be part of the Flexible Benefits Plan. Additionally, it is a group insurance policy for which the Company has no fiduciary responsibility (see page 114).This Plan may not be available in all states. Plan features may vary by state. To confirm availability in your state, call MetLife at Home/Community Care Services home care adult day care at-home hospice care Additional Services respite care COVERAGE OPTIONS You have several options when electing Long-Term Care (LTC) Insurance. First, decide how much coverage you want $100, $200 or $300 per day. Then decide how long you want your coverage to last three years or five years. Non-Forfeiture Option If you purchase this option and stop paying premiums, you keep a reduced level of benefit (a percentage of your total lifetime benefit). The amount will be based on the premiums you have paid after three years and will last at least 30 days. COVERED SERVICES Planning Services initial care advisory visit Facility Services nursing home care assisted living facility Alzheimer s facility hospice care PLAN FEATURES Long-Term Care Insurance is a portable benefit. If you leave the Company or retire, your coverage moves with you at your current premium rate. Premiums are based on your age when you enroll. The younger you are when you enroll, the lower your premium will be. Your premium will not increase because you get older or need benefits. 98 Long-Term Care Insurance

101 Coverage is guaranteed renewable. Once you have been approved for coverage, it cannot be cancelled because of your age or your health as long as you pay premiums. Premium Waiver. You do not pay premiums while receiving benefit payments. You ll have the option to buy inflation adjustments. Over time, the cost of care is likely to rise and diminish your benefits. This feature allows you to increase your coverage. Inflation adjustment offerings may be made every three years. Rates for increased coverage are based on your age when you buy the increase. If you don t use your benefits, your premium contributions are returned to your estate. All of the premiums you ve paid up to age 65, less benefits received, will be returned to your estate. Payment is reduced by approximately 10 percent per year if death occurs after age 65. No payment will be made if death occurs at or after age 75. Take advantage of discounted services. As a MetLife member, you will have the option to take advantage of discounts offered by providers. Alternate plan of service. A MetLife care manager can authorize benefits for services that are not specifically defined as covered under the Plan. The service must meet your needs and be a cost-effective alternative to covered Plan services. Transition expense benefit helps you to modify your home or buy equipment. Up to five times your daily benefit, this feature helps pay for expenses needed to adjust to your new lifestyle (such as emergency response system or durable medical equipment). Simply provide proof of the expense for reimbursement. Coverage under this plan is intended to be tax qualified.this means that premiums paid will be deductible on your federal income tax return to the extent that they (in conjunction with other medical expenses) exceed 7.5% of your adjusted gross income. This also means that benefits paid will generally not be considered federally taxable income. ELIGIBILITY You may elect Long-Term Care Insurance at any time. Your spouse, children and stepchildren over age 18, your parents, parentsin-law, grandparents and grandparents-in-law are also eligible. As an employee, you are guaranteed coverage in the Long-Term Care Insurance Plan if you enroll within 60 days of your date of hire, as long as you are actively at work (not absent due to illness, disability or leave) on the effective date of your coverage. Otherwise, you must provide a statement of health and be approved for coverage. Your dependents and eligible relatives must provide a statement of health and be approved for coverage. There are no age limits. Long-Term Care Insurance 99

102 You will be eligible for benefits when you provide proof satisfactory to MetLife, and you have been certified by a licensed health care practitioner that you are chronically ill. Chronically ill means that you are unable to perform two of six Activities of Daily Living (ADLs): eating, dressing, bathing, continence, transferring (e.g. from bed to chair) or toileting, and are certified by a licensed health care practitioner to require assistance for at least 90 days. You will also be eligible if you require substantial supervision to protect yourself due to a severe cognitive impairment such as Alzheimer s disease. Once you are authorized for benefits and fulfill the 90-day waiting period, the Plan pays for covered services up to your daily benefit amount under the coverage options selected. (For Georgia residents, the waiting period will be fulfilled on the earlier of 60 home care visits or 90 calendar days.) The Plan will continue to pay as long as you remain benefit eligible or until you reach your lifetime benefit, which is the maximum amount available to you under the Plan. EXCLUSIONS This Plan does not provide benefits for: losses due to war or an act of war, participation in a felony, riot, or insurrection; service in the armed forces or auxiliary units; aviation (non-fare paying) care or treatment outside the U.S. or its territories treatment for alcoholism or drug addiction (chemical dependency) unless such drug addiction results from a doctor s care illness or injury that is intentionally self-inflicted treatment in a government facility unless required by law hospital care except for services in a distinct section licensed as a nursing home or hospice facility expenses reimbursable by Medicare including deductible, coinsurance and copayment amounts except where Medicare is the secondary payor charges for which you are not legally liable or which would not have been made if you were not a covered person services by a member of your immediate family These exclusions may not apply in all states and may vary depending on the state in which you live. The certificate of insurance you receive once you are insured will outline the exact exclusions for your state. If you move to another state, the state guidelines where the certificate of insurance was originally delivered to you will apply. HOW TO ENROLL You may enroll in the Long-Term Care Insurance plan at any time during the year. Call MetLife at , Monday through Thursday, 8:00 a.m. to 10:00 p.m., Friday, 8:00 a.m. to 9:00 p.m. and Saturday, 9:00 a.m. to 4:30 p.m. Eastern time. Hearing impaired individuals with a TDD may call You will be sent an enrollment packet and application. Visit MetLife s Web site at Long-Term Care Insurance

103 Cancer Expense Insurance Cancer Expense Insurance, underwritten by American Family Life Assurance Company (AFLAC), offers you a personal health insurance policy expressly designed to reimburse you if you are diagnosed with or treated for cancer. Cancer Expense Insurance pays cash directly to you, unless you assign the benefit to a provider, regardless of any other insurance you may have. WHEN COVERAGE STARTS If you are enrolling for the first time, coverage is effective on the first day of the first pay period following approval of your application by AFLAC. Your Cancer Expense Insurance application must be postmarked by your Flexible Benefits Plan enrollment deadline, which is printed on your Enrollment Worksheet. Some of the items covered under Cancer Expense Insurance are also covered by the Flexible Benefits medical plan. At annual enrollments, coverage is effective on January 1 following the annual enrollment period. Although Cancer Expense Insurance is summarized in this booklet, it is not intended to be nor should it be construed to be part of the Flexible Benefits Plan. Additionally, it is a personal policy for which the Company has no fiduciary responsibility (see page 114). ELIGIBILITY You are eligible to purchase Cancer Expense Insurance if you are eligible for the Flexible Benefits Plan and age 70 or under in all states except California, Massachusetts, and New Jersey. If you live in California, you may purchase this insurance through age 65. Cancer Expense Insurance is not available in Massachusetts or New Jersey. 30-Day Waiting Period in Florida, Iowa and Mississippi In Florida, Iowa and Mississippi, there is a 30-day waiting period before coverage begins. This means that no benefits are payable for any covered person who has cancer diagnosed before coverage has been in force 30 days from the effective date shown in the Policy Schedule. If a covered person has cancer diagnosed during the waiting period, benefits for treatment of that cancer will apply only to treatment occurring after two years from the effective date of the policy. Or, at your option, you may elect to void the policy from its beginning and receive a full refund of the premium. Cancer Expense Insurance is guaranteed renewable for life subject to AFLAC s right to change the applicable table of premium rates for all policies of this class. Cancer Expense Insurance 101

104 WHEN COVERAGE ENDS Generally, Cancer Expense Insurance continues as long as you make premium payments. If you leave the Company or retire, it can be continued on a direct billed basis. If you have paid at least one month s premium by payroll deduction, you may retain the payroll deduction rates after leaving the Company. If you have not paid by payroll deduction, you will be billed at a direct rate. Cancer Expense Insurance is guaranteed renewable for life subject to AFLAC s right to change the applicable table of premium rates for all policies of this class. BENEFITS Benefits, limitations and exclusions are described in AFLAC s Cancer Expense Insurance brochure. The following summarizes the key benefits: first occurrence hospital confinement radiation and chemotherapy outpatient surgery waiver of premium cancer wellness screening TAXES AND CANCER EXPENSE PROTECTION INSURANCE Any benefits you receive from AFLAC that exceed your unreimbursed medical expenses are taxable. You are responsible for determining the amount of any excess reimbursement and including it in your tax return. Consult your tax advisor. Please keep in mind that if you pay less Social Security (FICA) taxes because of your participation in this plan, then your Social Security benefits at retirement, death or disability may also be lower. You pay less FICA tax if your pay is at or below the wage base for Social Security taxes. However, whether your Social Security benefits will actually be lower depends on a number of factors, such as your current age, your earnings before participation in this plan and future pay levels. HOW TO ENROLL You may enroll for Cancer Expense Insurance during either your initial enrollment period or during annual enrollment. Once you receive your policy from AFLAC, you have a 30-day review period during which you may decline coverage. You may only add or drop Cancer Expense Insurance between enrollments if you have a change in status. MEMBER SERVICES If you have questions, or would like to obtain a copy of AFLAC s Cancer Expense Insurance brochure, call AFLAC at ( AFLAC). HOW TO FILE A CLAIM Call AFLAC for claim forms and filing instructions at AFLAC. 102 Cancer Expense Insurance

105 Income Protection Plan A total disability following an accident or illness is something that most people don t like to think about. However, should such a tragedy occur, the Income Protection Plan helps you bridge the financial gap caused as a result of lost income. All employees covered by the Flexible Benefits Plan are provided with coverage in the event of a disability. SHORT-TERM DISABILITY Short-term disability (STD) protects your salary if you have an absence caused by an illness or accidental injury. An absence for maternity is treated like an absence for illness. Eligibility Short-term disability is available to all fulltime and part-time employees eligible for the Flexible Benefits Plan when coverage begins under the Plan (see your Insert). Your date of disability (as determined by your doctor) must occur while you are covered under the Flexible Benefits Plan. STD Benefits STD pays a percentage of your base pay for any one continuous period of disability, up to the maximum coverage period. For the exact percentage and the maximum coverage period, refer to your Insert. If you are a non-exempt* employee, your STD benefit payment is based on your average weekly straight-time pay, which is calculated by averaging the paid hours (maximum of 40 per week) each week during the last full quarter you worked and multiplying that by your hourly rate. For example, if your disability begins in February, the last full quarter is October, November and December. If you are an exempt* employee, your STD benefit payment is based on your monthly base pay. *Exempt and non-exempt status is determined in accordance with the Fair Labor Standards Act classifications. Generally, hourly employees are non-exempt and management employees are exempt. Contact your Human Resources department if you are unsure of your classification. When Do STD Benefits Begin? STD benefits usually begin after a waiting period of up to four days, based on the reason for the disability. Refer to your Insert for details about when STD benefits begin. Who Qualifies for STD Benefits? For STD purposes, you are considered disabled if the Plan Administrator, CIGNA, determines that you are unable to perform the material and substantial duties of your regular occupation because of an illness or injury. In some cases, STD benefits will be reduced if you refuse to participate in the residual disability return-to-work program. STD benefits are paid at the same interval that you are paid as an active employee, for example, weekly if you are a weeklypaid employee. Income Protection Plan 103

106 Qualification for STD benefits is subject to CIGNA obtaining information supporting your disability. You may also need medical approval prior to returning to work. If you can t return to work when your benefits end, and you are not eligible to apply for LTD, you may be eligible for Permanent and Total Disability coverage. See page 83 for details. You should also contact your manager to keep him or her informed of your progress. If you are eligible for long-term disability benefits, CIGNA will automatically review your case for LTD coverage, or you may call CIGNA to discuss your eligibility for LTD. If You Have More Than One STD Absence If you are absent and receiving STD benefits and return to work for at least one day, and are later absent for an entirely different cause, you are eligible for a new disability period of STD benefits (after the four-day waiting period, if applicable). If your second absence is due to the same cause, you must have returned to work for a minimum period before a new disability period will begin. (Refer to your Insert for details on the length of the minimum period.) This minimum period cannot include any vacation, personal, or discretionary days. Residual Disability/Return to Work Program The Plan will pay a residual benefit if you attempt to return to work, at the Company or another employer, while recovering from a disability. You will be considered residually disabled if you perform any CIGNA preapproved work for wage or profit while disabled. The benefit you receive from STD will be calculated as follows: your STD benefit minus 75 percent of any earnings you receive while you are disabled Your residual earnings from all sources, combined with your STD payment, may not exceed 100 percent of your pre-disability earnings (including earnings from other employers). Your STD payment will be reduced by any amounts in excess of your pre-disability earnings. If CIGNA and the Company determine that you can return to work for the Company under a residual disability program, and you fail to do so, your STD benefit payment will be offset by the amount you would have received as a residual disability benefit. For purposes of this return-to-work program, you may be asked to return in any position for which you are reasonably qualified based on your education, training or experience. Otherwise your second absence will be considered a continuation of the first disability period, and both periods of absence count toward the maximum coverage period described in your Insert. 104 Income Protection Plan

107 Disability Benefit Offsets California and Rhode Island have stateadministered disability benefits. In these states, the Plan offsets your STD benefits by the amount of the state plan benefits so that the combined amount paid by the Flexible Benefits Plan and the state plan would be no more than the amount the Plan would pay if there were no other coverage. Unless you provide documentation that you are not receiving state disability benefits, your Flexible Benefits Plan benefit will automatically be offset. Hawaii, New Jersey and New York have state-mandated benefits. In these states, the amount paid to you will be the greater of either the state-mandated benefit or your STD benefit, but not both. Additionally, your STD benefit will be reduced by the full amount of other earnings (subject to the residual disability provisions), disability income or retirement income you may receive, or be eligible to receive, including: any amount received from a retirement plan or pension plan that the Company or its affiliates contribute to or sponsor (other than the UPS Savings Plan) any residual disability/return-to-work amounts that you may be eligible to earn any amount you receive from another group insurance plan (individual insurance plans are not offset) any disability benefits received from the Veterans Administration any work-loss provision of a no-fault or third-party benefit or settlement any primary benefit received under the U.S. Social Security Act any Workers Compensation payment It is a requirement of the Plan that you apply for the Social Security disability insurance benefit as well as any state-provided disability benefits to which you may be entitled. You are also required to appeal any denials. If you do not apply or appeal denials, the claims administrator will estimate the Social Security amount that you could have received and offset your benefit by that amount. Additionally, it is a requirement of the Plan that you apply for Workers Compensation if your disability is work-related. Income Protection Plan 105

108 Should you receive a lump sum payment (from Social Security, a Workers Compensation, no-fault, or third-party settlement related to your injury or illness, for example), your disability benefit will be fully offset until the entire amount of the settlement that represents disability benefits has been completely offset. For example, if you receive a $100,000 settlement (that represents disability benefits), and your STD benefit is $1,000 per month after all other offsets have been taken, you would receive no disability benefit from the Flexible Benefits Plan for 100 months, until the full $100,000 had been offset. At that time, your disability benefit would begin again.this example assumes qualification for LTD coverage after the STD benefit period ends. If CIGNA is unable to determine the exact amount of the award that represents disability benefits, 50 percent of the award will be considered disability benefits. If you receive STD benefits for an illness or injury that is later determined to be an occupational illness or injury, your STD benefits received after the date of such determination will be offset by any retrospective and prospective Workers Compensation benefits that are paid to you. Additionally, if your remaining STD benefit period is not sufficient to repay amounts that would not have been paid to you if the Workers Compensation claim had been determined earlier: either your Workers Compensation benefits will be reduced by the amount owed to the Income Protection Plan (to the extent allowed by law), or you will be required to reimburse the Plan for such excess STD benefit payments Exclusions and Limitations No STD benefits are payable from this Plan for any disability that results from: intentionally self-inflicted injuries participation in a felony war, or act of war (whether such is declared or not), insurrection, rebellion, or participation in a riot or civil commotion serving on active duty in any armed forces of any government any vague or undefinable condition that cannot be described by a standard medical nomenclature diagnosis No STD benefits are payable for days when you receive: discretionary days (such as sick pay or optional holiday pay, if applicable) holiday pay vacation pay Benefit Termination There are certain conditions that could cause your STD benefits to be terminated or reduced. These occur when you: cease to have a disability as determined by the Plan Administrator terminate employment due to a pre-disability scheduled termination date (e.g., because of resignation or a facility closing) fail to comply with a residual disability/ return-to-work plan approved by CIGNA and the Company 106 Income Protection Plan

109 fail to provide medical documentation requested by the Plan Administrator. CIGNA can request additional medical documentation of an ongoing disability as often as it deems reasonably necessary. fail to comply with a reasonable course of medical treatment and care necessary and appropriate to treat and/or resolve the condition for which you re receiving disability benefits fail to comply with an independent medical examination, functional capacity evaluation or other evaluation as may be required by the Plan Administrator have been paid the maximum disability period of STD benefits Health Care Coverage and STD If you re unable to work due to either an occupational or a non-occupational injury or illness, Flexible Benefits Plan coverage for you and your dependents continues for up to 12 months following the date your disability began. You continue to be responsible for your share of the costs, either through billing statements or payroll deductions (if you are receiving a check from the Company). At the latest, coverage will end on the last day of the twelfth full month of continuous disability. The Flexible Benefits Plan does not cover any expenses related to an occupational disability. You must submit claims for occupational disabilities to the Workers Compensation Administrator. When your 12-month extension of health care coverage ends, you and your dependents may elect COBRA continuation for 18 months, for a total of 30 months of coverage. (Please see the COBRA section for more information.) Or, if you are eligible and approved for LTD, you may begin coverage under the LTD health care plan. Coordination With Medicare If you become eligible for Medicare benefits as a result of a disability, there are rules that determine whether the Flexible Benefits Plan pays benefits first, or whether Medicare is primary. See page 50. Life Insurance and Accidental Death and Dismemberment (AD&D) During your 12-month extension of health care coverage, any basic life and AD&D will continue to be provided by the Company, including spouse s and children s basic. Any supplemental life insurance and AD&D coverage can be continued as if you were an active employee. You continue to be responsible for the costs of supplemental coverage. When your 12-month extension ends, your and your spouse s supplemental Group Universal Life (GUL) insurance can be continued on a direct-billed basis. You may also choose to convert your and your spouse s GUL policies to individual policies without providing evidence of insurability. Prudential will automatically send you the necessary forms to fill out and return. Income Protection Plan 107

110 Your CIGNA case manager will work with you, your doctor and the Company to help you return to work as quickly as is safely possible. Your Company-paid basic life insurance, including your spouse s and your children s, can be converted to individual policies within 31 days of the end of your 12-month extension.* To obtain a conversion kit, call Prudential at Your AD&D coverage ends on the last day of your 12-month extension and cannot be converted.* See the Life Insurance section on page 77 for additional information. *If you are approved for LTD, any Company-paid basic life insurance and AD&D, including spouse s and children s, will continue only as long as you are a participant in the Income Protection Plan. Taxes and Your STD Benefit STD benefits are taxed when paid to you. See the Insert for further details about receiving a W-2 form. How to File a Claim If you become unable to work because of an injury or illness, you are encouraged to call the Plan Administrator, CIGNA, at ( CIGNA) by the fifth day of your absence so CIGNA can begin processing your claim. You must call no later than 60 days after the illness or injury. If you do not call within 60 days of the initial date of disability, you will not be eligible for benefits. A representative will: ask you for information: name and address of the Company, date of hire and supervisor s name and phone number your name, phone number, home address and Social Security number the date of your injury or illness and the first day you were absent from work your doctor s name, address and phone number, the date you were first treated for this condition, and your next appointment verify how you became disabled explain the claim process, including the need to obtain medical information from your doctor The representative will send you a release form that allows CIGNA to obtain information about your condition. Your claim will then be assigned to a case manager, who will gather the required documentation from your doctor. If you do not return the release form in the time specified you may not be eligible for benefits. If you do not file a claim within 60 days of the initial date of disability you will not be eligible for an STD benefit and you will be required to reimburse the Company for any disability benefits already paid. 108 Income Protection Plan

111 If your claim is approved, you will receive an approval letter providing you a number to call if you have questions about your coverage, and indicating your expected return-to-work date. CIGNA will notify the Company of your anticipated returnto-work date and your claim approval. You should receive your first weekly payment (if you are a non-exempt employee) within two weeks from the date of your call. If your claim is denied, you ll receive a letter providing specific reasons for the denial. CIGNA will notify the Company that your claim has been denied. You must immediately contact your manager to schedule your return to work. Right of Recovery Provision In some situations, you or your covered dependents may be entitled to certain payments from another source following an injury or illness. See page 122 for details on the Plan s right of recovery provisions. In addition, the Plan has the right to recover any STD benefits that are deemed to be paid incorrectly. LONG-TERM DISABILITY Long-term disability (LTD) provides protection from disabilities caused by an occupational or non-occupational illness or injury that lasts longer than the STD benefit period. Eligibility LTD covers all eligible full-time employees covered under the Flexible Benefits Plan who have exhausted their STD benefits. Refer to your Insert for details about LTD eligibility. Part-time employees are not eligible for LTD, but may be eligible for Permanent and Total Disability benefits (see page 83). Your Employment Status If you are absent from work for 12 months, you will be administratively terminated from employment at the end of the twelfth month, regardless of your status on STD or LTD. If your disability should end after your termination and you are able to return to work, you will be considered for employment based on your experience and skills, as would any other applicant. LTD Benefits LTD benefits pay a percentage of your monthly base salary. For weekly-paid employees, your monthly salary is calculated by multiplying your average weekly straighttime pay by 52 weeks, then dividing by 12 months. For the exact percentage payable under LTD, please refer to your Insert. COLA Option You may also purchase a three percent cost of living adjustment (COLA) option. COLA is designed to keep your disability payment up to date with inflation. Your monthly disability benefit payment will be increased by three percent on each anniversary of the date monthly benefits became payable to you. Your first COLA adjustment will be effective after you ve received 12 monthly benefits. COLA option prices are based on your income and are shown on your Enrollment Worksheet. Income Protection Plan 109

112 Who Qualifies for LTD Benefits? For the first 24 months of disability under LTD, you are considered disabled if the Plan Administrator determines that you: are unable to perform the material and substantial duties of your regular occupation due to an illness or accidental injury After 24 months of payments, you will be considered disabled if the Plan Administrator determines that you: are unable to perform the material duties of any gainful occupation for which you are reasonably qualified based on your education, training or experience, except for psychiatric benefits, which end at 24 months Residual Disability During the first 24 months of LTD, the Plan will pay a residual benefit if you attempt to return to work, at the Company or another employer, while recovering from a disability. You will be considered residually disabled if you perform any CIGNA pre-approved work for wage or profit while disabled. The benefit you receive from LTD will be calculated as follows: your LTD benefit minus 75 percent of any earnings you receive while you are disabled Your residual earnings from all sources, combined with your LTD payment, may not exceed 100 percent of your predisability earnings (including earnings from other employers). Your LTD payment will be reduced by any amounts in excess of your pre-disability earnings. During the first 24 months of disability under LTD, if CIGNA and the Company determine that you can return to work for the Company under a residual disability program, and you fail to do so, your LTD benefit payment will be offset by the amount you would have received as a residual disability benefit. For purposes of this return-to-work program, you may be asked to return in any position for which you are reasonably qualified based on your education, training or experience. Disability Benefit Offsets Your LTD benefit will be reduced in full by any disability or retirement income or earnings you may receive (subject to the residual disability provisions), or be eligible to receive, including: any amount received from a compulsory state disability plan any residual disability/return-to-work amounts that you may be eligible to earn any amount received from a retirement plan or pension plan that the Company or its affiliates contribute to or sponsor (other than the UPS Savings Plan) any amount you receive from another group insurance plan (individual insurance plans are not offset) any no-fault or third-party settlement any primary benefits received under the U.S. Social Security Act any Workers Compensation benefit any incorrectly paid STD or LTD benefits 110 Income Protection Plan

113 It is a requirement of the Plan that you apply for the Social Security disability insurance benefit as well as any state-provided disability benefits to which you may be entitled. You are also required to appeal any denials. If you do not apply or appeal denials, the claims administrator will estimate the Social Security amount that you could have received and offset your benefit by that amount. Should you receive a lump sum payment (from Social Security, a Workers Compensation, no-fault, or third-party settlement related to your injury or illness, for example), your disability benefit will be fully offset until the full amount of the settlement that represents disability benefits has been completely offset. For example, if you receive a $100,000 settlement (that represents disability benefits), and your LTD benefit is $1,000 per month after all other offsets have been taken, you would receive no disability benefit from the Flexible Benefits Plan for 100 months, until the full $100,000 had been offset. At that time, your disability benefit would begin again. If CIGNA is unable to determine the exact amount of the award that represents disability benefits, 50 percent of the award will be considered disability benefits. Disabled at: Exclusions and Limitations No LTD benefits are payable from this Plan for any disability that results from: intentionally self-inflicted injuries, while sane or insane participation in a felony war, or act of war (whether such is declared or not), insurrection, rebellion, or participation in a riot or civil commotion any vague or undefinable condition that cannot be described by a standard medical nomenclature diagnosis substance abuse and alcoholism conditions psychiatric conditions, except during the first 24 months of LTD any disability that begins prior to LTD coverage under the Plan Additionally, the Internal Revenue Code limits the compensation that can be used in computing long-term disability benefits. The calculation of long-term disability benefits under the Income Protection Plan will be limited to annual base compensation levels not exceeding $200,000. If your annual base compensation exceeds $200,000 per year, you may be eligible for additional LTD benefits under the UPS Coordinating Benefit Plan. Benefit Termination LTD benefits will be terminated when an eligible employee reaches age 65, if the date of disability is prior to age 62. If disabled on or after age 62, LTD benefits terminate in accordance with the following schedule: Benefits continue: age 61 or younger To end of month age 65 age 62 for 42 months age 63 for 36 months age 64 for 30 months age 65 for 24 months age 66 for 21 months age 67 for 18 months age 68 for 15 months age 69 or older for 12 months Income Protection Plan 111

114 In addition to the above schedule, there are certain conditions that could cause your LTD benefits to be terminated. These occur when you: cease to have a disability as defined by the Plan and as determined by the Plan Administrator fail to provide medical documentation requested by the Plan Administrator fail to comply with a reasonable course of medical treatment and care necessary and appropriate to treat and/or resolve the condition for which you re receiving disability benefits fail to comply with an independent medical examination, functional capacity evaluation or other evaluation as may be required by the Plan Administrator fail to apply, reapply and appeal any denials of Social Security disability insurance benefit as well as any state-provided disability benefits to which you may be entitled, until all such applications and appeals are exhausted fail to comply with a residual disability/ return-to-work plan approved by CIGNA and the Company Health Care Coverage and LTD The Company provides health care coverage for you and your eligible dependents as well as basic life insurance (for you and your family) and AD&D coverage for you: once your 12-month health care extension under the Flexible Benefits Plan ends, and you are approved for LTD coverage For information about the 12-month extension, see Health Care Coverage and STD. You will receive a booklet describing your LTD health care, life insurance and AD&D coverage when you are approved for LTD. 112 Income Protection Plan

115 Taxes and Your LTD Benefit LTD benefits are taxed when paid to you. The Plan Administrator, CIGNA, will issue all W-2 forms for any benefits received under the LTD Plan. How to File a Claim Your CIGNA case manager for STD will automatically review your case for LTD eligibility. If you do not have a case manager, call CIGNA at ( CIGNA). Remember that STD benefits may be paid weekly, while LTD benefits are paid monthly. LTD benefits are calculated on a monthly cycle beginning with your eligibility date for LTD, and paid near the end of that benefit period. For instance, if your LTD date of disability is June 15, your monthly benefit payment will be calculated from June 15 to July 14, and will be mailed to you about one week prior to the end of that benefit period. Right of Recovery Provisions In some situations, you or your covered dependents may be entitled to certain payments from another source following an injury or illness. See page 122 for details on the Plan s right of recovery provisions. In addition, the Plan shall have the right to recover any LTD benefits that are deemed to be paid incorrectly. PERMANENT AND TOTAL DISABILITY (PTD) FOR PART-TIME EMPLOYEES If you are not eligible for LTD and you become permanently and totally disabled while you re a participant in the Flexible Benefits Plan, you may be eligible to receive a lump sum benefit from your basic employee life insurance. See If You Become Disabled in the Life Insurance section on page 83. Income Protection Plan 113

116 If a Claim Is Denied If your claim for benefits from the Flexible Benefits Plan is denied in whole or in part, you usually will receive a written notification of the denial within 90 days of submitting the claim. If you don t receive any response within 90 days, you should consider your claim denied. The notice will explain: the reasons for the denial, the Plan provisions on which it is based, any additional material or information needed to make the claim acceptable and the reason it is necessary, and the procedure for requesting a review If special circumstances require more than 90 days for processing the claim, you ll be notified of that fact, in writing, within 90 days of filing. The notice you receive will explain what special circumstances make an extension necessary and indicate the date a final decision is expected to be made. The extension may be for up to another 90 days. APPEALING YOUR DENIAL You (or your beneficiary) are entitled to a review of a denied claim.the situation should first be appealed to the highest available level with the administrator of the services (e.g., Aetna U.S. Healthcare, CIGNA, BCBS, Prudential). If you then believe further review is needed on a plan for which UPS decides appeals, you may (within 60 days of the administrator s final appeal denial) submit a written request for an appeal with the Claims Review Committee at 55 Glenlake Parkway, NE, Atlanta, GA All appeals to the Company must be submitted through the region Human Resources department. Neither the Company nor UPS is a fiduciary with respect to the benefits or programs for which it does not have the responsibility to decide appeals. The chart on the next page indicates whether you should appeal a denial of claims to UPS or to another entity. If you are required to appeal to a different entity, please contact that entity for required appeal procedures. IF YOU APPEAL TO UPS The Claims Review Committee will normally make a decision on the denial within 60 days after your request for review is received. You ll receive a copy of the decision, in writing, including the specific reasons for it and references to the Plan provisions on which it s based. If special circumstances require a review period of longer than 60 days, the time for making a final decision may be extended and you ll be furnished notice of the extension within 60 days after your requested review. However, the total review period will not be longer than 120 days. 114 If a Claim Is Denied

117 Appeal to program If you are covered by: Appeal to UPS administrator Aetna U.S. Healthcare Blue Cross/Blue Shield CIGNA Solutions PAID Prescriptions Kaiser Permanente Group Health Cooperative Humana Prudential, Options 1, 2 Prudential, Option 3 Vision Service Plan Life Insurance AD&D Spending Accounts Short-/Long-Term Disability LegalCare Adoption Assistance Liberty Mutual Cancer Expense Insurance Long-Term Care CLAIMS PROCEDURES FOR INCOME PROTECTION PLAN All of the claims procedure information described above applies to disability claims filed under the Income Protection Plan except as follows. The amount of time the Plan has to respond to your claim is reduced from 90 days to 45 days, and the extension period changes from one 90-day period to two 30-day periods. If an extension is needed because of incomplete information, you will have 45 days in which to respond (during which the time period for making a determination does not run). If your claim is denied, you must file an appeal within 180 days (instead of 60 days). You will be notified of the decision within 45 days, with one 45-day extension period permitted for reasons beyond the Plan s control. If a Claim Is Denied 115

118 Continuation of Coverage Under COBRA In certain circumstances, health care coverage for you and your dependents can continue beyond the date it would otherwise end. This continuation of coverage is required by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The information included here is a general overview of COBRA provisions. If you become eligible for continued coverage (that is, if you have a qualifying event), you ll be given more information that reflects your situation at the time. HOW COBRA WORKS Eligibility for COBRA is triggered by a qualifying event. The following table describes the types of qualifying events and the maximum length of coverage available for each event. The maximum coverage period is measured from the date of the qualifying event. If you decide to continue coverage, you must pay the full cost of that coverage, plus a two percent administrative cost.the monthly premium amount will be provided to you at the time a qualifying event occurs. Qualifying Events Continuation of Coverage Your dependent Your dependent You spouse child You terminate Company 18 months 18 months 18 months employment before retiring Your work hours are reduced* 18 months 18 months 18 months You retire 18 months 18 months 18 months You become divorced or legally separated NA 36 months 36 months Your child ceases to be a qualified dependent NA NA 36 months You die** NA 36 months 36 months **And, as a result, you re ineligible for health care coverage. **The 13-month Company-paid extension period is included as part of the 36-month maximum coverage period (see page 14). 116 Continuation of Coverage Under COBRA

119 Continued coverage will usually be available for either the 18- or 36-month period, as noted above. However, this continued coverage will end sooner for an individual if: the premium for continued coverage is not paid when it s due, that person becomes entitled to Medicare, that person becomes covered by another health care plan (except a plan that excludes a pre-existing condition for which that person needs treatment), or the Flexible Benefits Plan terminates for all employees If you (or your dependent) are disabled at the time (or within 60 days from the time) you terminate employment or have a reduction in hours, you may extend COBRA coverage for an additional 11 months. This coverage is available at 150 percent of the applicable premium. To be eligible for this extension, you (or your dependent) must: receive a determination of disability from the Social Security Administration, and notify the Plan Administrator within 60 days of receiving the disability determination and before the original 18-month period ends If during the 11-month extension you re no longer considered disabled based on the Social Security Act, you must notify the Benefits Service Center at within 30 days of this determination. COBRA coverage may then continue until the end of the first month that starts more than 30 days after Social Security s decision. COBRA NOTIFICATION DEADLINE In most cases, you ll be notified when you become entitled to continue health care coverage. However, for other events, you or your dependent should notify the Benefits Service Center immediately. You must notify the Benefits Service Center within 60 days of the qualifying event or continued coverage will not be available. The chart below shows when the Company will automatically send COBRA enrollment materials and when you or your dependent must notify the Benefits Service Center. The 60-Day Notice If you do not notify the Benefits Service Center within 60 days of a divorce, legal separation or loss of dependent status (not due to age) you forfeit your right to COBRA coverage. Notification Deadline Event Termination Retirement Layoff Death of employee Transfer to ineligible position Reaching 12 months on Leave of Absence Loss of dependent status due to age Divorce Legal Separation Loss of dependent status not due to age Responsible for notification Benefits Service Center will automatically send your COBRA enrollment materials to the employee s address on file. You, your spouse or your child should call the Benefits Service Center at immediately. If you do not notify the Service Center within the 60 days, you forfeit any right to COBRA coverage. Continuation of Coverage Under COBRA 117

120 ENROLLMENT As with active employees, there are two types of enrollment: initial enrollment, when you first become eligible, and annual enrollment. Annual Enrollment At each annual enrollment, you can make new choices. An enrollment kit will be sent to you and must be returned by the deadline indicated on the enrollment form. Initial Enrollment When you become eligible for COBRA, you and your covered eligible dependents may each independently choose to continue medical, dental and vision coverage for up to the entire coverage period. You may choose to continue the Health Care Spending Account on an after-tax basis until the end of that calendar year. During initial COBRA enrollment, you may not make changes to your coverage (options) except to stop coverage in a particular plan (i.e., medical, dental or vision). You may, however, decrease your coverage level (you only, you plus spouse, you plus children, you plus family). A change in status at the time of your qualifying event may allow you to change certain coverages during initial COBRA enrollment. (see the Life Events section for more information.) THE COBRA ADMINISTRATOR The Benefits Service Center is the COBRA administrator and will handle all COBRA enrollment and billing. The Service Center can be reached at YOUR RIGHT TO OBTAIN INDIVIDUAL COVERAGE A federal law, Health Insurance Portability and Accountability Act, requires all health insurance carriers offering coverage in the individual market to accept any eligible individuals who apply for coverage, without imposing a preexisting condition exclusion. To take advantage of this HIPAA right you must complete your 18-, 29- or 36-month COBRA coverage period under the Flexible Benefits Plan and apply for coverage with an individual carrier before you have a 63-day lapse in coverage. Since this coverage is not sponsored by the Company, you should contact your state s department or commission of insurance or see your independent insurance specialist to secure coverage. 118 Continuation of Coverage Under COBRA

121 Plan Administration and ERISA Information The information contained in this booklet, including the schedule of benefits, is a summary of the applicable administrative and legal documents relating to the Flexible Benefits Plan. For insured benefits, in the event there is any difference between this booklet and the applicable contracts or certificates, the insurance documents will govern. United Parcel Service, as Plan Administrator, shall have the exclusive right and discretion to interpret the terms and conditions of the Plan, and to decide all matters arising in its administration and operation, including questions of fact and issues pertaining to eligibility for, and the amount of, benefits to be paid by the Plan. Any such interpretation or decision shall, subject to the claims procedure described herein, be conclusive and binding on all interested persons, and shall, consistent with the Plan s terms and conditions, be applied in a uniform manner to all similarly situated participants and their covered dependents. All benefits described in this book both for you and your family are paid for by you and the Company, and are made available to you as part of the compensation you receive or received for your work with the Company. Certain HMOs, the DMO, life insurance, accidental death and dismemberment, personal lines insurance, LegalCare, Cancer Expense Insurance and long-term care benefits are provided to Flexible Benefits Plan participants by means of insurance contracts, for which you and/or the Company pay the premiums. STD benefits for exempt employees are paid from Company assets. With regard to the Plan s other benefits, UPS has established a special trust, called a voluntary employee beneficiary association trust, to serve as the funding vehicle. All contributions to the trust are made from the general assets of UPS and its affiliated Companies. Depending on the coverage you select, you may be required to pay a portion of the cost of providing those benefits. Your participation in the Flexible Benefits Plan does not guarantee your continued employment with the Company. If you quit, are discharged or laid off, the Plan does not give you a right to any benefit or interest in the Plan except as specifically provided in the Plan document. Plan Administration and ERISA Information 119

122 The Plan Administrator is United Parcel Service, which is authorized to delegate its administrative duties to one or more individuals or committees within UPS, or to one or more outside administrative service providers. Presently, certain administrative services with regard to the processing of claims and the payment of benefits are provided under contract as follows: Medical coverage is administered by the following: Aetna 151 Farmington Avenue Hartford, CT Mental health/substance abuse coverage is administered by: ValueOptions 3110 Fairview Park Drive Falls Church,VA Prescription drug coverage is administered by: Merck-Medco 1900 Pollit Drive Fairlawn, NJ Dental coverage is administered by: Prudential HealthCare 56 North Livingston Avenue Roseland, NJ Blue Cross/Blue Shield of Illinois 300 East Randolph Street Chicago, IL CIGNA HealthCare 900 Cottage Grove Road Bloomfield, CT Kaiser Permanente 1950 Franklin Oakland, CA Humana 500 West Main Street Louisville, KY Vision coverage is administered by: Vision Service Plan 3333 Quality Drive Rancho Cordova, CA Legal coverage is administered by: The Signature Group Bluegrass Parkway Louisville, KY Personal Lines coverage is administered by: Liberty Mutual 175 Berkeley Street Boston, MA United HealthCare (Uniprise) 9900 Bren Road East Minnetonka, MN Plan Administration and ERISA Information 120

123 Short- and long-term disability are administered by: CIGNA 900 Cottage Grove Road Bloomfield, CT Cancer Expense Insurance is administered by: AFLAC 1932 Wynnton Road Columbus, GA Health Care and Child/Elder Care Spending Accounts are administered by: Aetna 151 Farmington Avenue Hartford, CT Life and AD&D Insurance are administered by: Prudential Life Insurance Company 751 Broad Street Newark, NJ Long-Term Care is administered by: MetLife Long-Term Care Group P.O. Box 927 Westport, CT General Information Name of Plan: The Flexible Benefits Plan Plan Number:501 Plan Year: January 1 through December 31 Employer and Plan Sponsor: United Parcel Service of America, Inc. 55 Glenlake Parkway, NE Atlanta, GA VEBA Trustee: Boston Safe Deposit and Trust Company 135 Santilli Highway Everett, MA Employer Identification Number (EIN): Plan Administrator: The Flexible Benefits Plan United Parcel Service of America, Inc. 55 Glenlake Parkway, NE Atlanta, GA Name of Plan Cancer Expense Insurance Plan Plan Number: 529 Plan Year: January 1 through December 31 Employer and Plan Sponsor: United Parcel Service of America, Inc. 55 Glenlake Parkway, NE Atlanta, GA Employer Identification Number (EIN): Plan Administrator: AFLAC 1932 Wynnton Road Columbus, GA Plan Administration and ERISA Information 121

124 RIGHT OF RECOVERY PROVISION This section describes the Plan s right to seek reimbursement of expenses that are paid by the Plan on behalf of you or your covered dependents (referred to in this section as a Covered Individual ) if those expenses are related to the acts of a third party (for example, if you are involved in an automobile accident). The Plan may seek reimbursement of these expenses from any recovery you may receive from the third party or another source, including from any insurance proceeds, settlement amounts or amounts recovered in a lawsuit. The terms of the Plan s reimbursement rights are described below: If a Covered Individual incurs expenses covered by the Plan as a result of the act of a third party (person or entity) you may receive benefits pursuant to the terms of the Plan. However, the Covered Individual shall be required to refund to the Plan all benefits paid if the Covered Individual recovers from any other party (such as proceeds from a settlement, judgment, lawsuit or otherwise as a result of the act).the Covered Individual may be required to: a) Execute an agreement provided by the Company or the claims administrator acknowledging the Plan s right of recovery, agreeing to repay any claims paid by the Plan, pledging amounts recovered by the Covered Individual from the third party as security for repayment of any claims paid by the Plan, and to the extent provided below, assigning the Covered Individual s cause of action or other right of recovery to the Plan. If the Covered Individual fails to execute such an agreement, by filing claims (assigning benefits or having claims filed on your behalf) related to such act of a third party, the Covered Individual shall be deemed to agree to the terms of this reimbursement provision; b) Provide such information as the Company, the network manager or claims administrator may request; c) Notify the Company and/or the network manager or claims administrator in writing by copy of the complaint or other pleading of the commencement of any action by the Covered Individual to recover damages from a third party; d) Agree to notify the Company and/or the network manager or claims administrator of any recovery. The Plan s right to recover the benefits it has paid is not subject to reduction for attorney s fees or other expenses of recovery, and shall apply to the entire proceeds of Plan Administration and ERISA Information 122

125 any recovery by the Covered Individual. This includes any recovery by judgment, settlement, arbitration award or otherwise. The Plan s right to recover shall not be limited by application of any statutory or common law make whole doctrine (i.e., the Plan has a right of first reimbursement out of any recovery, even if the Covered Individual is not fully compensated) or the characterization of the nature or purpose of the amounts recovered or by the identity of the party from which recovery is obtained. The Plan shall have a lien against the proceeds of any recovery by the Covered Individual and against future benefits due under the Plan in the amount of any claims paid. If the Covered Individual fails to repay the Plan from the proceeds of any recovery, the Plan Administrator may satisfy the lien by deducting the amount from future claims otherwise payable under the Plan. If the Covered Individual fails to take action against a responsible third party to recover damages within one year or within 30 days after the Plan requests, the Plan shall be deemed to have acquired, by assignment or subrogation, a portion of the Covered Individual s claim equal to the amounts the Plan has paid on the Covered Individual s behalf. The Plan may thereafter commence proceedings directly against any responsible third party. The Plan shall not be deemed to waive its rights to commence action against a third party if it fails to act after the expiration of one year nor shall the Plan s failure to act be deemed a waiver or discharge of the lien described above. The Covered Individual shall cooperate fully with the Plan in asserting claims against a responsible third party and such cooperation shall include, where requested, the filing of suit by the Covered Individual against a responsible third party and the giving of testimony in any action filed by the Plan. If a Covered Individual fails or refuses to cooperate in connection with the assertion of claims against a responsible third party, the Plan Administrator may deny payment of claims and treat prior claims paid as overpayments recoverable by offset against future Plan benefits or by other action of the Plan Administrator. Plan Administration and ERISA Information 123

126 YOUR ERISA RIGHTS The Flexible Benefits Plan is an employee welfare benefit plan covered by the Employee Retirement Income Security Act of 1974 (ERISA). As a participant in the Plan, you have certain rights and protection based on ERISA. ERISA provides that, as a Plan participant, you are entitled to receive information about your Plan and benefits You may examine, without charge, at the Plan Administrator s office and at other specified locations such as work-sites, all 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 Pension and Welfare Benefit Administration. You may obtain, upon written request to the Plan Administrator, copies of all documents governing the operation of the Plan, including insurance contracts and copies of the latest annual report (Form 5500 series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies. You may 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 Group Health Plan coverage You may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents will have to pay for such coverage. You should review this summary plan description for information concerning your COBRA continuation coverage rights. You may be eligible for a reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your Group Health Plan, if you move to another plan and you have creditable coverage from this Plan. The Flexible Benefits Plan does not contain any exclusionary periods of coverage for pre-existing conditions. You will be provided a certificate of creditable coverage, free of charge, from the Flexible Benefits Plan when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage in another plan. 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 Plan Administration and ERISA Information 124

127 operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of the 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 from the plan, or from exercising your rights under ERISA. enforce your rights If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials 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 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. 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. assistance with your questions If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance obtaining documents from the plan administrator, you should contact: the nearest office of the U.S. Department of Labor, Pension and Welfare Benefits Administration listed in your telephone directory, or Division of Technical Assistance and Inquiries Pension and Welfare Benefits Administration U.S. Department of Labor 200 Constitution Ave., N.W. Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration. PLAN AMENDMENT OR TERMINATION The Company has established these Plans with the expectation that they will be continued indefinitely. Nevertheless, the Company reserves the right to amend or terminate any of the Plans at any time. The right to amend or terminate any of the Plans applies to all coverage hereunder, including coverage for active and disabled employees. Plan Administration and ERISA Information 125

128 This booklet and its accompanying insert, as updated by any future summary of material modification, constitutes the Summary Plan Description (SPD) and a portion of the plan document for the Flexible Benefits Plan. In some cases, certain benefits (e.g., cancer expense insurance and/or certain dental benefit options) are provided through insurance contracts. In such cases, the benefits may be more fully described in the insurance certificate booklet(s) you receive. If there is any conflict between this document and the insurance certificate you receive, the insurance certificate will control. In all other cases, the text of this document will control. The Company reserves the right to amend or terminate the Plan or any portion of the Plan at any time for any reason.

129 Who To Call ehr 800-UPS-1508 Single-call access to all your benefits Benefits Service Center Enrollment (Available 24 hours a day except 1 a.m. to 12 noon on Sundays) Service Center Representative (Press *0# at main menu; 8 a.m. to 8 p.m. CST, Monday through Friday) Medical Aetna Network coverage Non-Network coverage HMO Options Blue Cross/Blue Shield CIGNA United HealthCare Humana HMO (KY) ChoiceCare/Humana HMO (OH) Kaiser Permanente California Georgia Denver, CO Colorado Springs, CO Hawaii Oregon Group Health Cooperative East West Prescription Merck-Medco ValueOptions (Solutions) Dental Aetna Vision VSP Life Insurance and AD&D Prudential Insurance Company Conversions Legal LegalCare Spending Accounts Aetna Your Local Network Manager or HMO 2000, United Parcel Service of America, Inc. PDF Rev. 09/01 50M