Gap Inc. Welcome to Gap Inc. Benefits. Lifestyle Benefits and Programs

Transcription

1 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Welcome to Benefits Lifestyle Benefits and Programs This is your guide to benefits for full-time benefit-eligible U. S. employees (including Puerto Rico). It is designed to be easy to read and understand and there are lots of ways to help you find the information you need. As a employee, you have a variety of lifestyle benefits and programs available to you. Find information on all your benefits on Gapweb. In addition to discounts and deals in your local community, offers several programs to make your life a little easier, such as: This guide covers the topics/plans shown here. Click on any section and you will go straight there. Once there, a table of contents will appear on the left to help you navigate to any item in the section. PTO / Holidays / Leaves of Absence* Weight Watchers Financial Planning You can also use the buttons here to find your way around the document as well as look up for a specific plan, go to the, for terms and more. Employee Merchandise Discount GapShare 401(k) If you have any questions or need support, please contact Employee Services at , ext The plans outlined in this summary plan description (SPD) may be updated or amended at any time. You can find the most up-todate information on Gapweb ( benefits > select U.S. Full-Time Benefits. Employee Stock Purchase Program (ESPP) Commuter Benefits Smoking Cessation Travel Assistance Adoption Assistance Reimbursement Your HealthCare Advocate * For additional information on leaves of absence at, see the Employee Leave of Absence Guide on Gapweb or call the Leave of Absence and Administrator at 800.GAP When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident This guide also incorporates other materials by reference, such as enrollment materials, benefit summaries and plan-related communications you may receive from time to time. These materials are also a part of this summary plan description. This summary plan description (SPD) summarizes information about certain benefits. Although every effort has been made to ensure the accuracy of this information, this SPD is not a legal contract. The plan documents and contracts govern the terms, conditions, and provisions of the benefits. If there are differences between the information in this SPD and the provisions of the plan, the official plan document or contract will generally govern unless otherwise provided by law. Plan benefits are available only if provided for in the official plan documents or contracts. intends to continue this plan, but reserves the right, in its sole discretion, to modify, change, revise, amend, or terminate the plan and any health benefit program sponsored under the plan at any time, for any reason, and without prior notice as it relates to the provision of benefits for any active or former employee, including any beneficiary or dependent of such active or former employee. This SPD is not to be construed as a contract of or for employment. 1

2 Welcome The following dependents are eligible for coverage: Eligible Employees Eligibility Your legal opposite or same-sex spouse, if you are not legally separated or divorced and have not had your marriage annulled. Eligible Dependents Eligible Employees Your partner (see Eligible Partners below). Employees classified as full-time in the U.S. and Puerto Rico are eligible to participate in the benefit programs. Employees classified as part-time or seasonal are not eligible. Your or your spouse s/partner s eligible children (see Eligible Children on page 3). Eligibility Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Some benefits may have additional eligibility requirements, which are outlined in the benefits summaries on Gapweb ( benefits > select U.S. Full-Time Benefits. The plans outlined in this summary plan description (SPD) may be updated or amended at any time. Important: Due to tax laws, Puerto Rico employees are not eligible to participate in certain benefit programs, including Flexible Spending Accounts. When you enroll, you may elect to cover your eligible dependents under the, Dental, Vision Plus, Dependent Life Insurance, and Accidental Death & Dismemberment plans. If you and your eligible dependents work for, you may not be covered as both an employee and as a dependent on the Gap Inc. medical plans or the Dependent Life Insurance plan. If you and your spouse/partner have children, they may not be covered on more than one employee s medical or Dependent Life Insurance plan. 1. A domestic partnership or civil union that is legally established under state law, or 2. A domestic partnership of the same or opposite sex, and you: Are in an exclusive, committed relationship that is expected to last indefinitely Are jointly responsible for each other s financial obligations and common welfare Share the same principal residence(s) with each other Eligible Dependents 2 Eligible Partners Partner means domestic partners and civil union partners. Your partner is eligible for coverage if you and your partner have: Are at least 18 years of age Are not legally married to another person, and Are not related by blood in a way that would prevent you from being legally married.

3 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Important: reserves the right to request proof of eligibility for any dependent you enroll. Failure to provide sufficient proof of eligibility may result in loss of coverage and denial of claims for your dependent. If it is determined that coverage was obtained through fraud or intentional misrepresentation, coverage may be rescinded retroactively with 30 days advance notice and you may be subject to discipline up to and including termination. Same-sex Spouse and Domestic Partner Benefits and Taxes Health coverage for a same-sex spouse or domestic partner is generally deducted from paychecks on an after-tax basis due to tax laws. You may also be subject to imputed income, which is a tax on the value of the -paid portion of the health coverage provided to your same-sex spouse or partner and his or her children. If your same-sex spouse or partner is your IRS qualifying relative or meets certain state exemptions, you may not have to pay imputed income. For more information, visit Gapweb ( benefits. See Federal Tax Rules for Tax-Favored Health Benefits on the right for more information about qualifying relatives. Health coverage for legally married same-sex spouses will be deducted from paychecks on a pre-tax basis for federal income tax purposes. Depending on where you live, state taxes may apply. Please contact your tax advisor for more information on the tax consequences of same-sex spouse and domestic partner coverage. Federal Tax Rules for Tax-Favored Health Benefits Benefits are not taxable for employees or their dependents (including partners and their children) who are either Qualifying Children or Qualifying Relatives as defined by the Internal Revenue Code (IRC). However, the plan permits coverage of people (such as partners and certain categories of eligible children) who may not satisfy either of these definitions. This means that the value of benefits provided to such individuals will be reported as taxable income to you (known as imputed income) and that your share of the premiums for that coverage must be paid on an after-tax basis. Consult your own tax advisor or see IRS Publication 502 at to determine if your dependent is eligible for tax-free health coverage. Contact Employee Services at , ext , if you have questions. Eligible Children Eligible children must be under age 26 and include your: Biological or legally adopted children, as well as children placed with you for adoption Stepchildren Children of enrolled partners Children for whom you are responsible to provide health coverage based on a qualified medical child support order (QMCSO), and Foster children, if you are the court-appointed guardian of the child. 3

4 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Disabled Children Your child who is disabled or becomes disabled while covered under the plans may continue to be covered at age 26 and beyond. The term disabled means that the child: Is incapable of self-sustaining employment because of intellectual or physical disability Is chiefly dependent upon you for support and maintenance, and Is unmarried. Coverage for a disabled child who has been covered under the plans before age 26 will continue after the child reaches age 26, as long as the above criteria are met. To continue a disabled child s coverage, proof of disability must be given to the insurer or claims administrator within 60 days after the child reaches age 26. The insurer or claims administrator will make the final determination regarding eligibility for coverage. For insurer or claims administrator information, see Claims Administrators and Plan Numbers on page 255. Note that the dependent criteria for the reimbursement of Flexible Spending Account expenses may differ from the dependent eligibility definitions above. When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Eligibility for the (EAP) Any member of your household can use the Employee Assistance Program (EAP). Coverage is not limited to eligible dependents. EAP coverage is automatic; you do not need to enroll yourself or your household members. 4 Qualified Child Support Orders (QMCSO) A QMCSO is any judgment, decree, or order, including a courtapproved settlement agreement, that is issued by: A domestic relations court or other court of competent jurisdiction, or An administrative process established under state law which has the force and effect of law in that state, and that Assigns to a child the right to receive health benefits for which a participant or beneficiary is eligible under the plan. The plan administrator determines what is qualified under the terms of ERISA and applicable state law. In general, only children who meet the eligibility requirements as dependents can be covered under a QMCSO. However, a QMCSO can also apply to children who: Were born out of wedlock Are not claimed as dependents on your federal income tax return, and Do not live with you. The order will be considered qualified if it meets the following conditions: The order creates or recognizes the child s right to participate in s health plan options as the dependent of an eligible employee. The order includes: 1. The name and last known address of the participant 2. The name and mailing address of each alternate recipient

5 Welcome 3. A description of the type of coverage to be provided or the manner in which the type of coverage will be determined Eligible Employees 4. The period to which the order applies, and Even if you do not enroll in benefits, you should designate a beneficiary on Gapweb for company-paid Basic Life Insurance benefits. Eligible Dependents 5. Each plan to which the order applies. If You Do Not Enroll Eligibility Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes The order does not require new types or forms of benefits unless specified by state law. If the QMCSO is qualified, will enroll the child and the eligible employee, if not already enrolled, in one of s health plan options as a dependent of the employee. The child will not have to provide proof of insurability to enroll. All other provisions, limitations, and exclusions of the plan will apply to the child as they would to any other participant. Appropriate deductions will be taken from the employee s pay as required to cover a child under the plan. To obtain a copy of the QMCSO procedures from the plan administrator, contact Employee Services at , ext Changing Your Benefit Elections Enrollment How to Enroll When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Enroll by your deadline on Gapweb ( benefits. Enrollment will close at midnight Central Time on the 30th day after your date of hire, rehire or job classification change to full-time. You can also enroll or change your benefits each year during the annual Open Enrollment, which is generally held in May. If you do not enroll in benefits by your deadline or during Open Enrollment each year, you will be automatically enrolled in default coverage. Newly hired or newly eligible employees: Default coverage includes benefits that are 100% paid by and cover only you, not your dependents: - Vision (basic) - Life Insurance (basic) - Short-Term (basic) - Long-Term (basic). Keep in mind that wage replacement benefits received through the basic Short-Term and Long-Term plans are considered taxable income. Also, once you are enrolled in default benefits, you may elect the Plus plans only during annual Open Enrollment, and your future disability benefits will be limited for conditions including pregnancy that exist before you elect coverage. Current employees: Default coverage includes the benefits that you currently have, with the exception of the Flexible Spending Accounts (FSAs). Default coverage may change in a new plan year if there are any differences in your benefits that are announced during Open Enrollment and you take no action. If you choose to enroll dependents in any of the benefit plans, you will be required to provide a Social Security number for each dependent to secure coverage. 5

6 Welcome After You Enroll Eligibility You should review your enrollment summary page at the end of the online enrollment process. This will give you an opportunity to make further changes before you log off. Be sure to print out a copy of your benefits enrollment summary page for your records. You may go online any time before your enrollment deadline to make changes. Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends An enrollment confirmation statement will be mailed after your enrollment deadline. The statement will list all your coverage, including company-paid and optional coverage you elected. When you receive the confirmation statement, make sure it reflects the coverage you selected. If you enroll in a medical or dental plan, you will receive ID cards for each plan. For UnitedHealthcare plans, you will receive a medical ID card from UnitedHealthcare and a separate prescription drug ID card from Express Scripts. If you have questions, call your health plan or on Gapweb. Reminder: A few weeks after you have enrolled, make sure that the appropriate deductions for your benefits are being taken from your paycheck. If deductions do not start promptly, notify Employee Services immediately at , ext to ensure coverage. Health Care, EAP, Health Care FSA If you decline enrollment for yourself or for an eligible dependent (including your spouse) because you have other medical coverage, you may be able to enroll yourself and your dependents in a medical plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing to that coverage). You may also generally drop coverage in a medical plan if you become eligible for coverage under another plan, including Medicaid or the Children s Health Insurance Program (CHIP). However, you must request to enroll or drop coverage within 30 days, ending at midnight Central Time, after you or your dependents become eligible for the other coverage or after the other coverage ends (or after the employer stops contributing toward other coverage). If you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents in a medical plan. You must enroll within 30 days, ending at midnight Central Time, after the marriage, birth, adoption, or placement for adoption. To request a special enrollment, you must process a life event on Gapweb ( benefits. Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 6 HIPAA Special Enrollment Notice Plan Coverage

7 Welcome Late Enrollment for Life Insurance Designating Your Beneficiaries Eligibility Late enrollment rules apply to coverage under the Supplemental Life Insurance or Spouse Life Insurance plans. If you do not enroll in these benefits when you are first eligible, you are considered a late enrollee and evidence of insurability (EOI) or proof of good health will be required to enroll. If approved, coverage takes effect on the approval date by the insurance company, subject to the pre-existing condition limitations (if any). EOI will not be required for enrollment in Spouse Life Insurance (for coverage amounts up to $25,000) in the case of marriage or start of a partnership. See You Get Married or Establish a Partnership on page 207. You should name a beneficiary for your Basic and Supplemental Life Insurance, AD&D, and Business Travel Accident plans. You may choose your spouse or partner, children, parents, a friend, estate, or trust as a beneficiary, and you may name one or multiple beneficiaries. Please complete your beneficiary elections when you enroll online for benefits coverage. Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Important: Late enrollment is not allowed for the medical, dental, vision, or Flexible Spending Account plans unless you have a qualified life event. Actively-at-Work Requirements You may change your beneficiary elections at any time on Gapweb ( benefits. If you haven t named a beneficiary, or if none of the named beneficiaries are living at the time the benefit is payable, payment will be made in this order: 1. To the executors or administrators of your estate 2. To your spouse if there is no executor or administrator 3. To your children in equal shares if you have no spouse Mandated Coverage for Hawaii Employees 4. To your parents in equal shares if you have no children 5. To your brothers or sisters in equal shares if your parents are deceased. Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 7

8 Welcome When Coverage Begins Eligibility Full-Time Employees Eligible Employees Coverage under the following plans will be effective on your eligibility date: Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll Dental Vision Group Life Insurance Late Enrollment for Life Insurance Short-Term and Long-Term plans Beneficiaries When Coverage Begins Health Care or Dependent (Day) Care Flexible Spending Account (FSA) plans, and Full-Time Employees (EAP). Part-Time or Seasonal Employees Your eligibility date is the first of the month following the date of the events listed below or on the first of the month if the event occurs on that date: Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Your hire date Your rehire date The date you are classified as full-time, subject to plan limitations and exclusions, or The date you experience a life event for health coverage (note: in the case of birth, adoption or legal guardianship, changes you make take effect on the date of birth, adoption or legal guardianship). For other benefits, you must be activelyat-work in order for coverage to be effective. See Actively-atWork Requirements Life, AD&D and Coverage on page 9. If your hire date is entered into the payroll system outside of the 30-day enrollment period, you will be given an additional 15 days to enroll, ending at midnight Central Time, from the date on 8 For example: If your hire or full-time status date is May 1 and the status change is not entered into the payroll system until July 15, your effective date would be August 1 (the first of the month following the date your status change was entered). Part-Time or Seasonal Employees Who Experience a Status Change to Full-Time After You Enroll Actively-at-Work Requirements which your hire date was entered. Your coverage effective date for benefits will be the first of the month following the date your hire date was entered. If your status changes to full-time from part-time or seasonal classification, you are eligible to participate in the benefits programs on the first of the month following the date your classification changes to full-time or the first of the month if the change occurs on that date. See the Directory on page 205 for more information. You must complete your online enrollment within 30 days, ending at midnight Central Time, of your job classification change to fulltime. If you do not complete your enrollment within the required timeframe, you cannot enroll in coverage until the next Open Enrollment or if you experience a life event. If your classification to full-time is entered into the system outside of the 30-day enrollment period, you will be given an additional 15 days, ending at midnight Central Time, from the date on which your classification to full-time was entered, to enroll. Your coverage effective date for benefits will be the first of the month following the date your classification to full-time was entered. For example: If your job classification changes from part-time to full-time on May 1 and the status change is not entered into the payroll system until July 15, your effective date would be August 1 (the first of the month following the date your status change was entered).

9 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Please notify Employee Services at , ext , if you need assistance enrolling in benefits. Actively-at-Work Requirements Life, AD&D and Coverage You must be actively at work on your eligibility date for your Basic, Supplemental or Dependent Life Insurance, Short-Term and Long-Term, and Accidental Death & Dismemberment (AD&D) coverage to take effect. Actively at work means you are performing all the material duties of your job at your usual place of business or at any other place your job requires you to go. If you are not actively at work on your eligibility date, your coverage will go into effect once you return to work. Mandated Coverage for Hawaii Employees You are eligible to participate in the medical plans on the date you are classified as a full-time employee in Hawaii. You will be automatically enrolled in the UnitedHealthcare Hawaii PPO medical plan for yourself only. You may enroll your dependents or change your coverage to another available medical plan by enrolling on Gapweb within 30 days, ending at midnight Central Time, of your date of hire, rehire or job classification change to full-time. If you have other medical coverage, or are otherwise exempt from the state of Hawaii s health coverage requirements, you may terminate your coverage by completing and returning the Employee Notification to Employer form (Form HC-5) to the Benefits Department. You will receive the Form HC-5 with your benefit enrollment package. The Form HC-5 is also available from the state of Hawaii s Department of Labor and Industrial Relations at You must complete a new Form HC-5 each January 1 to remain exempt from mandatory coverage. If your other coverage or exemption ends, notify Employee Services immediately at , ext You must enroll in a medical plan effective on the date your other coverage ends. If you are disabled and unable to work, your medical coverage will continue for up to three months after the month in which you became disabled. You must continue to pay your contribution during this period. Premiums will be deducted from your disability checks while you are on a leave of absence. If Gap Inc. is unable to deduct benefits premiums from your disability checks, any past-due contributions will be deducted upon your return from work. When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 9

10 Welcome Making Changes Eligibility Changing Your Benefit Elections Eligible Employees, Dental, Vision, and Flexible Spending Account Plans You can make changes to your medical, dental, vision, and Flexible Spending Account plan elections: Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident During the annual Open Enrollment (with changes effective July 1) If you or your dependent has a life event (as defined below) that is consistent with the change in coverage. You must complete your changes on Gapweb ( benefits within 30 days, ending at midnight Central Time, from the date of the life event. You may also make changes to your medical coverage within 30 days, ending at midnight Central Time, if you experience a special enrollment event. Supplemental and Dependent Life Insurance, AD&D Insurance and You can make changes to your Supplemental and Dependent Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance elections during Open Enrollment or if you have a life event: If you are enrolled in Supplemental Life Insurance, you may increase your coverage by one level, without having to provide evidence of insurability (EOI), to up to three times your annual base pay. For election amounts greater than three times your annual base pay, you must submit EOI. If you have previously waived Supplemental Life coverage, you may increase your supplemental coverage by one level without EOI. Any other election requires EOI. 10 If you are enrolled in Dependent Life Insurance for a spouse or partner, you may increase your coverage without having to provide EOI, up to the lesser of 50% of your Basic Life Insurance amount or $25,000. EOI is required for amounts of insurance greater than $25,000. If you previously waived Dependent Life Insurance, any election requires EOI (except in the event of marriage or start of a partnership, for coverage amounts up to $25,000). See You Get Married or Establish a Partnership on page 207. You can make changes to your Short-Term and Long-Term coverage only during Open Enrollment: If you enroll in the Plus plans, your future disability benefits will be limited to the basic level for pre-existing conditions including pregnancy for the first 12 months of coverage. The following are considered life events that may allow you to make changes to your pre-tax benefit elections, which include medical, dental or vision coverage, and Flexible Spending Accounts (FSAs). See the Directory on page 205 for a detailed list of life events. Legal marital status. An event that changes your legal marital status, including marriage, divorce, death of a spouse, legal separation, or annulment. Partnership status. An event that changes the status of your partnership, including establishment or termination of a partnership, or death of your partner. Number of children. An event that changes your number of children, including birth, death, adoption, and placement for adoption.

11 Welcome Eligibility Eligible Employees Employment status. An event that changes your, your spouse s, or your child s employment status, resulting in a gain or loss of eligibility for coverage. Examples include: Eligible Dependents - Beginning or terminating employment Child Support Orders - Starting or returning from an unpaid leave of absence Enrollment How to Enroll - Changing from part-time to classified full-time employment or vice versa If You Do Not Enroll - A change in worksite. After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Child eligibility status. An event that causes your children to become eligible or ineligible for coverage because of age or similar circumstances. Residence. A change in your or your dependent s place of residence, resulting in a gain or loss of eligibility for coverage. Consistency Requirements According to federal law, the change you make to your benefit elections must be due to and consistent with your life event. Your life event and corresponding change in election must meet both of the following requirements: Effect on eligibility. Except for the Dependent (Day) Care FSA, the life event must have an effect on eligibility for coverage under a -sponsored plan or under a plan sponsored by the employer of your spouse or other dependent. Eligibility for coverage is affected if you become eligible (or ineligible) for coverage or if the life event results in an increase or decrease in the number of your dependents who may benefit from coverage under the plan. Corresponding election change. The election change must correspond with the life event. For example, if your dependent loses eligibility for coverage under the terms of a medical plan, you may cancel medical coverage only for that dependent. 11 For the Dependent (Day) Care FSA, the life event must affect the amount of dependent care expenses eligible for reimbursement. (For example, your child reaches age 13, and day care expenses are no longer eligible for reimbursement.) Changes in Coverage or Cost In some instances, you can make changes to your elections for other reasons, such as mid-year events affecting your cost or coverage, as described below. These rules do not apply to the Health Care FSA. Changes in Coverage If adds or eliminates a plan option in the middle of the plan year, or if -sponsored coverage is significantly reduced or ends, you can elect different available coverage for yourself and/or eligible dependents in accordance with IRS regulations (if the other plan option permits). Coverage events may also include election opportunities allowed under other Gap Inc. plans. Here are some examples: If there is a reduction under a plan option that reduces coverage to participants overall, in general, participants enrolled in that plan option may revoke their election and elect coverage under another option providing similar coverage. If adds another plan option mid-year, participants can drop their existing coverage and enroll in the new plan option. You may also enroll yourself and/or eligible dependents in the new plan option even if not previously enrolled for coverage at all (if that plan option permits). If another employer s plan allows you, your spouse, or your child to make an election change during that plan s annual Open Enrollment period, you may make a corresponding mid-year election change.

12 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident If another employer s plan (for example, your spouse s employer) allows you, your spouse, or your child to change his or her health plan elections in accordance with IRS regulations, you may make a corresponding mid-year election change to your coverage. If you or your dependents become eligible for medical coverage under Medicaid or the Children s Health Insurance Program (CHIP), you may make a corresponding mid-year election change to your coverage. If your or your dependent s Medicaid or Children s Health Insurance Program (CHIP) coverage terminates as a result of loss of eligibility, you may make a corresponding mid-year election change to your coverage. You must contact within 30 days, ending at midnight Central Time, of termination. Changes in Cost If your cost for coverage increases or decreases significantly during the plan year, you may make a corresponding election change. For example, you may elect another plan option with similar coverage (if that plan option permits), or drop coverage if no other coverage is available. In addition, if there is a significant decrease in the cost of a plan option during the year, you may enroll in that plan option, even if you declined to enroll in that plan option earlier. Any change in the cost of your plan option that is not significant will result in an automatic increase or decrease, as applicable, in your share of the total cost. For example, if you change your dependent care provider mid-year, you may change your Dependent (Day) Care FSA contributions to correspond with the new provider s charges. If your dependent care provider (other than a provider who is your relative) raises or lowers its rates mid-year, you may increase or decrease your contributions. Additionally, if your dependent care provider 12 reduces or increases the number of hours that it provides care, you may make a corresponding change to your Dependent (Day) Care FSA election. Special Note Regarding Partner Coverage The events qualifying you to make a mid-year election change described in this section also apply to events related to your same-sex spouse/partner or his or her tax dependents. However, IRS rules generally do not permit you to make a mid-year change on a pre-tax basis for such events unless they involve tax dependents. Special enrollment rules that apply to spouses will also apply to partners. The plan administrator may from time to time establish and communicate a maximum number of changes that can be made to Dependent (Day) Care FSA elections in a particular plan year. HIPAA Special Enrollment for Plan Coverage You and your eligible dependents may also enroll in a medical plan outside of annual Open Enrollment if you lose coverage or acquire newly eligible dependents, as long as you enroll yourself and/or your dependents within 30 days, ending at midnight Central Time, of one of the events described below. These are similar to life events described above. Loss of other coverage. This rule applies if you meet the following conditions: - You (or your dependents) were covered under other medical coverage (for example, under another employer s medical plan) when coverage was offered to you

13 Welcome - You (or your dependents) lose other coverage because: Eligibility You or your dependents exhaust rights to COBRA coverage, Eligible Employees The employer s contributions to the other coverage stop, or Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D You or your dependent is no longer eligible under that plan. Loss of eligibility does not include a loss due to a failure to timely pay premiums or termination of coverage for cause. - You or your covered dependents lose medical coverage under Medicaid, CHIP, or a state premium assistance program. Acquiring new dependents. When you acquire a newly eligible dependent (through marriage, birth, partnership, adoption, or placement for adoption), you may enroll yourself, your spouse or partner and your eligible children in a medical plan. You must enroll within 30 days, ending at midnight Central Time, of the date you acquire the new dependent. Coverage will start on the date of birth, adoption or placement for adoption, as long as the child is enrolled within 30 days. Medicare or Medicaid Entitlement You may change an election for health coverage mid-year if you, your spouse, or your child becomes entitled to or loses eligibility for coverage under Medicare or Medicaid. However, you are limited to reducing your medical coverage only for the person who becomes entitled to Medicare or Medicaid, and to adding medical coverage only for the person who loses eligibility for Medicare or Medicaid. and Business Travel Accident 13

14 Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Medicaid and the Children s Health Insurance Program (CHIP) Free or Low-cost Health Coverage for Children and Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, access the website listed in the next column or contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office by calling 877.KIDS.NOW, or visit to apply. If you qualify, ask if there is a program to help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 30 days, ending at midnight Central Time, of being determined eligible for premium assistance. Special enrollment rules that apply to spouses will also apply to partners. For more information refer to: ebsa/pdf/chipmodelnotice.pdf. Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Judgment, Decree or Order You may change health plans if a judgment, decree or order requires health coverage for your child, including a foster child. The order must have resulted from a divorce, legal separation, annulment, or change in legal custody, and must meet the requirements of a Qualified Child Support Order (QMCSO). You may change your health plan election to provide coverage for the eligible child if the order requires coverage to be provided under the plan. You may also cancel coverage for the child if the order requires your spouse, former spouse, or other individual to provide coverage for the child, but only if coverage for the child is actually provided. Proof of coverage may be required. 14 Making Your Election Changes Remember: To take advantage of the life event rules, you must make your election change within 30 days of the event, ending at midnight Central Time. Enroll or elect additional coverage on Gapweb ( benefits. reserves the right to request documents that support your request to change coverage due to a life event.

15 Welcome When Coverage Ends Eligibility, Dental, Vision, (EAP), and the Health Care FSA Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Coverage under the medical, dental and vision plans, the (EAP), and the Health Care FSA ends at midnight on the earliest of: The last day of the month in which your employment with Gap Inc. ends. - For example, if your termination date is July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) become ineligible. - For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. If you or a member of your household started counseling with an EAP counselor when your coverage ends, you may continue to receive clinically appropriate counseling for up to the maximum visits allowed by the plan, regardless of whether you elect COBRA. The UnitedHealthcare medical plans, dental plans, vision plans, EAP, and Health Care FSA do not have options to continue coverage under individual policies after your active or COBRA coverage ends. If you are enrolled in an HMO, contact the HMO for information regarding individual policy options. Dependent (Day) Care FSA Your participation in the Dependent (Day) Care FSA ends at midnight on the earliest of: The last day of the month in which your active employment with ends, including termination and leave of absence. The last day of the month you become ineligible. The date the plan(s) terminate. The date the plan terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). The last day of the month you fail to make a required contribution under the terms of the plan. You may have the opportunity to continue your medical, dental, vision, EAP, and Health Care FSA coverage for a limited time under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Please see Continuation of Coverage Under COBRA on page 241 for COBRA information. You may submit claims for the expenses you have incurred at any time during the plan year, including expenses incurred after your termination date, up to the amount remaining in your account when you leave. All claims must be submitted before September 30 following the end of the plan year. 15 If your employment termination date or status change from fulltime to part-time is entered into the payroll system more than 44 days after your termination or status change date, coverage will end at the end of the month in which your change was entered. COBRA notifications will be sent to you effective the day after coverage ends.

16 Welcome Life Insurance and AD&D Coverage Eligibility Coverage for all persons covered by Basic Life Insurance, Supplemental Life Insurance, Dependent Life Insurance, and Accidental Death & Dismemberment (AD&D) Insurance ends at midnight on the earliest of: Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident The last day of the month in which your employment with ends. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) becomes ineligible. - For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July 31. and Business Travel Accident Coverage Coverage for all persons covered by Short-Term, LongTerm, and Business Travel Accident plans ends at midnight on the earliest of: The day your employment with ends. The day you become ineligible. The date the plan(s) terminates. The date you fail to make a required contribution under the terms of the plan(s). - However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. The date the plan(s) terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). When coverage ends, you may be able to convert your Basic Life Insurance, Supplemental Life Insurance, or AD&D Insurance without evidence of insurability (EOI) to an individual policy if you apply for conversion and pay your first premium within 31 days of the termination of your coverage(s). 16 Your Life Insurance coverage is also portable. You can elect to keep your current level of coverage (up to the maximum stated in Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance starting on page 168) through age 70 if you terminate employment for any reason other than disability, if you become ineligible for coverage, or if your employment status changes to part-time or seasonal. Call Minnesota Life at to request an application. You must apply within 31 days of the end of your coverage to be eligible for this option.

17 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Plans offers you medical coverage with flexibility and choice. Depending on your location, you have a choice of medical plan options: UnitedHealthcare Plans: Health Reimbursement Account (HRA) plans HRA or HRA Plus (all locations except Hawaii & Puerto Rico) Important definitions and phrases can be found in Terms You Should Know on page 106. It s a good idea to take a minute to look up a term or phrase you do not know so you better understand how the plan works. Hawaii Preferred Provider Organization (PPO) plan (Hawaii only) Out-of-Area plan (available if your address is not within a reasonable distance from network providers as determined by UnitedHealthcare) Kaiser Health Plans: Kaiser California Health Maintenance Organization (HMO) plan (California only) Kaiser Hawaii Health Maintenance Organization (HMO) plan (Hawaii only) MVP Health Maintenance Organization (HMO) plan (Fishkill, NY only) MCS medical plan (Puerto Rico only) All of the plans cover a wide range of medical services and supplies. You choose the coverage that s right for your personal situation. 17

18 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work UnitedHealthcare Plans HRA and HRA Plus Plans Plans at a Glance How the HRA Plans Work Using the Plans The HRA plans give you direct access to your health care dollars and the flexibility to make choices that meet your needs. The plans offer a variety of tools, resources and support, so you can make informed decisions on what works best for you and your family. The HRA plans provide covered preventive care services at no cost to you and a safety net for major health care expenses. The HRA plans are health plans with two parts: Other Important Information A comprehensive medical plan, plus Kaiser California HMO Plan A health reimbursement account (HRA) funded by Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Kaiser Hawaii HMO Plan MVP HMO Plan Below is an overview of each of these components. For additional plan details, see Using the HRA and HRA Plus Plans on page 26. Preventive Care Preventive care is the foundation of the HRA plans and is covered at 100%. All eligible preventive services (physicals, routine tests, well-baby care, and women s preventive health care including contraceptives) are free to you. Regular preventive care can help identify and prevent health issues before they become problems or chronic conditions. 18 The health reimbursement account is only available if you enroll in an HRA plan. You cannot elect a health reimbursement account separately. It s a component of the HRA medical plans and is funded only by You can, however, enroll in and contribute to a Health Care Flexible Spending Account (FSA), regardless of which medical plan you enroll in. The Health Care FSA allows you to save money on a pre-tax basis to pay for eligible out-of-pocket health care expenses. Comprehensive Coverage The HRA plans provide comprehensive medical coverage, including: Preventive care at no cost to you. Access to UnitedHealthcare s extensive network of doctors and hospitals. MCS Plan (Puerto Rico) Important Plan Notices Important! Flexibility of in- and out-of-network coverage, with higher benefits (and lower out-of-pocket expenses) when you use innetwork providers. You also don t need to file a claim when you use in-network providers. Prescription drug coverage through Express Scripts. A plan year (July 1 to June 30) deductible that may be offset by your HRA dollars, which are deposited by into your health reimbursement account. You pay the remainder of the deductible.

19 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan After the plan year deductible is met, you pay co-insurance (a share of the cost for services) and pays the rest. receive in the next year. You can use your HRA dollars to pay all or a portion of your deductible and co-insurance. An out-of-pocket maximum that limits what you pay each plan year (July 1 to June 30) and protects you from the expense of a catastrophic illness or injury. If your employment terminates or you retire, your HRA dollars will be forfeited and any remaining HRA dollars will revert back to, unless you elect COBRA coverage. If you elect COBRA coverage, any remaining HRA dollars can be used to pay your medical expenses while COBRA coverage is in effect. Health Reimbursement Account (HRA) At the beginning of each plan year, makes a contribution to your health reimbursement account, called HRA dollars. The amount the company contributes depends on: The plan you select HRA or HRA Plus, and The coverage category you choose. You cannot make contributions to your health reimbursement account it is funded solely from s general assets. HRA dollars are also forfeited if you cancel your coverage in a HRA plan. Note: Any reimbursement you receive through your health reimbursement account or Health Care FSA cannot be used as a medical expense deduction on your federal income tax return. At the end of the plan year, your unused HRA dollars will roll over to the next plan year and will be added to the HRA dollars you MCS Plan (Puerto Rico) Important Plan Notices 19

20 UnitedHealthcare Plans The HRA Plans: Step-by-Step HRA and HRA Plus Plans Here s how the HRA and HRA Plus Plans work and how you receive benefits for covered medical services: How the Plans Work One Plans at a Glance Using the Plans Out-of-Area Plan Your eligible medical expenses are paid by your health reimbursement account first. contributes HRA dollars to your health reimbursement account each plan year: Hawaii PPO Plan HRA dollars contributed by Additional Information for UnitedHealthcare Plans HRA Plan HRA Plus Plan What s Covered Employee $200 $700 Employee + spouse/partner or Employee+ child(ren) $300 $1,050 Other Important Information Employee + family $400 $1,400 Kaiser California HMO Plan Your HRA dollars can be used for eligible medical expenses, such as your deductible and co-insurance amounts. Kaiser Hawaii HMO Plan HRA dollars cannot be used to pay for prescription drug expenses. MVP HMO Plan Preventive care is free, so HRA dollars are never used for these services. MCS Plan (Puerto Rico) You can use a Health Care FSA to help pay your share. See page 153 for more information. Important Plan Notices 20

21 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Two When you receive a covered non-preventive service, you must first satisfy the deductible, which is the amount you pay before the plan starts paying benefits: Plans at a Glance Using the Plans Annual Deductible Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices HRA Plan HRA Plus Plan Employee $1,200 $1,200 Employee + spouse/partner or Employee+ child(ren) $1,800 $1,800 Employee + family $2,400 $2,400 Your deductible is paid first with your available HRA dollars. If you use all of your HRA dollars, you pay the rest out of your pocket. Unused HRA dollars carry over to the following plan year, providing additional resources to help cover your costs. You can use a Health Care FSA to help pay your share. See page 153 for more information. Three After you meet the deductible, you and share the cost of any non-preventive services. Your share is called co-insurance and varies depending on the plan you choose and whether you use in- or out-of-network providers: Most covered services Amount you pay (co-insurance) HRA Plan HRA Plus Plan In-network 30% 20% Out-of-network 50% 40% If you have HRA dollars, they will be used first to pay your co-insurance. You pay any remaining amount. You can use a Health Care FSA to help pay your share. See page 153 for more information. For your protection, there is a limit on how much you pay out of your own pocket each plan year, called the out-ofpocket maximum. If the amount you pay in deductible and co-insurance (including your HRA dollars) reaches the out-of-pocket maximum (shown on the following page), your eligible expenses are covered at 100% for the rest of the plan year. 21

22 UnitedHealthcare Plans HRA Plan Options at a Glance HRA and HRA Plus Plans The charts below provide an overview of the HRA medical plans. For details about covered services, including benefit limitations, see What s Covered Under the UnitedHealthcare Plans on page 60 and Under the UnitedHealthcare Plans on page 84. How the Plans Work Plans at a Glance Using the Plans Plan Features and Covered Services Out-of-Area Plan Feature HRA Plan HRA Plus Plan Employee $200 $700 Employee + spouse/partner or Employee + child(ren) $300 $1,050 Employee + family $400 $1,400 Hawaii PPO Plan Health reimbursement account (funded each plan year by ) Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Deductible Employee $1,200 $1,200 Kaiser California HMO Plan Employee + spouse/ partner or Employee + child(ren) $1,800 $1,800 Kaiser Hawaii HMO Plan Employee + family $2,400 $2,400 In-network pays 70%; you pay 30% of discounted rates pays 80%; you pay 20% of discounted rates Out-of-network pays 50%; you pay 50% pays 60%; you pay 40% MVP HMO Plan Co-insurance (after the deductible is met) MCS Plan (Puerto Rico) Important Plan Notices Out-of-pocket maximum (the most you pay during the plan year, including the deductible) Employee In-network: $3,950 Out-of-network: $7,700 HQ/Field employees: In-network: $2,800/Out-of-network: $4,900 LNE employees: In-network: $2,000/Out-of-network: $4,000 Employee + spouse/partner or Employee + child(ren) In-network: $5,800 Out-of-network: $11,400 HQ/Field employees: In-network: $4,200/Out-of-network: $7,350 LNE employees: In-network: $3,350/Out-of-network: $7,350 Employee + family In-network: $7,900 Out-of-network: $15,400 HQ/Field employees: In-network: $5,600/Out-of-network: $9,800 LNE employees: In-network: $4,000/Out-of-network: $9,200 Note: HQ/Field = Headquarters, Field, and Exempt Logistics; LNE = Non-Exempt Logistics and GID Ohio 22

23 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Covered Services What the HRA Plan pays What the HRA Plus Plan pays In-network Out-of-network* In-network Out-of-network* 100% 100% 100% 100% Doctor Office Visits 70% 50% 80% 60% Diagnostic Lab Work, X-rays and Radiology 70% 50% 80% 60% Maternity Pre-natal Office Visits 100% 100% 100% 100% 70% 50% 80% 60% Preventive Care (not subject to deductible) Plans at a Glance Includes: Using the Plans Breast Pumps Out-of-Area Plan Contraceptive Devices (covers device, fitting and removal) Tubal Ligation Hawaii PPO Plan Travel Immunizations Additional Information for UnitedHealthcare Plans Outpatient Services (after deductible) What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Hospital Services (after deductible) Inpatient and Outpatient Surgery Rehabilitation 70% 50% 80% 60% Hospital Stay 70% 50% 80% 60% Acupuncture (up to 20 visits/plan year) 70% 50% 80% 60% Allergy Diagnosis and Treatment 70% 50% 80% 60% Ambulance Emergency: 70%/Non-emergency: 50% Emergency: 80%/Non-emergency: 50% Chiropractic Care/Spinal Treatment 70% 50% 80% 60% Durable Equipment 70% 50% 80% 60% Emergency Room Emergency: 70%/Non-emergency: 50% Emergency: 80%/Non-emergency: 50% Enteral Feeding 60% 50% 80% 80% Family Planning 70% 50% 80% 60% Other Services (after deductible ) (up to 20 visits/plan year) Vasectomy Abortion, Therapeutic or Voluntary * The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. 23

24 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Covered Services What the HRA Plan pays What the HRA Plus Plan pays In-network Out-of-network* In-network Out-of-network* Foot Orthotics 70% 50% 80% 60% Gender Identity Disorder Treatment 70% 50% 80% 60% Hearing Benefit (up to $3,000/ three years) 70% 50% 80% 60% (up to one gender reassignment surgery per lifetime, which Out-of-Area Plan Hawaii PPO Plan may include several staged procedures) Additional Information for UnitedHealthcare Plans Home Health Care (up to 100 visits/plan year) 70% 50% 80% 60% Hospice (respite care maximum is five days in a 30-day period) 70% 50% 80% 60% What s Covered Infertility Services 70% 50% 80% 60% 70% 50% 80% 60% Obesity Surgery 70% Not Covered 80% Not Covered Podiatry (for severe systemic disease) 70% 50% 80% 60% Other Important Information ($7,500 lifetime maximum for medical and separate lifetime maximum of $2,500 for prescription drug benefit. Requires enrollment in the Reproductive Resource Services Program.) Kaiser California HMO Plan Newborn Care (inpatient) Kaiser Hawaii HMO Plan (newborns are not eligible beyond the first day if the employee MVP HMO Plan MCS Plan (Puerto Rico) does not enroll them in coverage) Important Plan Notices Pre-Admission Testing 70% 50% 80% 60% Pregnancy (Maternity) Services 70% 50% 80% 60% (post-natal office visits, ultrasound and delivery) 70% 50% 80% 60% 70% 50% 80% 60% Preventive services related to pregnancy will be covered as preventive. Private Duty Nursing (20-visit lifetime maximum) Prosthetic Devices * The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. 24

25 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Covered Services Radiologists, Anesthesiologists, Pathologists & Lab (RAPL) Plans at a Glance What the HRA Plan pays What the HRA Plus Plan pays In-network Out-of-network* In-network Out-of-network* 70% 50% 80% 80% 70% 50% 80% 60% 70% Not covered 80% Not covered 70% 50% 80% 60% (Includes charges for the cost and administration of Using the Plans anesthesia. Eligible expenses do not apply if using out- Out-of-Area Plan of-network providers. Applies to inpatient or ambulatory services.) Hawaii PPO Plan Skilled Nursing Facility/Inpatient Rehabilitation Additional Information for UnitedHealthcare Plans Facility Services What s Covered Other Important Information Transplant Services (if services rendered by a Designated Facility) Urgent Care Mental Health and Substance Use Disorder (after deductible) Kaiser California HMO Plan Inpatient and Outpatient Kaiser Hawaii HMO Plan Mental Health 70% 50% 80% 60% Substance Use Disorder 70% 50% 80% 60% MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices * The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. Prescription Drug Coverage Through Express Scripts Your pharmacy benefits are separate from your medical benefits and are administered through Express Scripts. See Prescription Drug Plan on page 117 for details. Questions regarding your pharmacy benefits should be directed to Express Scripts at or 25

26 UnitedHealthcare Plans Using the HRA and HRA Plus Plans HRA and HRA Plus Plans When you need medical care, you have a choice: How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices You can go to any in-network provider who participates in the UnitedHealthcare Choice Plus network. Providers within the network have agreed to charge negotiated fees to their patients. This means when you use an in-network provider, your out-ofpocket expenses are lower. You can go to any out-of-network provider who does not participate in the UnitedHealthcare Choice Plus network, but your out-of-pocket expenses will likely be higher. In addition, you are responsible for any amount charged above the plan s maximum allowable amount for services. The UnitedHealthcare Choice Plus network is made up of licensed doctors, nurses, hospitals, labs, and other health care providers selected by the claims administrator who have agreed to provide their services at negotiated rates. These providers are independent contractors and have no relationship to Member Identification Card Your UnitedHealthcare ID card must be shown every time you receive health care services. Your ID card may be used only by you and your enrolled dependents. If your ID card is lost or stolen or if you need additional ID cards, visit or call You will receive a separate ID card for your pharmacy benefits through Express Scripts. Using In-Network Providers When you visit an in-network provider, you receive the maximum benefits available through the HRA plans: Preventive care is covered at 100% with no annual dollar limit. Your out-of-pocket costs will generally be lower because innetwork providers have agreed to charge patients negotiated fees this means your HRA dollars will last longer. Your co-insurance for services is lower. You will not be charged more than the plan allows for a covered service. You do not need to file a claim form. Finding a Network Provider UnitedHealthcare s website, lists the health care professionals and facilities in UnitedHealthcare s network. While network status may change from time to time, has the most current source of network information. To find a provider, log in and select Find a Doctor. Using Out-of-Network Providers If you choose to see an out-of-network provider, you will receive a lower level of benefits: Preventive care is still covered at 100% of eligible expenses. Your HRA dollars may be used up more quickly because you do not receive discounted rates. Your co-insurance for services is higher. 26

27 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work You pay for any amount that exceeds what the plan allows for a covered service. You are required to pay the full cost of your medical care first, then complete and file a claim form to receive reimbursement. Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices When Out-of-Network Care May Be Covered at the In-Network Level If specific covered health services are not available from an innetwork provider, you may be eligible to receive in-network level benefits from an out-of-network provider. You or your physician can contact UnitedHealthcare at and request consideration for a network gap exception. UnitedHealthcare has the discretion and authority to determine on the plan s behalf whether a treatment or supply is a covered health service and how the eligible expense will be covered under the plan. For in-network benefits, you are not responsible for any difference between the eligible expense and the amount the provider bills, unless you agreed to reimburse the provider for such services. For out-of-network benefits, you are responsible for paying directly to the provider any difference between the amount the provider bills you and the amount the plan will pay for eligible expenses. Exceptions to this include fees that are negotiated by an out-ofnetwork provider and either the claims administrator or one of its vendors, affiliates, or subcontractors. Amounts charged over eligible expenses do not apply towards your deductible or outof-pocket maximum. Eligible expenses are based on either of the following: When covered health services are received from out-of-network providers, the claims administrator calculates eligible expenses based on available data resources of competitive fees in that geographic area, unless you received services as a result of an emergency or as otherwise arranged through the claims administrator. In this case, eligible expenses are the fee(s) that are negotiated with the out-of-network provider. Percentages and benefits are considered for covered health care supplies and services only. Benefits are determined at the time your claim is received. Eligible Expenses Eligible expenses are charges for covered health services that are provided while you are covered under the plan as defined below: For: Eligible expenses are based on: In-network benefits Contracted rates with the provider. Out-of-network benefits Negotiated rates agreed to by the out-ofnetwork provider and either UnitedHealthcare or one of its vendors, affiliates, or subcontractors. Selected data resources which, in the judgment of the claims administrator, represent competitive fees in that geographic area, and fee(s) that are negotiated with the provider. Note: These provisions do not apply if you receive covered health services from an outof-network provider during an emergency. In that case, eligible expenses are the amounts billed by the provider, unless UnitedHealthcare negotiates lower rates. When covered health services are received from in-network providers, eligible expenses are the contracted fee(s) with that provider. 27

28 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices has given UnitedHealthcare the discretion and authority to decide whether a treatment, service or supply is covered and how the eligible expense will be covered by the plan. For out-of-network benefits, you are responsible for paying the provider any difference between the amount the provider bills you and the amount the plan will pay for eligible expenses. Amounts charged over eligible expenses do not apply toward your deductible or out-of-pocket maximum. Possible Limitations on Provider Use If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a network provider to coordinate all of your future covered health services. If you do not select a network provider within 31 days of the date you are notified, UnitedHealthcare s Personal Health Support will select an in-network physician for you. In the event that you do not use the network provider to coordinate all of your care, any covered health services you receive will be paid at the out-of-network benefits levels. For more information, see Personal Health Support on page 56. Coverage While Traveling Abroad The plan pays benefits for covered persons while traveling outside the United States. Eligible expenses for non-emergency services incurred while outside the United States are reimbursed at the out-of-network benefit level and are subject to the annual deductible. Emergency services received outside the United States will be paid at the in-network benefit level, subject to the annual deductible. If you receive treatment while traveling outside the United States, you will have to pay for the services up-front and then submit a claim form along with the receipt and an itemized bill from the provider. For details on the procedures for filing a claim, see on page 31. If you have 28 any questions about benefits while traveling abroad, please call UnitedHealthcare at the toll-free number on your ID card. Paying for Care Paying for your care with the HRA plans is a little different than with traditional medical plans. This section provides details on the HRA plans, your HRA dollars and other plan features. Health Reimbursement Account and Your HRA Dollars contributes HRA dollars to your health reimbursement account each plan year. The health reimbursement account allows to allocate a specified amount of HRA dollars into your account each plan year in your name. The amount of HRA dollars allocated to your health reimbursement account each plan year is determined by and depends on the coverage level you elect, as shown below. HRA dollars Coverage Level HRA Plan HRA Plus Plan Employee $200 $700 Employee + spouse/partner or $300 $1,050 $400 $1,400 Employee + Child(ren) Employee + family You are not permitted to make any contributions to your health reimbursement account. Your HRA dollars will be used first to pay for eligible expenses that apply toward meeting your annual deductible. Your HRA dollars may only be used for health services that are covered by the HRA plans as defined in this SPD. If you do not spend all your HRA dollars in a plan year, and you continue enrollment in the HRA for the following plan year, any remaining account balance will roll over into your account for the next plan year.

29 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Note: If UnitedHealthcare processes a claim at the beginning of a plan year for expenses incurred in the prior plan year, the plan will automatically use available HRA dollars remaining in your account from the prior plan year. Claims with expenses incurred in the current plan year will automatically use available HRA dollars you received in the prior plan year and the current plan year. Annual Deductible The annual deductible is the amount of eligible expenses you must pay each plan year (July 1 June 30) for covered health services before the plan begins covering your non-preventive costs. Eligible expenses charged by both in-network and out-of-network providers are applied toward both the in-network and outof-network deductibles for all levels of coverage. Prescription drug expenses do not apply toward the deductible. For more information on deductible amounts, see HRA Plan Options at a Glance on page 22. The HRA dollars you receive from are automatically applied toward your deductible. The remainder of the deductible is paid by you. Co-insurance Once the plan s deductible has been met, your co-insurance starts for some covered health services. Co-insurance is the sharing of costs between you and There is a percentage of eligible expenses that pays and a percentage that you are responsible for paying. Keeping Track of Your HRA Dollars You can keep track of your HRA dollars by logging on to by calling the toll-free number on the back of your ID card, or by checking your monthly Health Statement from UnitedHealthcare. Out-of-Pocket Maximum The annual out-of-pocket maximum is the most you will pay each plan year for covered health services. There are separate innetwork and out-of-network individual and family out-of-pocket maximums. For more information, see HRA Plan Options at a Glance on page 22. Once the amount you pay in annual deductible and co-insurance (including your HRA dollars) in a plan year reaches the annual maximum, the plan pays 100% of remaining eligible expenses through the end of the plan year. The out-of-pocket maximum applies to all covered health services under the HRA plans, except for prescription drugs. However, the out-of-pocket maximum does not apply to charges for non-covered health services, amounts that exceed an eligible expense, or the amounts of any reductions in benefits you incur by not notifying Personal Health Support. For more information, see Personal Health Support on page 56. If there are any HRA dollars left in your health reimbursement account after your annual deductible is met, those funds may be used to pay your co-insurance. 29

30 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Using a Health Care Flexible Spending Account (FSA) with Your Health Reimbursement Account If you use all your HRA dollars, you can use your Health Care FSA to pay for eligible out-of-pocket expenses such as your deductible, co-pays, co-insurance, and other out-of-pocket health care costs. Using a Health Care FSA can help you save money on your health care expenses. You can contribute up to $2,500 in your Health Care FSA each plan year, before taxes are taken out of your pay. Percentage of HRA dollars you ll receive and Month your portion of annual deductible and out-of- coverage begins: pocket maximum that apply: July 100% August 91.66% September 83.33% October 75.00% November 66.66% The money in your Health Care FSA does not carry over to the next plan year like your HRA dollars. Make sure you carefully estimate your out-of-pocket expenses for the plan year before you decide how much you want to contribute to your Health Care FSA. December 58.33% January 50.00% February 41.66% March 33.33% April 25.00% It is also important to consider that you must use your health reimbursement account balance first before you can use your Health Care FSA for medical expenses. You can, however, use your FSA at anytime for prescription drug, dental and vision expenses. May 16.66% June 8.33% For more information about the Health Care FSA plan, see Health Care Flexible Spending Account (FSA) on page HRA Dollar Proration The plan will prorate the amount of your HRA dollars, deductible, and out-of-pocket maximum depending on when your coverage begins: If you are rehired by and enroll in an HRA plan, will allocate HRA dollars as if you were a mid-plan year new hire based on the above chart. Mid-Year Life Event Changes and HRA Dollars If you have a life event or status change, such as having a baby, getting married/divorced, or starting/ending a partner relationship during the plan year, that results in an allowable change to your coverage category, your HRA dollars, deductible, and out-of-pocket maximum will be adjusted accordingly.

31 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices If you increase your coverage category (e.g., you change from Employee to Employee + spouse/partner), your HRA dollars, deductible and out-of-pocket maximum are adjusted to your new coverage category for that plan year and prorated based on the calendar month during which your enrollment change was effective. Any HRA dollars that had rolled over from previous plan years will remain with you. For more information about filing claims and the claims appeal process, see Claims and Appeals Procedures on page 228. If you decrease your coverage category (e.g., you change from Employee + family to Employee coverage), your HRA dollars will not be reduced. Any HRA dollars that had rolled over from previous plan years will remain with you. Your deductible and outof-pocket maximum are prorated based on the calendar month during which your enrollment change was effective. After UnitedHealthcare receives the bill from your doctor, your claim will be processed in this order: If your employment terminates for any reason, your HRA dollars will be forfeited and the funds in your health reimbursement account will revert back to the plan, unless you elect COBRA and continue your HRA coverage. Additionally, HRA dollars are nontransferable to another non-hra plan offered by, such as an HMO. 2. Deductible If you do not have enough HRA dollars to pay the bill, UnitedHealthcare will review your deductible amount. If their claim system shows that you have not met your share of the deductible, UnitedHealthcare will notify your doctor that you still need to meet all or a portion of your deductible, and your doctor will send you a bill for this amount that you must pay. When You Receive Services From an In-Network Provider In general, if you receive covered health services from an innetwork provider, UnitedHealthcare will pay the physician or facility directly. If an in-network provider bills you for any covered health service other than your deductible or co-insurance, please contact the provider or call UnitedHealthcare at the phone number on your ID card for assistance. 31 More Information About Claims 1. HRA Dollars UnitedHealthcare will first check your HRA account balance to see if you have enough money in your account to pay the bill. If you have enough money in your account, they will pay the doctor directly, and you pay nothing. 3. Co-insurance If you have paid your doctor enough to meet your deductible, the plan will start to pay at the co-insurance level. This means UnitedHealthcare will pay your doctor for 70% of eligible expenses for the HRA Plan or 80% for the HRA Plus Plan. UnitedHealthcare will check your HRA balance to see if you have enough money in your account to pay your co-insurance share. If you have enough money, they will pay the doctor directly from your HRA, and you pay nothing. If you do not have enough funds in your HRA, UnitedHealthcare will notify your doctor and he/she will bill you for the remaining amount which you must pay.

32 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 4. Out-of-Pocket Maximum If your deductible and your share of the co-insurance (including your HRA dollars) add up to your innetwork or out-of-network out-of-pocket maximum amount, all of your eligible in-network or out-of-network medical services will be paid at 100% by the plan for the rest of the plan year. The co-insurance amounts apply to both your in-network and outof-network out-of-pocket maximum amounts. When You Receive Services from an Out-of-Network Provider If you receive a bill for covered health services from an outof-network provider, you (or the provider) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card. Your claim must be submitted within one year of the date of service. Funds from your health reimbursement account or Health Care FSA (if participating) will automatically be used to reimburse you, up to the amount available in your health reimbursement account first and then from your Health Care FSA. You will only be reimbursed for eligible medical services incurred while you are covered under the plan. If Your Provider Does Not File Your Claim You can obtain a claim form by visiting on Gapweb ( benefits, by calling the toll-free number on your ID card, or by contacting Employee Services. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter: Your name and address The patient s name, age, and relationship to the employee 32 Update Dependent Information If any of your enrolled dependents have medical coverage under another plan, your medical plan will coordinate to pay benefits. For more information, see Coordination of Benefits on page 225. You can avoid delays on your enrolled dependent s claims by updating his or her other medical coverage information with UnitedHealthcare. Just log on to or call the toll-free number on your ID card to update the information. You will need the name of your dependent s other medical coverage, along with the policy number. The number as shown on your ID card The name, address, and tax identification number of the provider of the service(s) A diagnosis from the physician The date of service An itemized bill from the provider that includes: - The Current Procedural Terminology (CPT) codes - A description of, and the charge for, each service - The date the sickness or injury began. A statement indicating either you are, or you are not, enrolled in coverage under any other health insurance plan or program. If you are enrolled in other coverage you must include the name and address of the other carrier(s). Failure to provide all the information listed above may delay processing.

33 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices After the Claim Is Processed After UnitedHealthcare has processed your claim, you will receive payment for benefits that the plan allows. It is your responsibility to pay the out-of-network provider the charges you incurred, including any difference between what you were billed and what the plan paid. UnitedHealthcare will pay benefits to you unless: The provider notifies UnitedHealthcare that you have provided signed authorization to assign benefits directly to that provider, or You make a written request for the out-of-network provider to be paid directly at the time you submit your claim. UnitedHealthcare will only pay benefits to you or, with written authorization by you, your provider, and not to a third party, even if your provider has assigned benefits to that third party. Explanation of Benefits (EOB) You may request that UnitedHealthcare send you a paper copy of an explanation of benefits (EOB) after processing your claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, call the toll-free number on your ID card to request them. You can also view and print all of your EOBs online at Health Statements Each month in which UnitedHealthcare processes at least one claim for you or a covered dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family s medical costs by providing claims information in easy-to-understand terms. 33 You can also track claims for yourself and your covered dependents online at You may also elect to discontinue receipt of paper Health Statements on this site. File Claims Within 12 Months All claims must be submitted within 12 months after the date of service. Otherwise, the plan will not pay any benefits for that eligible expense, or benefits will be reduced, as determined by UnitedHealthcare. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends. Requesting Reimbursement from Your Health Reimbursement Account If you have funds available in your HRA, you may submit a claim for reimbursement from your account for HRA eligible expenses. If you submit a request for reimbursement for network claims, the request must be received no later than 90 days following the end of the plan year in which you are eligible under this plan. All claim forms for non-network claims must be submitted within 365 days of the date of service. If you do not provide this information to us within this timeframe, your claim will not be eligible for reimbursement, even if there are funds available in your health reimbursement account. This time limit does not apply if you are legally incapacitated. You cannot be reimbursed for any expense paid under your medical plan, and any expenses for which you are reimbursed from your health reimbursement account cannot be included as a deduction or credit on your federal income tax return.

34 UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Claim Denials and Appeals If a claim for benefits is denied in part or in whole, you may call UnitedHealthcare at the number on your ID card before requesting a formal appeal. If UnitedHealthcare cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal. For information on the process for appealing denied claims, see Claims and Appeals Procedures on page 228. Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 34

35 Out-of-Area Plan Prescription drug benefits through Express Scripts. You will be eligible to enroll in the Out-of-Area plan only if it is determined by UnitedHealthcare that there is no provider network within a reasonable distance from your place of residence. An out-of-pocket maximum to limit the amount of money you might have to pay each year and protect you from the expense of a catastrophic illness or injury. How the Out-of-Area Plan Works Hawaii PPO Plan The Out-of-Area plan has the following key features: Additional Information for UnitedHealthcare Plans Preventive care at no cost to you. The chart below shows what the Out-of-Area medical plan may pay for eligible expenses. Benefits are subject to the plan s deductibles, co-insurance, exclusions and limitations, unless otherwise noted. For details about covered services and benefit limitations, see What s Covered Under the UnitedHealthcare Plans on page 60 and Under the UnitedHealthcare Plans on page 84. UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan Direct access to any provider or facility. If you use a provider that is not part of the UnitedHealthcare Choice Plus Network, you may be responsible for any charges over eligible expenses. Out-of-Area Plan at a Glance After the annual deductible is met, the plan pays for covered medical expenses at 70% of eligible expenses. Plan Features and Covered Services Feature Your Out-of-Area Plan Benefits MCS Plan (Puerto Rico) Annual Deductible You pay: $600 per person/$1,500 per family Important Plan Notices Annual Out-of-Pocket Maximum You pay: $3,000 per person/$7,500 per family Covered Services What the plan pays after deductible (unless noted)* Outpatient Services Preventive Care Includes: Breast Pumps Contraceptive Devices (covers device, fitting and removal) Tubal Ligation Travel Immunizations 100%, not subject to deductible Doctor Office Visits 70% Diagnostic Lab Work, X-rays and Radiology 70% Maternity Pre-natal Office Visits 100% * Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses. 35

36 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Covered Services What the plan pays after deductible (unless noted)* Hospital Services Inpatient and Outpatient Surgery 70% Rehabilitation 70% Hospital Stay 70% Other Services Acupuncture (up to 20 visits/plan year) 70% Allergy Diagnosis and Treatment 70% What s Covered Ambulance Emergency: 70%/Non-emergency: 50% Chiropractic Care/Spinal Treatment (up to 20 visits/plan year) 70% Other Important Information Durable Equipment 70% Kaiser California HMO Plan Emergency Room Emergency: 70%/Non-emergency: 50% Enteral Feeding 70% Family Planning Vasectomy Abortion, Therapeutic or Voluntary 70% of eligible expenses MCS Plan (Puerto Rico) Foot Orthotics 70% Important Plan Notices Gender Identity Disorder Treatment (up to one gender reassignment surgery per lifetime, which may include several staged procedures) 70% Hearing Benefit (up to $3,000/ three years) 70% Home Health Care (up to 100 visits/plan year) 70% Hospice (respite care maximum is five days in a 30-day period) 70% Additional Information for UnitedHealthcare Plans Kaiser Hawaii HMO Plan MVP HMO Plan 70% Infertility Services ($7,500 lifetime maximum for medical and separate lifetime maximum of $2,500 for prescription drug benefit. Requires enrollment in the Reproductive Resource Services Program.) Newborn Care (inpatient) (Newborns are not eligible beyond the first day if the employee does not enroll them in coverage.) 70% * Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses. 36

37 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Covered Services What the plan pays after deductible (unless noted)* Podiatry (for severe systemic disease) 70% Pre-Admission Testing 70% Pregnancy (Maternity) Services (post-natal office visits, ultrasound and delivery) 70% Preventive services related to pregnancy will be covered as preventive. Hawaii PPO Plan Private Duty Nursing (20-visit lifetime maximum) 70% Prosthetic Devices 70% Radiologists, Anesthesiologists, Pathologists & Lab (RAPL) (Includes charges for the cost and administration of anesthesia. Eligible expenses do not apply if using out-of-network providers. Applies to inpatient or ambulatory services.) 70% Skilled Nursing Facility/Inpatient Rehabilitation Facility Services 70% Transplant Services If using Transplant Program (United Resources Network): Paid at 70% of eligible expenses with travel and lodging Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan If not using Transplant Program: Paid at 70% of eligible expenses with no travel and lodging benefit MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Urgent Care 70% Mental Health and Substance Use Disorder Inpatient and Outpatient Mental Health 70% Substance Use Disorder 70% * Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses. Prescription Drug Coverage Administered Through Express Scripts Your pharmacy benefits are coordinated separately from your medical benefits and are administered through Express Scripts. See Prescription Drug Plan on page 117 for details on your pharmacy coverage. Questions regarding your pharmacy benefits should be directed to Express Scripts at or 37

38 UnitedHealthcare Plans Using the Out-of-Area Plan HRA and HRA Plus Plans The Out-of-Area plan covers a broad range of medical services and supplies, including preventive care, emergency care, and mental health and chemical dependency treatment. Some services may require advance notification. Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices With the UnitedHealthcare Out-of-Area plan, you can receive benefits for covered health services from any licensed physician or other provider. If possible in your area, you may lower your out-ofpocket costs when you use UnitedHealthcare Choice Plus providers because these doctors, hospitals, and other health care providers offer their services to employees at negotiated rates. You will receive a separate ID card for your pharmacy benefits through Express Scripts. Eligible Expenses Eligible expenses are charges for covered health services that are provided while you are covered under the plan as defined below: For: Eligible expenses are based on: UnitedHealthcare Contracted rates with the provider. Choice Plus provider Any non- Negotiated rates agreed to by the out-of- UnitedHealthcare network provider and either UnitedHealthcare provider or one of its vendors, affiliates, or Member Identification Card Your UnitedHealthcare ID card must be shown every time you receive health care services. subcontractors. Your ID card may be used only by you and your enrolled dependents. If your ID card is lost or stolen or if you need additional ID cards, visit or call fees in that geographic area, and fee(s) that are Selected data resources that, in the judgment of the claims administrator, represent competitive negotiated with the provider. Note: These provisions do not apply if you receive covered health services from an out- Finding UnitedHealthcare Choice Plus Providers of-network provider during an emergency. In UnitedHealthcare s website, lists health care professionals and facilities in UnitedHealthcare s network. While network status may change from time to time, is the most current source of network information. To find a provider, log in and select Find a Doctor. billed by the provider, unless UnitedHealthcare that case, eligible expenses are the amounts negotiates lower rates. has given UnitedHealthcare the discretion and authority to decide whether a treatment or supply is covered and how the eligible expense will be covered by the plan. The Out-of-Area plan provides the same coverage with innetwork and out-of-network providers, but when you use innetwork providers, you can save through discounted rates. 38

39 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices For in-network benefits, eligible expenses are always within plan limits. For out-of-network benefits, you are responsible for paying the provider any difference between the amount the provider bills you and the amount the plan will pay. Amounts charged over eligible expenses do not apply toward your deductible or out-ofpocket maximum. Prescription drug expenses do not apply to the deductible Coverage While Traveling Abroad The plan pays benefits for covered persons while traveling outside the United States. Eligible expenses for non-emergency services incurred while outside the United States are reimbursed at the out-of-network benefit level and are subject to the annual deductible. Emergency services received outside the United States will be paid at the in-network benefit level, subject to the annual deductible. If you receive treatment while traveling outside the United States, you will have to pay for the services up-front and then submit a claim form along with the receipt and an itemized bill from the provider. For details on the procedures for filing a claim, see on page 40. If you have any questions about benefits while traveling abroad, please call UnitedHealthcare at the toll-free number on your ID card. Co-insurance Once the plan s deductible has been met, your co-insurance starts for some covered health services. Co-insurance is the sharing of costs between you and There is a percentage of eligible expenses that pays, and a percentage that you are responsible for paying. Paying for Care The following describes basic cost-sharing requirements for the Out-of-Area plan. Annual Deductibles The annual deductible is the amount of eligible expenses you must pay each plan year (July 1 June 30) for covered health services before you are eligible to begin receiving benefits for non-preventive services. The amounts you pay toward your annual deductible accumulate throughout the plan year. Remember: Your deductible may not be carried from one plan year to the next. For more information on deductible amounts, see the Out-of-Area Plan at a Glance on page 35. Amounts charged over eligible expenses are the employee s responsibility and do not apply to the out-of-pocket maximum. Out-of-Pocket Maximum The annual out-of-pocket maximum is the most you will pay each plan year for covered health services. Once the amount you pay in annual deductible and co-insurance in a plan year reaches the annual maximum, the plan pays 100% of remaining eligible expenses through the end of the plan year. Prescription drug expenses, non-notification penalties and amounts charged over eligible expenses do not apply to the outof-pocket maximum. There are separate individual and family out-of-pocket maximums. All enrolled family members eligible expenses apply toward the family out-of-pocket maximum. Your deductible is included in the out-of-pocket maximum. For more information, see Out-of-Area Plan at a Glance on page 35. All enrolled family members eligible expenses apply toward the family deductible 39

40 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan Use Your Health Care FSA Using a Health Care Flexible Spending Account (FSA) can help you save money on your health care expenses. You can contribute up to $2,500 to your Health Care FSA each plan year, before taxes are taken out of your pay. You can use the money to pay for your deductible, co-pays, co-insurance, and other out-of-pocket health care expenses. The money in your Health Care FSA does not carry over to the next plan year. Carefully estimate your out-of-pocket expenses for the plan year before you decide how much to contribute. For more information about Health Care FSAs, see Health Care Flexible Spending Account (FSA) on page 153. MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices When You Receive Services From a Non-UnitedHealthcare Provider If you receive a bill for covered health services from a provider who is not part of a UnitedHealthcare network, you (or the provider) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card. Your claim must be submitted within one year of the date of service. You must submit a claim for reimbursement from your Health Care FSA for any types of expenses other than covered health services and for any health expenses not submitted to UnitedHealthcare. When You Receive Services From a UnitedHealthcare Network Provider In general, if you receive covered health services from a provider who is part of the UnitedHealthcare Choice Plus network (an in-network provider), UnitedHealthcare will pay the physician or facility directly. If an in-network provider bills you for any covered health service other than your co-insurance, please contact the provider or call UnitedHealthcare at the phone number on your ID card for assistance. More Information About Claims For more information about filing claims and the claims appeal process, see Claims and Appeals Procedures on page 228. If you participate in a Health Care FSA, funds will automatically be reimbursed to you, up to the amount available in your FSA. You will only be reimbursed from your Health Care FSA for expenses incurred while you are covered under the plan. 40

41 The date of service UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Update Dependent Information An itemized bill from the provider that includes: If any of your enrolled dependents have medical coverage under another plan, your medical plan will coordinate to pay benefits. For more information, see Coordination of Benefits on page 225. You can avoid delays on your enrolled dependent s claims by updating his or her other medical coverage information with UnitedHealthcare. Just log on to or call the toll-free number on your ID card to update the information. You will need the name of your dependent s other medical coverage, along with the policy number. If Your Provider Does Not File Your Claim You can obtain a claim form at on Gapweb ( benefits, by calling the toll-free number on your ID card, or by contacting Employee Services. If you do not have a claim form, attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter: Your name and address The patient s name, age, and relationship to the employee The number as shown on your ID card The name, address, and tax identification number of the provider of the service(s) A diagnosis from the physician 41 - The Current Procedural Terminology (CPT) codes - A description of, and the charge for, each service - The date the sickness or injury began. A statement indicating either that you are, or you are not, enrolled in coverage under any other health insurance plan or program. If you are enrolled in other coverage you must include the name and address of the other carrier(s). Failure to provide all the information listed above may delay any reimbursement that may be due you. After the Claim Is Processed After UnitedHealthcare has processed your claim, you will receive payment for benefits that the plan allows. It is your responsibility to pay the out-of-network provider the charges you incurred, including any difference between what you were billed and what the plan paid. UnitedHealthcare will pay benefits to you unless: The provider notifies UnitedHealthcare that you have provided signed authorization to assign benefits directly to that provider, or You make a written request for the out-of-network provider to be paid directly at the time you submit your claim. UnitedHealthcare will only pay benefits to you or, with written authorization by you, your provider, and not to a third party, even if your provider has assigned benefits to that third party.

42 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan How the Plan Works Plan at a Glance Using the Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Explanation of Benefits (EOB) You may request that UnitedHealthcare send you a paper copy of an explanation of benefits (EOB) after processing your claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free number on your ID card to request them. You can also view and print all of your EOBs online at Health Statements Each month in which UnitedHealthcare processes at least one claim for you or a covered dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family s medical costs by providing claims information in easy-to-understand terms. You can also track claims for yourself and your covered dependents online at You may also elect to discontinue receipt of paper Health Statements on this site. File Claims Within 12 Months All claim forms must be submitted within 12 months after the date of service. Otherwise, the plan will not pay any benefits for that eligible expense, or benefits will be reduced, as determined by UnitedHealthcare. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends. Claim Denials and Appeals If a claim for benefits is denied in part or in whole, you may call UnitedHealthcare at the number on your ID card before requesting a formal appeal. If UnitedHealthcare cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal. For information on the process for appealing denied claims, see Claims and Appeals Procedures on page 228. Important Plan Notices 42

43 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan An out-of-pocket maximum to limit the amount of money you might have to pay each year and protect you from the expense of a catastrophic illness or injury. How the Hawaii PPO Plan Works Hawaii PPO Plan The Hawaii PPO plan has the following key features: How the Plan Works Preventive care at no cost to you. Plan at a Glance Access to UnitedHealthcare s extensive network of doctors and hospitals. Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan Flexibility of in- and out-of-network coverage, with higher benefits (and lower out-of-pocket expenses) when you use innetwork coverage. Flat-dollar co-pays for many common medical services. Plan covers up to 90% of most in-network covered services after the annual deductible is met. Plan Features and Covered Services In addition to these features, there are no claim forms to fill out when you use in-network providers and hospitals. Hawaii PPO Plan at a Glance The chart below shows what the Hawaii PPO medical plan may pay for eligible expenses, depending on whether you choose an in-network provider or an out-of-network provider for your care. Benefits are subject to the plan s deductibles, co-insurance, exclusions and limitations, unless otherwise noted. For details about covered services and benefit limitations, see What s Covered Under the UnitedHealthcare Plans on page 60 and Under the UnitedHealthcare Plans on page 84. Feature Your Hawaii PPO Plan Benefits MCS Plan (Puerto Rico) In-network Important Plan Notices Out-of-network ¹ Annual Deductible You pay: $200 per person/$500 per family You pay: $300 per person /$900 per family Annual Out-of-Pocket Maximum You pay: $2,500 per person/$6,250 per family You pay: $3,000 per person/$9,000 per family Covered Services What the plan pays after deductible (unless noted) ² In-network Out-of-network ¹ Outpatient Services Preventive Care Includes: Breast Pumps Contraceptive Devices (covers device, fitting and removal) Tubal Ligation Travel Immunizations 100%, not subject to deductible 1 The 2 co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses. 43

44 UnitedHealthcare Plans Covered Services HRA and HRA Plus Plans What the plan pays after deductible (unless noted) ² In-network Out-of-Area Plan Out-of-network ¹ Doctor Office Visits Not subject to deductible Primary care: 100% after you pay $15 co-pay Specialist: 100% after you pay $20 co-pay 70% Diagnostic Lab Work, X-rays and Radiology 90% 70% Maternity Pre-natal Office Visits 100%, not subject to deductible 100%, not subject to deductible Surgery 90% 70% Inpatient rehabilitation 90% 70% Other Important Information Outpatient rehabilitation (e.g. occupational, physical and speech therapy) 100% after you pay $20 co-pay, not subject to deductible 70% Kaiser California HMO Plan Hospital Stay 90% 70% Kaiser Hawaii HMO Plan Other Services Acupuncture (up to 20 visits/plan year) 80% 60% Allergy Diagnosis and Treatment Primary care: 100% after you pay $15 co-pay Specialist: 100% after you pay $20 co-pay 70% Ambulance Emergency: 100%, not subject to deductible Non-emergency: 50% not subject to deductible Blood/Plasma 90% 70% Chiropractic Care/Spinal Treatment (up to 20 visits/plan year) Not subject to deductible Specialist: 100% after $20 co-pay 70% Durable Equipment 90% 70% Emergency Room Emergency: Not subject to deductible, 100% after $100 co-pay Non-emergency: 50% after you pay $100 co-pay Enteral Feeding 90% Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Hospital Services Additional Information for UnitedHealthcare Plans Inpatient and Outpatient What s Covered MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 1 2 The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses %

45 UnitedHealthcare Plans Covered Services HRA and HRA Plus Plans What the plan pays after deductible (unless noted) ² In-network Out-of-Area Plan Out-of-network ¹ 70% Family Planning Vasectomy Abortion, Therapeutic or Voluntary 90% Foot Orthotics 90% 70% 90% 70% What s Covered Gender Identity Disorder Treatment (up to one gender reassignment surgery per lifetime, which may include several staged procedures) Hearing Benefit (up to $3,000/ three years) 90% 70% Other Important Information Home Health Care (up to 100 visits/plan year) 90% 70% Kaiser California HMO Plan Hospice (respite care maximum is five days in a 30-day period) 90% 70% Infertility Services ($7,500 lifetime maximum for medical and separate lifetime maximum of $2,500 for prescription drug benefit. Requires enrollment in the Reproductive Resource Services Program.) 90% 70% Newborn Care (inpatient) (Newborns are not eligible beyond the first day if the employee does not enroll them in coverage.) 90% 70% Podiatry (for severe systemic disease) Specialist: 100% after you pay $20 co-pay 70% Pre-Admission Testing 90% 70% Pregnancy (Maternity) Services Post-natal office visits Ultrasound and delivery, inpatient newborn care 100% after $15 co-pay, not subject to deductible 70% Private Duty Nursing (20-visit lifetime maximum) 90% Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 1 2 Primary care office visit: 100% of eligible expenses after you pay $15 co-pay Specialist office visit: 100% after you pay $20 co-pay Hospitalization and other health care services outside of an office visit: 90% The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses %

46 UnitedHealthcare Plans Covered Services HRA and HRA Plus Plans What the plan pays after deductible (unless noted) ² In-network Out-of-Area Plan Out-of-network ¹ Prosthetic Devices 90% 70% Radiologists, Anesthesiologists, Pathologists & Lab (RAPL) (Includes charges for the cost and administration of anesthesia. Eligible expenses do not apply if using outof-network providers. Applies to inpatient or ambulatory services.) 90% 90% Skilled Nursing Facility/Inpatient Rehabilitation Facility Services 90% 70% Transplant Services 90% Not covered Other Important Information Urgent Care Not subject to deductible 100% after $25 co-pay 70% Kaiser California HMO Plan Mental Health and Substance Use Disorder Kaiser Hawaii HMO Plan Inpatient 90% 70% Not subject to deductible 100% after $15 co-pay 70% Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Mental Health and Substance Use Disorder MVP HMO Plan Outpatient MCS Plan (Puerto Rico) Important Plan Notices Mental Health and Substance Use Disorder 1 2 The co-insurance amount is a percentage of the eligible expense without the benefit of a discounted rate. Plan pays up to eligible expenses; you are responsible for any charges over eligible expenses. Prescription Drug Coverage Administered Through Express Scripts Your pharmacy benefits are provided separately from your medical benefits and are administered through Express Scripts. See Prescription Drug Plan on page 117 for details on your pharmacy coverage. Questions regarding your pharmacy benefits should be directed to Express Scripts at or 46

47 UnitedHealthcare Plans Using the Hawaii PPO Plan HRA and HRA Plus Plans The Hawaii PPO plan covers a broad range of medical services and supplies, including preventive care, emergency care, and mental health and chemical dependency treatment. Out-of-Area Plan Hawaii PPO Plan How the Plan Works When you need medical care, you have a choice: Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices You can go to any in-network provider who participates in the UnitedHealthcare Choice Plus network. Health care providers within the network have agreed to charge negotiated fees to their patients. This means that when you use an in-network provider, your out-of-pocket expenses are lower. Keep in mind that some services require notification. You can go to any out-of-network provider who doesn t participate in the UnitedHealthcare Choice Plus network. When you use a provider who doesn t participate in the network, your out-of-pocket expenses will likely be higher. In addition, you are responsible for any amount charged above the plan s maximum allowable amount for services. Some services require notification. Your out-of-pocket costs generally will be less because innetwork providers have agreed to charge patients negotiated fees. You will not be charged more than the plan allows for a covered service. You do not need to file a claim form. Finding a Network Provider UnitedHealthcare s website, lists health care professionals and facilities in UnitedHealthcare s network. While network status may change from time to time, is the most current source of network information. To find a provider, log in and select Find a Doctor. The UnitedHealthcare Choice Plus network is made up of licensed doctors, nurses, hospitals, labs, and other health care providers. Member Identification Card Your UnitedHealthcare ID card must be shown every time you receive health care services. Using Out-of-Network Providers If you choose to see an out-of-network provider: Your ID card may be used only by you and your enrolled dependents. If your ID card is lost or stolen or if you need additional ID cards, visit or call You pay any charges that exceed the plan s eligible expense for the covered service. You will receive a separate ID card for your pharmacy benefits through Express Scripts. 47 Using In-Network Providers When you go to an in-network provider, you receive the maximum benefits available: You receive a lower level of benefits and will pay more. You will be required to pay the full cost of your medical care first, then complete and file a claim form to receive reimbursement.

48 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices When Out-of-Network Care May Be Covered at the In-Network Level If specific covered health services are not available from an innetwork provider, you may be eligible to receive in-network level benefits from an out-of-network provider. You or your physician can contact the UnitedHealthcare Customer Service Center at and request consideration for a network gap exception. UnitedHealthcare has the discretion and authority to determine on the plan s behalf whether a treatment or supply is a covered health service and how the eligible expense will be covered under the plan. For in-network benefits, you are not responsible for any difference between the eligible expenses and the amount the provider bills, unless you agreed to reimburse the provider for such services. For out-of-network benefits, you are responsible for paying directly to the provider any difference between the amount the provider bills you and the amount the plan will pay for eligible expenses. Exceptions to this include fees that are negotiated by an out-ofnetwork provider and either the claims administrator or one of its vendors, affiliates or subcontractors. Amounts charged over eligible expenses do not apply toward your deductible or out-ofpocket maximum. Eligible expenses are based on either of the following: an emergency or as otherwise arranged through the claims administrator. In this case, eligible expenses are the fee(s) that are negotiated with the out-of-network provider. Percentages and benefits are considered for covered health care supplies and services only. Benefits are determined at the time your claim is received. Eligible Expenses Eligible expenses are charges for covered health services that are provided while you are covered under the plan as defined below: For: Eligible expenses are based on: In-network benefits Contracted rates with the provider or with an out-of-network provider for emergency services. Out-of-network Negotiated rates agreed to by the out-of- benefits network provider and either UnitedHealthcare or one of its vendors, affiliates, or subcontractors. Selected data resources which, in the judgment of the claims administrator, represent competitive fees in that geographic area, and fee(s) that are negotiated with the provider. Note: These provisions do not apply if you receive covered health services from an outof-network provider during an emergency. In When covered health services are received from in-network providers, eligible expenses are the contracted fee(s) with that provider. that case, eligible expenses are the amounts billed by the provider, unless UnitedHealthcare negotiates lower rates. When covered health services are received from out-of-network providers, the claims administrator calculates eligible expenses based on available data resources of competitive fees in that geographic area, unless you received services as a result of 48

49 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices has given UnitedHealthcare the discretion and authority to decide whether a treatment or supply is covered and how the eligible expense will be covered by the plan. for filing a claim, see on page 50. If you have any questions about benefits while traveling abroad, please call UnitedHealthcare at the toll-free number on your ID card. For in-network benefits, expenses are always within plan limits. For out-of-network benefits, you are responsible for paying the provider any difference between the amount the provider bills you and the amount the plan will pay. Amounts charged over eligible expenses do not apply toward your deductible or out-of-pocket maximum. Paying for Care The following describes basic cost-sharing requirements for the Hawaii PPO plan. Possible Limitations on Provider Use If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a network provider to coordinate all of your future covered health services. If you do not select a network provider within 31 days of the date you are notified, UnitedHealthcare will select an in-network physician for you. If you do not use the network provider to coordinate all of your care, any covered health services you receive will be paid at the out-of-network benefits levels. For more information on the services requiring notification, see Personal Health Support on page 56. Coverage While Traveling Abroad The plan pays benefits for covered persons while traveling outside the United States. Eligible expenses for non-emergency services incurred while outside the United States are reimbursed at the out-of-network benefit level and are subject to the annual deductible. Emergency services received outside the United States will be paid at the in-network benefit level, subject to the annual deductible. If you receive treatment while traveling outside the United States, you will have to pay for the services up-front and then submit a claim form along with the receipt and an itemized bill from the provider. For details on the procedures 49 Annual Deductibles The annual deductible is the amount of eligible expenses you must pay each plan year (July 1 June 30) for covered health services before you are eligible to begin receiving benefits for non-preventive services. The amounts you pay toward your annual deductible accumulate throughout the plan year. Eligible expenses charged by both in-network and out-ofnetwork providers apply towards both the in-network and outof-network deductibles for all levels of coverage. Prescription drug expenses do not apply to the deductible. For more information on deductible amounts, see Hawaii PPO Plan at a Glance on page 43. Co-pay A co-pay is the flat-dollar amount you pay each time you receive certain covered health services. Co-insurance Once the plan s deductible has been met, your co-insurance starts for some covered health services. Co-insurance is the sharing of costs between you and There is a percentage of eligible expenses that pays, and a percentage that you are responsible for paying.

50 Health Support. For more information, see Personal Health Support on page 56. UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan Use Your Health Care FSA Using a Health Care Flexible Spending Account (FSA) can help you save money on your health care expenses. With a Health Care FSA, you can contribute up to $2,500 in your Health Care FSA each plan year, before taxes are taken out of your pay. You can use the money you save to pay for your deductible, co-pays, co-insurance, and other out-of-pocket medical expenses. Please keep in mind that the money in your Health Care FSA does not carry over to the next plan year. Therefore, it s important to carefully estimate your out-of-pocket expenses for the plan year before you decide how much you want to contribute to your Health Care FSA. For more information about Health Care FSAs, see Health Care Flexible Spending Account (FSA) on page 153. MCS Plan (Puerto Rico) Important Plan Notices Out-of-Pocket Maximum The annual out-of-pocket maximum is the most you will pay each plan year for covered health services. There are separate innetwork and out-of-network out-of-pocket maximums. For more information on specific out-of-pocket maximums, see Hawaii PPO Plan at a Glance on page 43. If your eligible out-of-pocket expenses in a plan year exceed the annual maximum, the plan pays 100% of eligible expenses for covered health services through the end of the plan year. The outof-pocket maximum applies to all covered health services except for prescription drugs. However, the out-of-pocket maximum does not apply to charges for non-covered health services, amounts that exceed an eligible expense, or the amounts of any reductions in benefits you incur by not notifying UnitedHealthcare s Personal 50 Eligible expenses charged by both in-network and out-of-network providers apply toward both the in-network and out-of-network individual and family out-of-pocket maximums. When You Receive Services From an In-Network Provider In general, if you receive covered health services from an innetwork provider, UnitedHealthcare will pay the physician or facility directly. If an in-network provider bills you for any covered health service other than your co-pay or co-insurance, please contact the provider or call UnitedHealthcare More Information About Claims For more information about filing claims and the claims appeal process, see Claims and Appeals Procedures on page 228. When You Receive Services From an Out-of-Network Provider If you receive a bill for covered health services from an outof-network provider, you (or the provider) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card. Your claim must be submitted within one year of the date of service. If you participate in a Health Care FSA, funds will automatically be reimbursed to you, up to the amount available in your Health Care FSA.

51 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan You must submit a claim for reimbursement from your Health Care FSA for any types of expenses other than covered health services and any health expenses not submitted to UnitedHealthcare. Update Dependent Information Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan An itemized bill from the provider that includes: - A description of, and the charge for, each service If any of your enrolled dependents have medical coverage under another plan, your medical plan will coordinate to pay benefits. For more information, see Coordination of Benefits on page 225. You can avoid delays on your enrolled dependent s claims by updating his or her other medical coverage information with UnitedHealthcare. Just log on to or call the toll-free number on your ID card to update the information. You will need the name of your dependent s other medical coverage, along with the policy number. MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices If Your Provider Does Not File Your Claim You can obtain a claim form by visiting on Gapweb ( benefits, calling the toll-free number on your ID card, or contacting Employee Services. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter: Your name and address The patient s name, age, and relationship to the employee The number as shown on your ID card The name, address, and tax identification number of the provider of the service(s) 51 The date of service - The Current Procedural Terminology (CPT) codes How the Plan Works A diagnosis from the physician - The date the sickness or injury began. A statement indicating either that you are, or you are not, enrolled in coverage under any other health insurance plan or program. If you are enrolled in other coverage you must include the name and address of the other carrier(s). Failure to provide all the information listed above may delay any reimbursement that may be due you. After the Claim Is Processed After UnitedHealthcare has processed your claim, you will receive payment for benefits that the plan allows. It is your responsibility to pay the out-of-network provider the charges you incurred, including any difference between what you were billed and what the plan paid. UnitedHealthcare will pay benefits to you unless: The provider notifies UnitedHealthcare that you have provided signed authorization to assign benefits directly to that provider, or You make a written request for the out-of-network provider to be paid directly at the time you submit your claim. UnitedHealthcare will only pay benefits to you or, with written authorization by you, your provider, and not to a third party, even if your provider has assigned benefits to that third party.

52 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan How the Plan Works Plan at a Glance Using the Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Explanation of Benefits (EOB) You may request that UnitedHealthcare send you a paper copy of an explanation of benefits (EOB) after processing your claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free number on your ID card to request them. You can also view and print all of your EOBs online at Health Statements Each month in which UnitedHealthcare processes at least one claim for you or a covered dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family s medical costs by providing claims information in easy-to-understand terms. You can also track claims for yourself and your covered dependents online at You may also elect to discontinue receipt of paper Health Statements on this site. File Claims Within 12 Months All claim forms must be submitted within 12 months after the date of service. Otherwise, the plan will not pay any benefits for that eligible expense, or benefits will be reduced, as determined by UnitedHealthcare. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends. Claim Denials and Appeals If a claim for benefits is denied in part or in whole, you may call UnitedHealthcare at the number on your ID card before requesting a formal appeal. If UnitedHealthcare cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal. For information on the process for appealing denied claims, see Claims and Appeals Procedures on page 228. Important Plan Notices 52

53 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Resources Personal Health Support What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Additional Information for UnitedHealthcare Plans (HRA, HRA Plus, Out-of-Area and Hawaii PPO) At you can: UnitedHealthcare Plan Resources Re health conditions and treatment options to discuss with your physician believes in giving you the tools you need to be a smart and educated health care consumer. We have partnered with UnitedHealthcare to provide many resources to help you: Manage a chronic health condition, and Navigate the health care system. Important! Information obtained through the services identified in this section is based on current medical literature and on physician review. It s not intended to replace the advice of a doctor. The information is intended to help you make better health care decisions and take a greater responsibility for your own health. UnitedHealthcare and are not responsible for the results of your decisions from the use of the information, including, but not limited to, your choosing to seek or not to seek professional medical care, or your choosing or not choosing specific treatment based on the text. Search for in-network providers through the online provider directory Access content and wellness topics from mynurseline, including Live Nurse Chat, 24 hours a day, seven days a week Take care of yourself and your family members UnitedHealthcare s member website, provides health information and convenient self-service tools to meet the needs of you and your family. 53 Receive personalized health messages that are posted to your own website Complete a health risk assessment to identify health habits you can improve, learn about healthy lifestyle techniques, and access health improvement resources (available to you and your spouse). Your health assessment is confidential. Completing the assessment will not impact your benefits or eligibility. To take the health assessment, log on to Access your personalized Health & Wellness page and click the Health Assessment link. Use the treatment cost estimator to help estimate the cost of procedures in your area, and Use the hospital comparison tool to compare hospitals in your area on patient safety and quality measures. Health Improvement Plan You can start a Health Improvement Plan at any time. This plan is created just for you and includes information and interactive tools, plus online health coaching recommendations based on your profile. Online coaching is available for: Nutrition Exercise

54 Weight management HRA and HRA Plus Plans Stress Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Resources Personal Health Support What s Covered Other Important Information UnitedHealthcare Plans Out-of-Area Plan Live Nurse Chat With mynurseline, you have access to nurses online. Log on to and click online now at the bottom of the screen under Ask a Nurse. You will instantly be connected with a registered nurse who can answer your general health questions 24 hours a day, seven days a week. You can also request an ed transcript of the conversation to use as a reference. Smoking cessation Diabetes, and Heart health. To help keep you on track with your Health Improvement Plan and online coaching, you will also receive personalized messages and reminders. Important Plan Notices mynurseline mynurseline is a free telephone service that puts you in immediate contact with an experienced registered nurse 24 hours a day, seven days a week. Nurses can provide health information for routine or urgent health concerns. When you call, a registered nurse may refer you to additional resources available to help you improve your health and well-being or manage a chronic condition. Call (PIN: 216) anytime to learn more about: A recent diagnosis Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) A minor sickness or injury How to take prescription drugs safely Self-care tips and treatment options Healthy living habits, or Any other health-related topic. You can also listen to one of the Health Information Library s over 1,100 recorded messages. Most messages are also available in Spanish. Pregnancy consultation to identify special needs Printed and online educational materials and resources Maternity nurses on duty 24 hours a day A phone call from a care coordinator during your pregnancy to check on your progress, and A phone call from a care coordinator approximately four weeks postpartum to give you information on infant care, feeding, nutrition, immunizations and more. This program is free and participation is completely voluntary. To take full advantage of the program, you are encouraged to enroll within the first 12 weeks of pregnancy. You can enroll up to week 34 of your pregnancy. Call to enroll. Men s, women s and children s wellness 54 Healthy Pregnancy Program If you are pregnant and enrolled in a UnitedHealthcare medical plan, you can get valuable educational information and advice by calling This program offers: Disease and Condition Management Services If you have been diagnosed with or are at risk for developing congestive heart failure, asthma or diabetes, you may be eligible to participate in a disease management program at no cost to you. You will receive free educational information through the mail, and may even be called by a registered nurse who is a

55 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan specialist in your specific medical condition. This nurse will be a resource to advise and help you manage your condition. These programs may offer: Personal Health Support Educational materials mailed to your home with guidance on managing your specific chronic condition. This may include information on symptoms, warning signs, self-management techniques, recommended exams and medications. What s Covered Access to online educational and self-management resources. One-on-one support from a registered nurse who specializes in your condition. Examples of support topics include: Additional Information for UnitedHealthcare Plans Plan Resources Other Important Information Kaiser California HMO Plan - Education about the specific disease and condition Kaiser Hawaii HMO Plan - Medication management MVP HMO Plan - Online behavior modification program goals MCS Plan (Puerto Rico) Important Plan Notices - Preparation and support for physician visits - Review of psychosocial services and community resources - Caregiver status and in-home safety - Use of mail-order pharmacy and in-network providers. An opportunity for the disease management nurse to work with your physician to ensure that you are receiving the appropriate care. This program is free and participation is completely voluntary. If you think you may be eligible to participate or would like additional information, please contact the number on the back of your ID card. 55 Diabetes Management Program The Diabetes Management Program helps you manage the ABCs of diabetes A1C (blood sugar control), blood pressure, and cholesterol. The program provides a variety of benefits that focus on medication, diet, and exercise to help you live a healthy life. You will receive coaching from experienced diabetes nurses who can answer your health questions and find ways to reduce risk factors. The nurses can also connect you with quality doctors and hospitals. If your medical condition qualifies you for this program, a registered nurse will call you, help you set up a diabetes selfmanagement plan, and provide ongoing support and guidance. The program is completely voluntary and confidential. Reminder Programs To help you stay healthy, UnitedHealthcare may send you and your covered dependents reminders to schedule recommended screening exams. Examples of reminders include: Mammograms for women between the ages of 51 and 68 Pediatric and adolescent immunizations Cervical cancer screenings for women between the ages of 20 and 64 Comprehensive screenings for individuals with diabetes Influenza/pneumonia immunizations for enrollees age 65 and older. There is no need to enroll in this program. You will receive a reminder automatically if you have not had a recommended screening exam.

56 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Resources Personal Health Support What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices HealtheNotesSM UnitedHealthcare provides a service called HealtheNotes to help educate members and make suggestions regarding your medical care. HealtheNotes provides you and your physician with suggestions regarding preventive care, testing, or medications, potential interactions with medications you have been prescribed, and certain treatments. In addition, your HealtheNotes report may include health tips and other wellness information. UnitedHealthcare makes these suggestions through a software program that provides retrospective, claims-based identification of medical care. Patients are identified who may benefit from suggestions using established standards of evidence-based medicine. If your physician identifies any concerns after reviewing his or her HealtheNotes report, he or she may contact you. You may also use the information in your report to talk to your physician about your health and the suggestions given. Any decisions regarding your care are always between you and your physician. If you have questions or would like additional information, please call the Customer Service number on the back of your ID card. Treatment Decision Support To help you make informed decisions about your health care, UnitedHealthcare has a program called Treatment Decision Support. This program targets specific conditions as well as the treatments and procedures for those conditions. This program offers: Access to accurate, objective and relevant health care information Coaching by a nurse through decisions in your treatment and care 56 Expectations of treatment Information on high-quality providers and programs. This program is available for: Back pain Knee and hip replacement Prostate disease Prostate cancer Benign uterine conditions Breast cancer Coronary disease Bariatric surgery. This program is free and participation is completely voluntary. If you think you may be eligible to participate or would like additional information, please contact the number on the back of your ID card. Personal Health Support UnitedHealthcare provides Personal Health Support to encourage personalized, efficient care for you and your covered family members. This program provides support from specially trained nurses to help you manage your health care. Personal Health Support Nurses Personal Health Support Nurses focus on prevention, education, and closing any gaps in your care. They help ensure you receive the most appropriate and cost-effective services available. A Personal Health Support Nurse is notified when you or your provider calls the toll-free number on your ID card regarding an upcoming treatment or service.

57 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Resources Personal Health Support What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Chronic Care Treatment If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign a Personal Health Support Nurse to guide you through your treatment. This nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with his or her telephone number so you can call with questions about your conditions or your overall health and well-being. Other Program Components The Personal Health Support program also includes: Admission counseling For upcoming inpatient hospital admissions for certain conditions, a Treatment Decision Support Nurse may call you to help answer your questions and to make sure you have the information and support you need for a successful recovery. Inpatient care advocacy If you are hospitalized, a nurse will work with your physician to make sure you are getting the care you need and that your physician s treatment plan is being carried out effectively. Readmission management This program serves as a bridge between the hospital and your home if you are at high risk of being readmitted. After leaving the hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home. 57 Risk management Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies. Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant s specific chronic or complex condition. Program components and notification requirements are subject to change without notice. If you do not receive a call from a Personal Health Support Nurse but feel you could benefit from any of these programs, please call the toll-free number on your ID card. Benefits Requiring Personal Health Support Notification There are some in-network benefits that require you to notify Personal Health Support. However, in-network providers are generally responsible for notifying Personal Health Support before they provide you with these services. You can contact Personal Health Support at When you choose to receive certain covered health services from out-of-network providers, you are responsible for notifying Personal Health Support before you receive the services. In many cases, your out-of-network benefits will be reduced if Personal Health Support is not notified. Services that require Personal Health Support notification are: Ambulance (non-emergent air and ground) Clinical trials Congenital heart disease services Dental services (accident only)

58 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Durable medical equipment for items that will cost more than $1,000 to purchase or rent, including diabetes equipment for the management and treatment of diabetes Breast reduction and reconstruction (except following cancer surgery) Gender identity disorder treatment Vein stripping, ligation, and sclerotherapy (an injection of a chemical to treat varicose veins), and Additional Information for UnitedHealthcare Plans Home health care Blepharoplasty (surgery to correct aging of the eyelids). Plan Resources Hospice care Personal Health Support Hospital inpatient stay - all elective admissions These services will not be covered when considered to be cosmetic procedures. What s Covered Infertility services Hawaii PPO Plan Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Manipulative treatment as described in Spinal Treatment, Chiropractic, and Osteopathic Manipulative Therapy on page 80 Maternity care that exceeds the delivery timeframes as described in Important Plan Notices on page 104 Outpatient dialysis treatments as described in Therapeutic Treatments (Outpatient) on page 81 Reconstructive procedures, including breast reconstruction surgery following a mastectomy or breast reduction surgery Skilled nursing facility/inpatient rehabilitation facility services, and Transplantation services. Notification is required within 48 hours of admission or on the same day of admission if reasonably possible after you are admitted to a non-network hospital as a result of an emergency. The following procedures also require that you notify Personal Health Support before receiving the services to determine whether they are covered: 58 Mental Health and Substance Use Disorder Services You must provide pre-service notification when you receive these services from out-of-network providers: Mental health services inpatient services (including partial hospitalization/day treatment and services at a residential treatment facility) Neurobiological disorders mental health services for autism spectrum disorders or inpatient services (including partial hospitalization/day treatment and services at a residential treatment facility) Substance use disorder services inpatient services (including partial hospitalization/day treatment and services at a residential treatment facility). For a scheduled admission, you must notify the mental health/ substance use disorder administrator before the admission, or as soon as reasonably possible for non-scheduled admissions (including emergency admissions). If you fail to notify the mental health/substance use disorder administrator as required, benefits will be subject to a $250 reduction (for the Hawaii PPO plan, up to a maximum of $1,000 per plan year combined for in- and out-ofnetwork notifications).

59 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Resources Personal Health Support What s Covered Other Important Information You are not required to provide pre-service notification when you seek these services from network providers. Network providers are responsible for notifying the mental health/substance use disorder administrator before they provide these services to you. Medicare If you are enrolled in Medicare and Medicare pays benefits first, you are not required to notify Personal Health Support before receiving covered health services. If Medicare pays benefits first, the plan will pay benefits second. For more information, see Coordination of Benefits on page 225. Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 59

60 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices What s Covered Under the UnitedHealthcare Plans and other health care professionals on the UnitedHealthcare Online website. It s possible that some treatments may not be covered under the UnitedHealthcare plans. To make informed decisions about the health care you receive, it s important to know which services are covered and which are not. UnitedHealthcare will inform you if a service is not covered. Acupuncture Services The plan pays for acupuncture services for pain therapy if performed in an office setting by a provider who is either practicing within the scope of his/her license (if state license is available) or certified by a national accrediting body: All covered services and benefits are subject to the plan s conditions, exclusions, limitations, terms, and provisions. The information in this section provides more details on covered health services (in addition to the benefits information found in the overviews of each plan). Doctor of Medicine Covered health services include services or supplies that UnitedHealthcare determines to be: Covered health services include treatment of nausea as a result of: Provided for the purpose of preventing, diagnosing, or treating sickness, injury, mental illness, substance use disorders, or their symptoms Pregnancy, or Included in What s Covered Under the UnitedHealthcare Plans (this section) Provided to a covered person who meets the plan s eligibility requirements, as described under Eligibility on page 2, and Not included in Under the UnitedHealthcare Plans on page 84. UnitedHealthcare maintains clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. You can access these clinical protocols (as revised from time to time) at or by calling the number on the back of your ID card. This information is available to physicians 60 Doctor of Osteopathy Chiropractor, or Acupuncturist. Chemotherapy Post-operative procedures. Any combination of in-network and out-of-network benefits is limited to 20 visits per plan year. Ambulance Services (Emergency) The plan covers emergency ambulance services and transportation provided by a licensed ambulance service to the nearest hospital that offers emergency health services. Ambulance service by air is covered in an emergency if ground transportation is impossible, or would put your life or health in serious jeopardy. If special circumstances exist, UnitedHealthcare may pay benefits for emergency air transportation to a hospital that is not the closest facility to provide emergency health services.

61 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Ambulance Services (Non-Emergency) The plan covers transportation provided by a licensed professional ambulance (either ground or air, as UnitedHealthcare determines appropriate) between facilities when the transport is: From an out-of-network hospital to an in-network hospital To a hospital that provides a higher level of care not available at the original hospital To a more cost-effective acute care facility, or From an acute facility to a sub-acute setting. In most cases, UnitedHealthcare will initiate and direct nonemergency ambulance transportation. If you are requesting nonemergency ambulance services, you must notify Personal Health Support as soon as possible before the transport. If Personal Health Support is not notified, you will be responsible for paying all charges, and no benefits will be paid. Blood/Plasma (Hawaii PPO Plan Only) The plan covers: Preservation of autologous blood products for scheduled surgery for up to eight weeks, and Blood and blood productions, including blood costs, blood bank and blood processing. Cancer Care Support Program To help UnitedHealthcare members and their covered dependents living with cancer, provides the Cancer Care Support Program. The program is administered through Alere, which has an experienced cancer team that will provide members with information, support and assistance. Eligibility and Enrollment To be eligible for the program, the patient must: Have clinically diagnosed cancer Have started or plans to undergo treatment Require more than a simple surgery as definitive treatment, and Be 18 years of age or older. The UnitedHealthcare Personal Health Support nurses work closely with Alere to establish eligibility and ensure timely referrals. In addition to the support provided by Alere, UnitedHealthcare can provide referrals to the Cancer Resource Services (CRS) nurses. These nurses will help you and your family locate UnitedHealthcare s Centers of Excellence for treatment. How the Program Works Once a case with a cancer diagnosis is identified, the care manager from Alere will contact the patient and/or family member by phone or mail to introduce the services and verify eligibility. UnitedHealthcare members can also contact Alere directly by calling Patients work directly with Alere s case manager who is a highly experienced oncology nurse. This program is completely confidential and accessible to participants 24 hours a day, 7 days a week. Alere s case manager can help answer questions about cancer or how the challenges of facing cancer affect you. They can also provide you with additional support and assistance to help you: Understand the disease and treatments Understand possible side effects Prepare for doctor visits 61

62 UnitedHealthcare Plans Access available support services HRA and HRA Plus Plans Access and better use your health care benefits by working with your health plan provider Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Identify resources in your community, and Understand how your family can support you while you are facing the challenge of cancer. Cancer Resource Services (CRS) The plan pays benefits for oncology services provided by designated facilities participating in the Cancer Resource Services (CRS) Program. For oncology services and supplies to be covered, they must be provided to treat a condition that has a primary or suspected diagnosis relating to cancer. If you or a covered dependent has cancer, you may be referred to CRS by a Personal Health Support Nurse. You can also call CRS toll-free at or visit Important! To receive benefits under the CRS program, you must contact CRS before obtaining covered health services. The plan will only pay benefits under the CRS program if CRS provides the proper notification to the designated facility provider performing the services (even if you self-refer to an in-network provider). To receive benefits for a cancer-related treatment, you are not required to visit a designated facility. If you receive oncology services from a facility that is not a designated facility, the plan pays benefits according to the plan provisions outlined in this guide. Cancer clinical trials and related treatment and services are covered by the plan. Such treatment and services must be recommended and provided by a physician in a cancer center. The cancer center must be a participating center in the Cancer Resource Services Program at the time the treatment or service is given. You must notify Personal Health Support as soon as the possibility of participation in a clinical trial arises. If Personal Health Support is not notified, you will be responsible for paying all charges, and no benefits will be paid. Congenital Heart Disease (CHD) The plan pays benefits for congenital heart disease (CHD) services ordered by a physician and received at a CHD Resource Services program. Benefits include the facility charge and the charge for supplies and equipment. Benefits are available for the following CHD services: Outpatient diagnostic testing Evaluation Surgical interventions Interventional cardiac catheterizations (insertion of a tubular device in the heart) Fetal echocardiograms (examination, measurement, and diagnosis of the heart using ultrasound technology), and Approved fetal interventions. 62

63 The following services are also covered by the plan: UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Important! Dental services related to medical transplant procedures United Resource Networks or Personal Health Support must be notified as soon as CHD is suspected or diagnosed. If one of these resources is not notified, benefits for covered health services will be reduced by $250. Contact United Resource Networks at or Personal Health Support at Initiation of an immunosuppressive (medication used to reduce inflammation and suppress the immune system) Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Direct treatment of cancer or cleft palate. Before the plan will cover treatment of an injured tooth, the dentist must certify that the tooth is virgin or unrestored, and that it: Has no decay CHD services other than those listed above are excluded from coverage, unless determined by United Resource Networks or Personal Health Support to be proven procedures for the involved diagnoses. For information about CHD services, contact United Resource Networks at or Personal Health Support at If you receive CHD services from a facility that is not a designated facility, the plan pays benefits according to the plan provisions outlined in this guide. Dental Services (Accident Only) Dental services are covered by the plan when all of the following are true: Treatment is necessary because of accidental damage to a sound, natural tooth Dental damage does not occur as a result of normal activities of daily living or extraordinary use of the teeth Dental services are received from a Doctor of Dental Surgery or a Doctor of Dentistry, and Has no filling on more than two surfaces Has no gum disease associated with bone loss Has no root canal therapy Is not a dental implant, and Functions normally in chewing and speech. Dental services for final treatment to repair the damage must be started within three months of the accident and completed within 12 months of the accident. Notify Personal Health Support at Notify Personal Health Support as soon as possible, but at least five business days before follow-up (post-emergency) dental treatment begins. You do not have to provide notification before the initial emergency treatment. When you provide notification, Personal Health Support can determine whether the service is a covered health service. The dental damage is severe enough that initial contact with a physician or dentist occurs within 72 hours of the accident. 63

64 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Diabetes Services The plan pays benefits for the covered health services listed below. Description Ordered or provided by a physician for outpatient use Diabetes Self- Benefits include: Used for medical purposes Management and Outpatient self-management training for the Training/Diabetic treatment of diabetes Not consumable or disposable Eye Examinations/ Education services Foot Care nutrition therapy services. Not of use to a person in the absence of a sickness, injury or disability These services must be ordered by a physician Durable enough to withstand repeated use, and and provided by appropriately licensed or Appropriate for use in the home. registered health care professionals. Benefits under this section also include medical MVP HMO Plan eye examinations (dilated retinal examinations) and preventive foot care for covered persons with MCS Plan (Puerto Rico) diabetes. Diabetic Self- Benefits include: Management Items Insulin pumps and related pump supplies and Equipment to administer oxygen Wheelchairs and treatment of diabetes, based upon the Hospital beds The following items are covered through the prescription drug plan administered by Express Delivery pumps for tube feedings Burn garments Scripts: Cranial helmets Blood glucose monitors Insulin pumps and all related necessary supplies as described under Diabetes Services as shown on the left Insulin syringes with needles Blood glucose and urine test strips Ketone test strips and tablets Lancets and lancet devices. Benefits for diabetes equipment that meet the definition of durable medical equipment are subject to the limit stated under Durable Equipment as shown on the right. If more than one piece of DME can meet your functional needs, you will receive benefits only for the most cost-effective piece of equipment. Benefits are provided for a single unit of DME (e.g., one insulin pump) and for repairs of that unit. Examples of DME include but are not limited to: blood glucose monitors for the management medical needs of the covered person. 64 Durable Equipment (DME) The plan pays for durable medical equipment (DME) that is: Type of Service Kaiser Hawaii HMO Plan Kaiser California HMO Plan Important Plan Notices External cochlear devices and systems. Surgery to place a cochlear implant is also covered by the plan. Cochlear implantation can either be an inpatient or outpatient procedure. See Hospital (Inpatient Stay) on page 69, Rehabilitation Services (Outpatient Therapy) on page 78 and Surgery (Outpatient) on page 81.

65 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Braces that stabilize an injured body part and braces to treat curvature of the spine Equipment for the treatment of chronic or acute respiratory failure or conditions Tubings, nasal cannulas, connectors, and masks used in connection with DME. Orthotic appliances that straighten or re-shape a body part (including certain types of braces) are not covered under the plan. Benefits are provided for the replacement of a type of DME once every three plan years. At UnitedHealthcare s discretion, replacements are covered for damage beyond repair with normal wear and tear, when repair costs exceed the new purchase price, or when a change in the covered person s medical condition occurs sooner than the threeyear timeframe. Repairs, including the replacement of essential accessories, such as hoses, tubes, mouth pieces, etc., for necessary DME, are only covered when required to make the item/device serviceable and the estimated repair expense does not exceed the cost of purchasing or renting another item/device. Requests for repairs may be made at any time and are not subject to the threeyear timeline for replacements. Note: DME is different from prosthetic devices see Prosthetic Devices on page 77. Notify Personal Health Support at For out-of-network purchase, rental, repair, or replacement of a DME, you must notify Personal Health Support if the cost will be more than $1,000. You must purchase or rent the DME from the vendor Personal Health Support identifies. If Personal Health Support is not notified, your benefits will be reduced by $250. Emergency Health Services If you are admitted as an inpatient to an in-network hospital for an emergency health service, you will be responsible for a portion of eligible expenses. Your share of the cost is shown in the Plan Features and Covered Services chart for each plan. In-network benefits will be paid for an emergency admission to an out-of-network hospital as long as Personal Health Support is notified within two business days of the admission or as soon as reasonably possible after you are admitted to an out-of-network hospital. If you continue your stay in an out-of-network hospital after the date your physician determines that it is medically appropriate to transfer you to an in-network hospital, out-ofnetwork benefits will apply. Notify Personal Health Support at If Personal Health Support is not notified of an emergency admission to an out-of-network hospital within the timeframe indicated above, your benefits for the inpatient hospital stay will be reduced by $

66 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Enteral Feedings Enteral nutrition is the delivery of nutrients in liquid form directly into the stomach, duodenum, or jejunum and is used when the patient s condition precludes oral intake. Enteral feedings are only covered by the plan when a certain nutritional formula treats a specific inborn error of metabolism, or if they are the only source of nutrition. The medical food or low protein modified food product is to be: Prescribed as medically necessary for the therapeutic treatment of an inborn error of metabolism, and Consumed or administered enterally under the supervision of a licensed physician. Family Planning Coverage is provided for the following services: Vasectomy Tubal ligation Abortion (therapeutic or voluntary). Reversals of voluntary sterilization are not covered. Contraceptive devices and tubal ligation are covered at 100%. For vasectomy and abortion services, your share of the cost is shown in the Plan Features and Covered Services chart for each plan. Continuous hormone replacement hormones of the desired gender - Hormones injected by a medical provider (i.e., during an office visit) are covered. Benefits for these injections are paid subject to the plan s deductible and co-insurance. - Oral and self-injected hormones from a pharmacy are not covered under the medical plan. Refer to the separate Prescription Drug Benefit on page 119 for coverage details for such oral and self-injected hormones from a pharmacy. - Complete hysterectomy - Salpingo-oophorectomy - Orchiectomy - Metoidioplasty - Penectomy - Scrotoplasty - Vaginoplasty - Urethroplasty - Vaginectomy - Clitoroplasty - Placement of testicular prosthesis - Labiaplasty - Phalloplasty. Surgery to change specified secondary sex characteristics, specifically: Oral contraceptives are covered by the drug plan. Foot Orthotics Benefits are provided for orthopedic shoes and other supportive devices for the feet. Psychotherapy for gender identity disorders and associated comorbid psychiatric diagnoses Surgery to change the genitalia, specifically: Contraceptive devices (covers device, fitting and removal), and 66 Gender Identity Disorder Treatment The plan pays benefits for the treatment of gender identity disorder as follows: - Thyroid chondroplasty (reduction of the Adam s Apple) - Bilateral mastectomy

67 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan - Augmentation mammoplasty if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social role. Laboratory testing to monitor the safety of continuous hormone therapy. Hormone Replacement Eligibility Qualifications You must meet all of the following eligibility qualifications for hormone replacement, in addition to the plan s overall eligibility requirements (see Eligible Employees on page 2 and Eligible Dependents on page 2, as well as the benefits summaries available on Gapweb): Eligible Dependents on page 2, as well as the benefits summaries available on Gapweb): 1. The surgery must be performed by a qualified provider at a facility with a history of treating individuals with gender identity disorder 2. The treatment plan must conform to the World Professional Association for Transgender Health Association (WPATH) standards* 3. You must be age 18 years or older for irreversible surgical interventions 4. You must complete 12 months of continuous hormone therapy for those without contraindications MCS Plan (Puerto Rico) 1. Be age 18 years or older for hormones to change physical characteristics 5. You must complete 12 months of successful continuous, fulltime, real-life experience in the desired gender, and Important Plan Notices 2. Demonstrate knowledge of what hormones medically can and cannot do and their social benefits and risks 6. You must meet the definition of gender identity disorder. 3. Meet the definition of gender identity disorder, and * The World Professional Association for Transgender Health Association (WPATH) is an advocacy group. 4. Initial hormone therapy must be preceded by: A documented, real-life experience (living as the other gender) of at least three months prior to the administration of hormones, or A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months). Eligibility for Genital Surgery and Surgery to Change Secondary Sex Characteristics You must meet all of the following eligibility qualifications for genital surgery and surgery to change secondary sex characteristics, in addition to the plan s overall eligibility requirements (see Eligible Employees on page 2 and 67 Benefits are limited to one gender reassignment surgery, which may include several staged procedures, during the entire time that you are covered under the plan. Notify Personal Health Support at For out-of-network gender identity disorder benefits, you must notify Personal Health Support before receiving treatment. If Personal Health Support is not notified, your benefits will be reduced by $250.

68 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Hearing Benefit The plan pays benefits for hearing aids required for the correction of a hearing impairment (a reduction in the ability to perceive sound, which may range from slight to complete deafness). Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver. Benefits are available for a hearing aid that is purchased as a result of a written recommendation by a physician. Benefits are provided for the hearing aid and for associated fitting and testing. Benefits do not include bone anchored hearing aids (BAHAs). Benefits for bone anchored hearing aids (BAHAs) are only available for covered persons who have either of the following: Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid, or Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. Any combination of in-network and out-of-network benefits for the hearing device and fitting is limited to $3,000 every three years. The hearing exam and screening are covered as a separate benefit and do not apply towards the $3,000 limit. Batteries for the hearing device are not covered. Home Health Care Covered home health services are services provided by a home health agency provider if you need care in your home due to your condition. Services must be: Ordered by a physician Provided by or supervised by a registered nurse in your home, or provided by either a home health aide or licensed practical nurse and supervised by a registered nurse 68 Not considered custodial care, and Provided on a part-time, intermittent schedule when skilled care is required. Personal Health Support will decide if skilled care is needed by reviewing both the skilled nature of the service and the need for physician-directed medical management. A service will not be determined to be skilled simply because there is not an available caregiver. Any combination of in-network and out-of-network benefits is limited to 100 visits per plan year. A visit of up to four hours of skilled care services is considered one home health care visit. Notify Personal Health Support at For out-of-network home health care or hospice care benefits, you must notify Personal Health Support five business days before receiving services. If Personal Health Support is not notified, your benefits will be reduced by $250. Hospice Care Hospice care is an integrated program recommended by a physician who provides comfort and support services for the terminally ill. Hospice care can be provided on an inpatient or outpatient basis and includes physical, psychological, social, spiritual, and respite care for the terminally ill person, and shortterm grief counseling for immediate family members while the covered person is receiving hospice care. Benefits are available only when hospice care is received from a licensed hospice agency, which can include a hospital.

69 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Hospice care benefits have a maximum lifetime benefit of six months per covered person. The plan also pays up to $500 for family counseling, and benefits are available for up to five days of respite care (during any 30-day period). Hospital (Inpatient Stay) Hospital benefits are available for: Non-physician services and supplies received during an inpatient stay, and Room and board in a semi-private room (a room with two or more beds). The plan will pay the difference in cost between a semi-private room and a private room only if a private room is necessary according to generally accepted medical practice. Benefits for an inpatient stay in a hospital are available only when the inpatient stay is necessary to prevent, diagnose or treat a sickness or injury. Benefits for hospital-based physician services are described under Physician Fees for Surgical and Services on page 73. Benefits for emergency admissions and admissions of less than 24 hours are described under: Emergency Health Services on page 65 Surgery (Outpatient) on page 81 Scopic Procedures (Outpatient Diagnostic and Therapeutic) on page 79 Notify Personal Health Support at For out-of-network benefits, you must notify Personal Health Support as follows: For elective admissions, five business days before admissions For emergency admissions (also called non-elective admissions), within two business days, or as soon as reasonably possible. If Personal Health Support is not notified, your benefits will be reduced by $250. Infertility Services To be eligible for this benefit, you must have one year of service with, and be enrolled and participating in the Reproductive Resource Services (RRS) program before seeking treatment. Infertility services must be provided at an RRS Center of Excellence to receive coverage. Infertility is defined as one of the following: The woman is under 35 and she has not conceived after at least one year or more of regular unprotected intercourse The woman is age 35 or older and she has not conceived after at least six months of regular unprotected intercourse Six months of unsuccessful donor insemination, or Impotence/sexual dysfunction. Therapeutic Treatments (Outpatient) on page 81. In the case of treatment after sterilization, the attempt at conception requirement would be waived. 69

70 UnitedHealthcare Plans Coverage maximums include: Ovulation induction and retrieval of eggs HRA and HRA Plus Plans A lifetime maximum benefit of $7,500 under medical, subject to the deductible and co-insurance (in- and out-of-network benefits combined) In vitro fertilization, and Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices An increased lifetime maximum benefit under medical of $2,500 from $7,500 to $10,000 if patient meets criteria for single embryo transfer and chooses this option. RRS must be notified before this procedure. A separate prescription drug benefit for infertility administered through Express Scripts, with a lifetime maximum benefit of $2,500. To enroll in the RRS program, call , Monday through Friday, 8:00 a.m. to 5:00 p.m. Central Time. The plan pays benefits for infertility services and associated expenses, including: Diagnosis and treatment of an underlying medical condition that causes infertility, when under the direction of a physician In vitro fertilization (IVF), gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), IUI, ICSI, and TESA/ MESA Embryo transport Donor ovum and semen and related costs, including collection, preparation and storage, and Artificial insemination. Individuals or Same-Sex Couples A female without a male partner may be considered infertile if she is unable to conceive or maintain pregnancy after six cycles of donor insemination; proof of insemination must be provided. If conception is not achieved with insemination, the member would then become eligible for advanced reproductive treatment, including in vitro fertilization (IVF). A male without a female partner is not covered for artificial insemination of a female surrogate. He is covered for the diagnosis and treatment of male factor infertility (e.g., treatment of sperm abnormalities including the surgical recovery of sperm). Injections (in a Physician s Office) The plan pays benefits for injections administered in the physician s office, for example allergy immunotherapy, when no other health service is received. Lab, X-ray, and Diagnostics (Outpatient) Services received on an outpatient basis at a hospital or alternate facility to diagnose sickness and injuries include, but are not limited to: Lab and radiology/x-ray The plan pays for infertility services when planned cancer treatment is likely to produce infertility. Coverage is limited to: Mammography. Collection of sperm Lab, X-ray and diagnostic services for preventive care are described under Preventive Care on page 75. Cryopreservation of sperm 70 Embryo cryopreservation (long-term cryopreservation costs anything longer than three months are the responsibility of the member).

71 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Lab, X-ray, and Major Diagnostics: CT, PET Scans, MRI, MRA, and Nuclear Medicine (Outpatient) Services for CT scans, PET scans, MRI, MRA, nuclear medicine, and major diagnostic services received on an outpatient basis at a hospital or alternate facility are covered under the plan. Mental Health Services Mental health services include those services received on an inpatient basis in a hospital or alternate facility, and those received on an outpatient basis in a provider s office or at an alternate facility. Benefits include the following services provided on either an outpatient or inpatient basis: Diagnostic evaluations and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group, and provider-based case management services The mental health/substance use disorder (MH/SUD) administrator determines coverage for the inpatient treatment. Required inpatient stays are covered on a semi-private room (a room with two or more beds) basis. You are encouraged to contact the MH/SUD administrator for referrals to providers and coordination of care. Special Mental Health Programs and Services Special programs and services that are contracted under the MH/ SUD administrator may be available to you as part of your mental health services benefit. The mental health services benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, partial hospitalization/day treatment, intensive outpatient treatment, outpatient, or a transitional care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your mental illness which may not otherwise be covered under this plan. Any decision to participate in such program or service is at the discretion of the covered person and is not mandatory. Crisis intervention. Benefits include the following services provided on an inpatient basis: Partial hospitalization/day treatment Services at a residential treatment facility. Benefits include the following services provided on an outpatient basis: Notify the MH/SUD Administrator at For out-of-network benefits, you must call the MH/SUD administrator to receive inpatient benefits in advance of any treatment. Without notification, your benefits will be reduced by $250. Intensive outpatient treatment. 71

72 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Neonatal Resource Services (NRS) The plan pays benefits for neonatal intensive care unit (NICU) services provided by designated facilities participating in the Neonatal Resource Services (NRS) program. NRS provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to manage NICU admissions. Benefits include the following services provided on either an outpatient or inpatient basis: To receive benefits under this program, the in-network provider must notify NRS or Personal Health Support if the newborn s NICU stay is longer than the mother s hospital stay. Medication management You or a covered dependent may also call Personal Health Support, or call NRS toll-free at and select the NRS prompt. To receive NICU benefits, you are not required to visit a designated facility. If you receive services from a facility that is not a designated facility, the plan pays benefits according to plan provisions outlined in this SPD. Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders The plan pays benefits for psychiatric services for autism spectrum disorders that are: Provided by or under the direction of an experienced psychiatrist and/or an experienced licensed psychiatric provider, and Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others, and property and impairment in daily functioning. These benefits describe only the psychiatric component of treatment for autism spectrum disorders. treatment of autism spectrum disorders is a covered health service for which benefits are available under the applicable medical covered health services categories described in this section. 72 Diagnostic evaluations and assessment Treatment planning Referral services Individual, family, therapeutic group, and provider-based case management services Crisis intervention. Benefits include the following services provided on an inpatient basis: Partial hospitalization/day treatment Services at a residential treatment facility. Benefits include the following services provided on an outpatient basis: Intensive outpatient treatment. The mental health/substance use disorder (MH/SUD) administrator determines coverage for the inpatient treatment. Required inpatient stays are covered on a semi-private room basis. You are encouraged to contact the MH/SUD administrator for referrals to providers and coordination of care. Notify the MH/SUD Administrator at For out-of-network benefits, you must call the MH/SUD administrator to receive inpatient benefits in advance of any treatment. Without notification, your benefits will be reduced by $250.

73 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Nutritional Counseling The plan will pay for medical education services provided in a physician s office by an appropriately licensed or health care professional when: Education is required for a disease in which patient selfmanagement is an important component of treatment, and The patient lacks the knowledge to manage the disease, which requires the intervention of a trained health professional. Pouches, face plates, and belts Irrigation sleeves, bags, and ostomy irrigation catheters, and Skin barriers. Coronary artery disease Physician Fees for Surgical and Services The plan pays physician fees for surgical procedures and other medical care received from a physician in: Congestive heart failure MVP HMO Plan Severe obstructive airway disease MCS Plan (Puerto Rico) Gout (a form of arthritis) Important Plan Notices Renal failure A hospital A skilled nursing facility Phenylketonuria (a genetic disorder diagnosed at infancy) Hyperlipidemia (excess of fatty substances in the blood). Benefits are limited to three individual sessions for each medical condition per person. Obesity Surgery The plan covers surgical treatment of obesity received on an inpatient basis provided all of the following are true: You have a minimum Body Mass Index (BMI) of 40; however, if you have complicating co-morbidities (such as sleep apnea or diabetes) directly related to, or exacerbated by obesity, your minimum BMI is 35, and The surgery is performed at an in-network hospital by an innetwork surgeon even if there are no in-network hospitals near you. 73 Ostomy Supplies Benefits for ostomy supplies are limited to: Some examples of such medical conditions include: Kaiser Hawaii HMO Plan Note: Benefits are available for obesity surgery services that meet the definition of a covered health service and are not experimental or investigational or unproven services. An inpatient rehabilitation facility, or An alternate facility. The plan also pays benefits for a physician making a house call. When these services are performed in a physician s office, benefits are described under Physician s Office Services below. Physician s Office Services Benefits are paid by the plan for covered health services received in a primary physician s office for the evaluation and treatment of a sickness or injury, including hearing exams in case of sickness or injury. Benefits for preventive services are described under Preventive Care on page 75. Coverage includes: Primary care physician office visits/home visits Specialist physician office visits

74 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Surgeries done in the physician s office. The plan will pay benefits for an inpatient stay of at least: Specialist office visits do not require a referral from your primary care physician. A specialist is a physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/gynecology, family practice or general medicine. 48 hours for the mother and newborn child following a vaginal delivery, or If your network provider refers you to an out-of-network specialist, you will be subject to the out-of-network benefit for all services received from the out-of-network provider. Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important! Your physician does not have a copy of your SPD, and is not responsible for knowing or communicating your benefits. Important Plan Notices Podiatry The plan pays for routine foot care for severe systemic disease only. Coverage includes removal of warts, corns or calluses, the cutting and trimming of toenails, foot care for flat feet, fallen arches, and chronic foot strain. Coverage also includes corrections necessary due to birth defects, accidents, fractures, bunions or diabetes. Pregnancy (Maternity Services) Benefits are provided for pregnancy care. This includes all maternity-related medical services for pre-natal care, post-natal care, delivery and any related complications. Coverage includes birthing centers and nurse midwives. 96 hours for the mother and newborn child following a Cesarean section delivery. These are the federally mandated requirements under the Newborns and Mothers Health Protection Act of 1996, which apply to this plan. The hospital or other provider is not required to get authorization for the time periods stated above. Authorizations are required for longer lengths of stay. If the mother agrees, the attending physician may discharge the mother and/or the newborn child earlier than these minimum timeframes. Both before and during a pregnancy, benefits include the services of a genetic counselor when provided or referred by a physician. These benefits are available to all covered persons in the immediate family. Covered health services include related tests and treatment. Healthy Pregnancy Program The plan provides a special pre-natal program to help during pregnancy. Participation is voluntary and free of charge. For details, see UnitedHealthcare Plan Resources on page 53. Services for an eligible child s pregnancy are covered. 74

75 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Notify Personal Health Support at For out-of-network benefits, you must notify Personal Health Support as soon as reasonably possible if the inpatient stay for the mother and/or the newborn will be longer than the timeframes indicated. If Personal Health Support is not notified, your benefits for the extended stay at an out-of-network hospital or facility will be reduced by $250. Type of Service Description Physician Office Routine physical, including vision and hearing Services screenings Phenylketonuria (PKU) tests Immunizations1 (except travel) Well-baby and well-child care up to age 6 Women s preventive health services, including: - Routine gynecological exam including breast and pelvic examination, treatment of minor infections, and PAP test Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices - Sexually-transmitted infection counseling Preventive Care The plan pays for services for basic preventive medical care provided on an outpatient basis at a physician s office, alternate facility or hospital. - HIV screening and counseling - Domestic violence screening and counseling. In general, the plan pays preventive care benefits at no cost sharing to participants and dependents based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) although other preventive care services may be covered as well. Your physician may recommend additional services based on your family or medical history. Examples of preventive medical care are outlined in the following table. 75 Mammogram Preventive Services Colorectal cancer screening and Tests Cervical cancer screening Bone mineral density tests Gestational diabetes screening HPV DNA testing FDA-approved contraception methods and counseling Breastfeeding support, supplies and counseling. 1 Lab, X-ray or Other Covered childhood immunizations generally include: Diptheria-tetanuspertussis (DTP), Oral poliovirus (OPV), Measles-mumps-rubella (MMR), Conjugate haemophilus influenza type B, Hepatitis B, Rotavirus vaccine, Varicella (Chicken Pox), and human papilloma virus (HPV) vaccine (Gardasil for females and males ages 9 18 and Cervarix for females ages 9 18).

76 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Breast Pump Coverage Preventive care benefits include the cost of renting one breast pump per pregnancy in conjunction with childbirth. Benefits for breast pumps also include the cost of purchasing one breast pump per pregnancy in conjunction with childbirth. Benefits are only available if breast pumps are obtained from an in-network durable medical equipment provider or physician. To rent or purchase a breast pump, contact a network physician, hospital or durable medical equipment (DME) supplier. UnitedHealthcare has contracted with national DME suppliers who can ship the breast pump directly to you. The physician, hospital or DME supplier will bill UnitedHealthcare directly for reimbursement. If you need assistance in locating a network provider or have questions, contact UnitedHealthcare at Important: You cannot obtain a breast pump until your baby is born. Also, if you purchase the breast pump at retail it will not be covered. Breast Feeding Supplies The following breastfeeding supplies are covered with a preventive diagnosis and can be received from the provider of the breast pump: Lactation Counseling If you need counseling, contact UnitedHealthcare at , the hospital where your baby was delivered or your OB/GYN to find a resource. Access to Preventive Care Benefits makes access to preventive care benefits as easy as possible. There Are No: This Means Previous If you have been treated for breast cancer or colon diagnosis cancer, the first annual mammogram or colonoscopy limitations for billed during the plan year will be covered as a mammograms preventive service instead of a diagnostic service. and colonoscopies Age Screenings such as a mammogram and colonoscopy limitations for will be covered once during the plan year regardless mammograms of your age. and colonoscopies If you have a family history of breast, colon, or prostate cancer, you can have the appropriate screening without having reached the recommended age for that screening (as recommended in the Preventive Care Guidelines). Annual Adaptor Cap for Breast Pump Bottle Breast Shield and Splash Protector If you have been diagnosed with a chronic physical condition such as diabetes, your annual physical limitations will be covered as a preventive service instead of a for chronic diagnostic service. conditions Polycarbonate Bottle Replacement Your annual physical will be covered at 100% of eligible expenses (and your HRA dollars won t be Locking Ring. used). 100% of eligible expenses with no dollar limit (your HRA dollars won t be used). Tubing Replacement 76 Your mammogram or colonoscopy will be covered at

77 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Private Duty Nursing (Outpatient) The plan covers private duty nursing care given on an outpatient basis by a licensed nurse such as a registered nurse (R.N.), licensed practical nurse (L.P.N.), or licensed vocational nurse (L.V.N.). Any combination of in- and out-of-network benefits is limited to a 20-visit lifetime maximum per covered person during the entire period you are covered under the plan. Kaiser Hawaii HMO Plan Prosthetic Devices Benefits are paid for prosthetic devices and appliances that replace a limb or body part, or help an impaired limb or body part work. Examples include, but are not limited to: MVP HMO Plan Artificial limbs MCS Plan (Puerto Rico) Artificial eyes Other Important Information Kaiser California HMO Plan Important Plan Notices Breast prosthesis following mastectomy as required by the Women s Health and Cancer Rights Act of 1998, including mastectomy bras and lymphedema stockings for the arm. If more than one prosthetic device can meet your functional needs, benefits are available only for the most cost-effective prosthetic device. The device must be ordered or provided either by a physician, or under a physician s direction. Benefits are provided for the replacement of a type of prosthetic device once every five plan years. At UnitedHealthcare s discretion, prosthetic devices may be covered for damage beyond repair with normal wear and tear, when repair costs are less than the cost of replacement or when a change in the covered person s medical condition occurs sooner than the five-year timeframe. Replacement of artificial limbs or any part of such devices may be covered when the condition of the device or part requires repairs that cost more than the cost of a replacement device or part. 77 Note: Prosthetic devices are different from durable medical equipment. For more information, see Durable Equipment (DME) on page 64. Reconstructive Procedures Reconstructive procedures are services performed when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function for an organ or body part. Reconstructive procedures include surgery or other procedures associated with an injury, sickness, or congenital anomaly. The primary result of the procedure is not a changed or improved physical appearance. Improving or restoring physiologic function means that the organ or body part is made to work better. An example of a reconstructive procedure is surgery on the inside of the nose to improve or restore a person s breathing. Breast Reconstruction Procedures Benefits for reconstructive procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the plan if the initial breast implant followed a mastectomy. Other services required by the Women s Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other covered health service. You can contact UnitedHealthcare at the telephone number on your ID card for more information about benefits for mastectomy-related services.

78 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Other Procedures There may be times when the primary purpose of a procedure is to make a body part work better. However, in other situations, the purpose of the same procedure is to improve the appearance of a body part. Cosmetic procedures are excluded from coverage. Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic procedures. An example is upper eyelid surgery. At times, this procedure will be done to improve vision, which is considered a reconstructive procedure. In other cases, improvement in appearance is the primary intended purpose, which is considered a cosmetic procedure. This plan does not provide benefits for cosmetic procedures. The fact that a covered person may suffer psychological consequences or socially avoidant behavior as a result of an injury, sickness, or congenital anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. Notify Personal Health Support at You must notify Personal Health Support at least five business days before undergoing a reconstructive procedure. When you provide notification, Personal Health Support can determine whether the service is considered reconstructive or cosmetic. Cosmetic procedures are always excluded from coverage. Rehabilitation Services (Outpatient Therapy) The plan provides short-term outpatient rehabilitation services for the following types of therapy: Physical therapy Occupational therapy Speech therapy Pulmonary rehabilitation Cardiac rehabilitation, and Post Cochlear Implant Aural Therapy. All rehabilitation services must be performed by a licensed therapy provider, under the direction of a physician. Benefits under this section include rehabilitation services provided in a physician s office or on an outpatient basis at a hospital or alternate facility. The plan requires a physician referral and assessment to determine the length of treatment. The plan will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, sickness, stroke, cancer, developmental delays, or a congenital anomaly, or is needed following the placement of a cochlear implant. The following maximums apply to in- and out-of-network benefits combined: 40 visits per plan year for physical therapy 40 visits per plan year for occupational therapy 40 visits per plan year for speech therapy 40 visits per plan year for pulmonary rehabilitation therapy 40 visits per plan year for cardiac rehabilitation therapy. 78

79 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Reproductive Resource Services (RRS) The plan pays benefits for infertility services provided under the Reproductive Resource Services (RRS) program, as described in Infertility Services on page 69. You will have access to a certain network of facilities and physicians participating in the RRS program for infertility services. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services Facility services for an inpatient stay in a skilled nursing facility or inpatient rehabilitation facility are covered by the plan. Benefits include: For infertility services and supplies to be considered covered health services, you must contact Reproductive Resource Services and speak with a nurse consultant before receiving services. You can contact RRS by calling, toll-free, Room and board in a semi-private room (a room with two or more beds). If you receive infertility services that are not performed as part of the Reproductive Resource Services program, the plan pays benefits according to plan provisions outlined in this SPD. Scopic Procedures (Outpatient Diagnostic and Therapeutic) The plan pays for diagnostic and therapeutic scopic procedures and related services received on an outpatient basis at a hospital or alternate facility. Diagnostic scopic procedures are those for visualization, biopsy, and polyp removal. Examples of diagnostic scopic procedures include colonoscopy, sigmoidoscopy and endoscopy. Note: Benefits under this section do not include surgical scopic procedures, which are for the purpose of performing surgery. Benefits for surgical scopic procedures are described under Surgery (Outpatient) on page 81. Examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy and hysteroscopy. Non-physician services and supplies received during the inpatient stay Benefits are available when skilled nursing and/or inpatient rehabilitation facility services are needed daily. Benefits are also available in a skilled nursing facility or inpatient rehabilitation facility for treatment of a sickness or injury that would have otherwise required an inpatient stay in a hospital. UnitedHealthcare will determine if benefits are available by reviewing both the skilled nature of the service and the need for physician-directed medical management. A service will not be determined to be skilled simply because there is not an available caregiver. Benefits are available only if: The initial confinement in a skilled nursing facility or inpatient rehabilitation facility was or will be a cost-effective alternative to an inpatient stay in a hospital, and You will receive skilled care services that are not primarily custodial care. Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when: It is delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient It is ordered by a physician 79

80 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information It is not delivered for the purpose of assisting with activities of daily living, including, but not limited to, dressing, feeding, bathing, or transferring from a bed to a chair It requires clinical training in order to be delivered safely and effectively, and You are expected to improve to a predictable level of recovery. Note: The plan does not pay benefits for custodial care or domiciliary care, even if ordered by a physician. Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Notify Personal Health Support at For out-of-network benefits, you must notify Personal Health Support: For elective admissions, at least five business days before admission For emergency admissions (also called non-elective admissions), within two business days, or as soon as is reasonably possible. If Personal Health Support is not notified, your benefits will be reduced by $250. maintain a level of functioning or to prevent a medical problem from occurring or recurring. Benefits include diagnosis and related services. The plan limits any combination of in- and out-of-network benefits for spinal treatment to one visit per day up to 20 visits per plan year. Substance Use Disorder Services Substance use disorder services include those received on an inpatient basis in a hospital or an alternate facility and those received on an outpatient basis in a provider s office or at an alternate facility. Benefits include the following services provided on either an inpatient or outpatient basis: Diagnostic evaluations and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group, and provider-based case management Crisis intervention Detoxification (sub-acute/non-medical). Spinal Treatment, Chiropractic, and Osteopathic Manipulative Therapy The plan pays benefits for spinal treatment when provided by an in-network or out-of-network spinal treatment specialist in the specialist s office. Covered health services include chiropractic and osteopathic manipulative therapy. The plan gives UnitedHealthcare the right to deny benefits if treatment ceases to be therapeutic and is instead administered to 80 Benefits include the following services provided on an inpatient basis: Partial hospitalization/day treatment Services at a residential treatment facility. Benefits include the following services provided on an outpatient basis: Intensive outpatient treatment.

81 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices The mental health/substance use disorder (MH/SUD) administrator determines coverage for the inpatient treatment. Required inpatient stays are covered on a semi-private room basis. You are encouraged to contact the MH/SUD administrator for referrals to providers and coordination of care. Special Substance Use Disorder Programs and Services Special programs and services that are contracted under the MH/SUD administrator may be available to you as part of your substance use disorder services benefit. The substance use disorder services benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, partial hospitalization/ day treatment, intensive outpatient treatment, outpatient, or a transitional care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your substance use disorder which may not otherwise be covered under this plan. Any decision to participate in such program or service is at the discretion of the covered person and is not mandatory. Notify the MH/SUD Administrator at For out-of-network benefits, you must call the MH/SUD administrator to receive inpatient benefits in advance of any treatment. Without notification, your benefits will be reduced by $ Surgery (Outpatient) The plan pays for surgery and related services received on an outpatient basis at a hospital or alternate facility. Benefits under this section include: The facility charge and the charge for supplies and equipment Certain surgical scopic procedures (examples of surgical scopic procedures include arthroscopy, laparoscopy, bronchoscopy, hysteroscopy). Therapeutic Treatments (Outpatient) The plan pays benefits for therapeutic treatments received on an outpatient basis at a hospital or alternate facility, including, but not limited to, dialysis (both hemodialysis and peritoneal dialysis), intravenous chemotherapy or other intravenous infusion therapy, and radiation oncology. Covered health services include medical education services that are provided on an outpatient basis at a hospital or alternate facility by appropriately licensed or registered health care professionals when: Education is required for a disease in which patient selfmanagement is an important component of treatment, and There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional. Transplant Services Inpatient facility services (including evaluation for transplant, organ procurement and donor es) for transplant procedures must be ordered by an in-network provider and received at a designated facility. Benefits are available to the donor and the recipient when the recipient is covered under this plan. The transplant must meet the definition of a covered health service and cannot be experimental or investigational, or unproven.

82 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Examples of transplants for which benefits are available include, but are not limited to: Heart Heart/lung Donor Costs Donor costs that are directly related to organ removal are covered health services for which benefits are payable through the organ recipient s coverage under the plan. The plan has specific guidelines regarding benefits for transplant services. Contact United Resource Networks at or Personal Health Support at for information about these guidelines. Lung Kidney Kidney/pancreas Liver Kaiser Hawaii HMO Plan Liver/intestinal Travel and Lodging United Resource Networks will assist the patient and family with travel and lodging arrangements related to: MVP HMO Plan Pancreas Congenital heart disease (CHD) MCS Plan (Puerto Rico) Intestinal Transplantation services, and Bone marrow (either from you or from a compatible donor) and peripheral stem cell transplants, with or without high dose chemotherapy. Cancer-related treatments. Note: Not all bone marrow transplants meet the definition of a covered health service. The for bone marrow/stem cells from a donor who is not biologically related to the patient is a covered health service only for a transplant received at a designated facility. The plan covers expenses for travel and lodging for the patient (provided he or she is not covered by Medicare) and a companion as follows: Kaiser California HMO Plan Important Plan Notices Liver/kidney Cornea Transplants Benefits are also available for cornea transplants that are provided by a provider at a hospital. You are not required to notify United Resource Networks or Personal Health Support of a cornea transplant and the cornea transplant is not required to be performed at a designated facility. 82 For travel and lodging services to be covered, the patient must be receiving services at a designated facility. Transportation of the patient and one companion who is traveling on the same day(s) to and/or from the site of the cancer-related treatment, the CHD service, or the transplant for the purposes of an evaluation, the procedure, or necessary postdischarge follow-up Eligible expenses for lodging for the patient (while not a hospital inpatient) and one companion. Benefits are paid at a per diem (per day) rate of up to $50 per day for the patient or up to $100 per day for the patient plus one companion, or

83 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information If the patient is an enrolled dependent minor child, the transportation expenses of two companions will be covered, and lodging expenses will be reimbursed at a per diem rate of up to $100 per day. Travel and lodging expenses are covered only if the recipient lives more than 50 miles from the designated facility (for CRS and transplantation) or the CHD facility. UnitedHealthcare must receive valid receipts for such charges before you will be reimbursed. Examples of travel expenses may include: Kaiser California HMO Plan Airfare at coach rate Kaiser Hawaii HMO Plan Taxi or ground transportation, or MVP HMO Plan Mileage reimbursement at the IRS rate for the most direct route between the patient s home and the designated facility. MCS Plan (Puerto Rico) Important Plan Notices If you or a covered family member has cancer or needs an organ or bone marrow transplant, UnitedHealthcare can put you in touch with quality treatment centers around the country. Urgent Care Center Services The plan provides benefits for services, including professional services, received at an urgent care center. When urgent care services are provided in a physician s office, the plan pays benefits as described under Physician s Office Services on page 73. There is a combined overall lifetime maximum benefit of $10,000 per covered person for all transportation and lodging expenses incurred by the transplant recipient and companion(s) and reimbursed under this plan in connection with all transplant procedures. 83 Support During a Serious Illness

84 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Under the UnitedHealthcare Plans Air conditioners The following items are excluded and not considered covered medical services under the UnitedHealthcare plans. This information should help identify certain common services that may be misconstrued as covered medical services. The list of ineligible expenses is in no way a limitation upon, or a complete listing of, the items that are considered to be ineligible expenses. Guest service Beauty/barber service Note: In listing services or examples, when the SPD says this includes, or including, but not limited to, it is not UnitedHealthcare s intent to limit the description to that specific list. When the plan does intend to limit a list of services or examples, the SPD specifically states that the list is limited to. Alternative Treatments Aromatherapy Hypnotism Rolfing (holistic tissue massage) Naturopath services Other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health, such as herbal medicine or holistic or homeopathic care, including drugs. Comfort and Convenience Supplies, equipment, and similar incidentals for personal comfort, including, but not limited to: Television Dehumidifiers and humidifiers Ergonomically correct chairs Non-hospital beds and comfort beds Devices and computers to assist in communication and speech Home remodeling to accommodate a health need (including, but not limited to, ramps, swimming pools, elevators, handrails, and stair glides). Note: This exclusion does not apply to dental care (oral examination, X-rays, extractions, and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which benefits are available under the plan. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), when the services are considered medical or dental in nature, including oral appliances Preventive dental care Diagnosis or treatment of the teeth or gums, including, but not limited to: - Extractions (including wisdom teeth) Telephone - Restoration and replacement of teeth Batteries and battery chargers Dental Dental care, except as identified under Dental Services (Accident Only) on page 63 Massage therapy 84 Air purifiers and filters

85 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices - or surgical treatments of dental conditions such as malocclusion - Services to improve dental clinical outcomes. Dental implants and braces - Cutting or removal of corns and calluses Dental X-rays, supplies and appliances, and all associated expenses, including hospitalizations and anesthesia - Nail trimming or cutting Treatment of malpositioned or supernumerary (extra) teeth, even if part of a congenital anomaly such as cleft lip or cleft palate. Drugs The exclusions listed below apply to the medical portion of the plan only. Prescription drug coverage is excluded under the medical plan because it is a separate benefit. Coverage may be available under the prescription drug portion of the plan. For more information, see Prescription Drug Plan on page 117. Prescription drugs for outpatient use that are filled by a prescription order or refill Self-injectable medications Non-injectable medications given in a physician s office, except as required in an emergency and consumed in the physician s office Over-the-counter drugs and treatments. Experimental or Investigational or Unproven Services Experimental or investigational services or unproven services, unless the plan has agreed to cover them. This exclusion applies even if experimental or investigational services or unproven services, treatments, devices, or pharmacological regimens are the only available treatment options for your condition. 85 Foot Care Routine foot care, except when needed for severe systemic disease. Routine foot care services that are not covered include: - Debriding (removal of dead skin or underlying tissue). Hygienic and preventive maintenance foot care. Examples include: - Cleaning and soaking the feet - Applying skin creams in order to maintain skin tone - Other services that are performed when there is not a localized sickness, injury, or symptom involving the foot. Treatment of flat feet Shoe inserts, unless prescribed by a physician Arch supports, unless prescribed by a physician Shoes (standard or custom), lifts and wedges (except for custom molded shoe inserts prescribed to treat a disease or illness of the foot). Gender Identity Disorder The following are not covered treatments: Reversal of genital surgery or reversal of surgery to revise secondary sex characteristics Sperm preservation in advance of hormone treatment or gender surgery Cryopreservation of fertilized embryos Voice modification surgery

86 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Facial feminization surgery, including, but not limited to: facial bone reduction, face lift, facial hair removal, and certain facial plastic procedures Suction-assisted lipoplasty of the waist Rhinoplasty (except if reconstructive criteria for rhinoplasty is met) Blepharoplasty (except if reconstructive criteria for blepharoplasty is met) Surgical or hormone treatment on plan members under 18 years of age Kaiser Hawaii HMO Plan Surgical treatment not preauthorized by UnitedHealthcare MVP HMO Plan Drugs for hair loss or growth MCS Plan (Puerto Rico) Drugs for sexual performance or cosmetic purposes (except for hormone therapy as specifically covered under the plan) Important Plan Notices - Elastic stockings, ace bandages, diabetic strips, syringes, and - Tubings, nasal cannulas, connectors, and masks that are not used in connection with durable medical equipment. Mental Health/Substance Use Disorder Services performed in connection with conditions not classified in the current edition of the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders Mental health services as treatments for V-code conditions as listed within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association Transportation, meals, lodging, or similar expenses associated with treatment of gender identity disorder. Mental health services as a treatment for a primary diagnosis of insomnia, other sleep disorders, sexual dysfunction disorders, neurological disorders, and other disorders with a known physical basis Jawbone Surgery Diagnosis or treatment of the jawbones, including orthognathic surgery (procedure to correct underbite or overbite), except as treatment of obstructive sleep apnea Treatment for the primary diagnoses of learning disabilities, conduct and impulse control disorders, personality disorders, and paraphilias (sexual behavior that is considered deviant or abnormal) Upper and lower jawbone surgery, except as required for direct treatment of acute traumatic injury, tumor, or cancer. Educational/behavioral services that are focused on primarily building skills and capabilities in communication, social interaction, and learning Voice therapy, and Supplies and Appliances Devices used specifically as safety items or to affect performance in sports-related activities 86 Prescribed or non-prescribed medical and disposable supplies, except for ostomy bags and related supplies, and urinary catheters. Examples of supplies that are not covered include, but are not limited to: Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act

87 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Learning, motor skills, and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association Mental retardation as a primary diagnosis defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association Intensive behavioral therapies such as applied behavioral analysis for autism spectrum disorders Services utilizing methadone, L.A.A.M. (1-Alpha-AcetylMethadol), Cyclazocine, or their equivalents as maintenance treatment for drug addiction Psychosurgery (lobotomy) Services and supplies for the diagnosis or treatment of mental illness, alcoholism, or substance use disorders that, in the reasonable judgment of the mental health/substance use disorder (MH/SUD) administrator, are any of the following: - Not consistent with generally accepted standards of medical practice for the treatment of such conditions - Not consistent with services backed by credible re soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and therefore considered experimental - Not consistent with the MH/SUD administrator s level of care guidelines or best practices as modified from time to time, or - Not clinically appropriate for the patient s mental illness, substance use disorder, or condition based on generally accepted standards of medical practice and benchmarks. 87 Nutrition and Health Education Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements, and other nutrition-based therapy Nutritional counseling for either individuals or groups, except as defined under Nutritional Counseling on page 73 Health club memberships and programs, and spa treatments Health education classes unless offered by UnitedHealthcare or its affiliates, including, but not limited to, asthma, smoking cessation and weight control classes Food of any kind. Foods that are not covered include: - Enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk, nutritional supplements, dietary supplements, electrolyte supplements, diets for weight control or treatment of obesity (including liquid diets or food), food of any kind (diabetic, low fat, cholesterol), oral vitamins, and oral minerals (unless they are the only source of nutrition and are specifically created to treat inborn errors of metabolism such as phenylketonuria (PKU)) infant formula over the counter is always excluded - Foods to control weight, treat obesity (including liquid diets), lower cholesterol or control diabetes - Oral vitamins and minerals - Meals you can order from a menu, for an additional charge, during an inpatient stay - Other dietary and electrolyte supplements.

88 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Physical Appearance Cosmetic procedures are excluded from coverage. Examples include: - Liposuction Pregnancy and Infertility Surrogate parenting The reversal of voluntary sterilization Additional Information for UnitedHealthcare Plans - Pharmacological regimens Artificial reproductive treatments done for genetic or eugenic (selective breeding) purposes What s Covered - Nutritional procedures or treatments Services provided by a doula (labor aide) - Tattoo or scar removal or revision procedures (such as salabrasion, chemosurgery, and other such skin abrasion procedures) Parenting, pre-natal, or birthing classes - Replacement of an existing intact breast implant if the earlier breast implant was performed as a cosmetic procedure. Home ovulation prediction kits Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion, or general motivation Weight loss programs whether or not they are under medical supervision or for medical reasons, even if for morbid obesity Wigs, regardless of the reason for the hair loss (except for loss of hair resulting from treatment of a malignancy or permanent loss of hair from an accidental injury) Sperm injection Gestational carrier programs. Providers Services: Performed by a provider who is a family member by birth or marriage, including your spouse or partner, brother, sister, parent or child A provider may perform on himself or herself Performed by a provider with your same legal residence Treatments for hair loss Ordered or delivered by a Christian Science practitioner A procedure or surgery to remove fatty tissue such as panniculectomy, abdominoplasty, thighplasty, brachioplasty, or mastopexy Performed by an unlicensed provider or a provider who is operating outside of the scope of his/her license Varicose vein treatment of the lower extremities when it is considered cosmetic Provided at a diagnostic facility (hospital or free-standing) without a written order from a provider Treatment of benign gynecomastia (abnormal breast enlargement in males). That are self-directed to a free-standing or hospital-based diagnostic facility 88 Fetal surgery, unless as described under Congenital Heart Disease (CHD) on page 62 Provided by foreign language and sign language interpreters

89 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Ordered by a provider affiliated with a diagnostic facility (hospital or free-standing), when that provider is not actively involved in your medical care: - Before ordering the service, or - After the service is received. Note: This exclusion does not apply to mammography testing. Services Provided Under Another Plan Services for which coverage is available: Donor costs for organ or tissue transplantation to another person (these costs may be payable through the recipient s benefit plan). Travel Travel or transportation expenses, even if ordered by a physician, except as identified under Travel and Lodging on page 82. Under another plan, except for eligible expenses payable as described under Coordination of Benefits on page 225 Vision and Hearing Routine vision examinations, including refractive examinations to determine the need for vision correction Under workers compensation, no-fault automobile coverage, or similar legislation if you could elect it, or could have it elected for you Purchase cost and associated fitting charges for hearing aids, bone anchored hearing aids (BAHAs), and all other hearing assistive devices that exceed $3,000 every three years While on duty with the armed forces Bone anchored hearing aids (BAHAs) except when either of the following applies: For treatment of military service-related disabilities when you are legally entitled to other coverage and facilities are reasonably accessible. Transplants Health services for organ and tissue transplants, except as identified under Transplant Services on page 81, unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare s transplant guidelines Determined by Personal Health Support not to be proven procedures for the involved diagnoses and not consistent with the diagnosis of the condition Mechanical or animal organ transplants, except services related to the implant or removal of a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available) 89 Transplants that are not performed at a designated facility (this exclusion does not apply to cornea transplants) - For covered persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid, or - For covered persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. Purchase cost of eyeglasses or contact lenses Fitting charges for eyeglasses and contact lenses Surgery and other related treatment intended to correct nearsightedness, farsightedness, presbyopia and astigmatism, including, but not limited to, procedures such as laser and other refractive eye surgery and radial keratotomy.

90 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan All Other Exclusions Autopsies and other coroner services and transportation services for a corpse Charges for: Diagnostic tests that are: - Delivered in other than a physician s office or health care facility - Self-administered home diagnostic tests, including, but not limited to, HIV and pregnancy tests. Additional Information for UnitedHealthcare Plans - Missed appointments What s Covered - Room or facility reservations Domiciliary care - Completion of claim forms Growth hormone therapy Other Important Information - Record processing Expenses for health services and supplies: Kaiser California HMO Plan - Services, supplies or equipment that are advertised by the provider as free. Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Charges by a provider sanctioned under a federal program for reason of fraud, abuse or medical competency Charges prohibited by federal anti-kickback or self-referral statutes Charges or expenses for or incident to sex change surgery or any treatment to alter physical characteristics to those of the opposite sex. This includes any complications that may be a result of such surgery or treatment. This exclusion does not apply to the treatment of gender identity disorder for which benefits are provided, as described in Gender Identity Disorder Treatment on page 66. Chelation therapy, except to treat heavy metal poisoning Claims received more than one year after the date of service Collection agency fees, interest charges, and other fees related to the collection of a debt Custodial care or services provided by a personal care assistant 90 - That, UnitedHealthcare or any other review organization that may designate, determine are not a covered health service, including any confinement or treatment given in connection with a service or supply that is not a covered health service. To determine whether a service is a covered health service,, UnitedHealthcare or any other review organization may rely upon the advice of medical peer review groups and other medical experts. This exclusion does not apply to breast pumps for which benefits are provided under the Health Resources and Services Administration (HRSA) requirement. - That are received as a result of war or any act of war, whether declared or undeclared, while part of any armed service force of any country - That are received after the date your coverage under this plan ends, including health services for medical conditions which began before the date your coverage under the plan ends - For which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under this benefit plan

91 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices - That exceed eligible expenses or any specified limitation in this SPD Services or supplies received before you or your eligible dependents become covered under the plan - For which an out-of-network provider waives the annual deductible or co-insurance amounts. Speech therapy to treat stuttering, stammering or other articulation disorders and surgical treatment of snoring, except when provided as a part of treatment for documented obstructive sleep apnea (a sleep disorder in which a person regularly stops breathing for 10 seconds or longer). Appliances for snoring are always excluded. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations, or treatments when: Speech therapy, except when required for treatment of a speech impediment or speech dysfunction that results from injury, stroke, or a congenital anomaly as identified under Rehabilitation Services (Outpatient Therapy) on page 78 Spinal treatment to treat a condition unrelated to alignment of the vertebral column, such as asthma or allergies Stand-by services required by a physician - Required solely for purposes of career, education, sports or camp, employment, insurance, marriage or adoption, or as a result of incarceration Storage of blood, umbilical cord, or other material for use in a covered health service, except if needed for an imminent surgery - Conducted for purposes of medical re The following treatments for obesity: - Related to judicial or administrative proceedings or orders, or - Non-surgical treatment, even if for morbid obesity - Required to obtain or maintain a license of any type. - Surgical treatment of obesity, unless there is a diagnosis of morbid obesity as described under Obesity Surgery on page 73. Private duty nursing received on an inpatient basis Respite care (this exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which benefits are described under Hospice Care on page 68. Rest cures Sensitivity training, educational training therapy or treatment for an education requirement Treatment of hyperhidrosis (excessive sweating) Upper and lower jawbone surgery, except as required for direct treatment of acute traumatic injury or cancer. Orthognathic surgery, jaw alignment, and treatment for the temporomandibular joint, except as a treatment for obstructive sleep apnea. Services given by volunteers or persons who do not normally charge for their services 91

92 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Other Important Information Your Relationship with UnitedHealthcare and It s important for you to understand how UnitedHealthcare interacts with s benefit plan so that you can make choices about your health care coverage and treatment. UnitedHealthcare helps administer the benefit plan in which you are enrolled. UnitedHealthcare does not provide medical services or make treatment decisions. This means: and UnitedHealthcare do not decide what care you need or will receive (you and your physician make those decisions) UnitedHealthcare is not considered to be an employer of for any purpose with respect to the administration or provision of benefits under this plan. UnitedHealthcare communicates to you decisions about whether the plan will cover or pay for the health care that you may receive (the plan pays for covered health services, which are more fully described in this SPD), and is solely responsible for: The plan may not pay for all treatments you or your physician may believe are necessary. If the plan does not pay, you will be responsible for the cost. s Relationship with Providers The relationships between, UnitedHealthcare, and innetwork providers are solely contractual relationships among independent contractors. In-network providers are not Gap Inc. s agents or employees, nor are they agents or employees of UnitedHealthcare. and any of its employees are not agents or employees of in-network providers, nor are UnitedHealthcare and any of its employees agents or employees of in-network providers. and UnitedHealthcare do not provide health care services or supplies, nor do they practice medicine. Instead, Gap Inc. and UnitedHealthcare arrange for health care providers to participate in a network and pay benefits. In-network providers 92 are independent practitioners who run their own offices and facilities. UnitedHealthcare s credentialing process confirms public information about the providers licenses and other credentials, but does not assure the quality of the services provided. and UnitedHealthcare do not have any other relationship with in-network providers such as principal-agent or joint venture. Gap Inc. and UnitedHealthcare are not liable for any act or omission of any provider. Enrollment and classification changes (including classification changes resulting in your enrollment or the termination of your coverage) The timely payment of benefits, and Notifying you of the termination or modifications to the plan. Information and Records and UnitedHealthcare may use your individually identifiable health information to administer the plan and pay claims, to identify procedures, products or services that you may find valuable, and as otherwise permitted or required by law. and UnitedHealthcare may request additional information from you to decide your claim for benefits. and UnitedHealthcare will keep this information confidential. Gap Inc. and UnitedHealthcare may also combine your data with data from other participants, remove the identities associated with the data, and use the non-personalized data for commercial purposes, including re, as permitted by law.

93 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices By accepting benefits under the plan, you authorize and direct any person or institution that has provided services to you to furnish and UnitedHealthcare with all information or copies of records relating to the services provided to you. and UnitedHealthcare have the right to request this information at any reasonable time. This applies to all covered persons, including enrolled dependents whether or not they have signed the employee s enrollment form. and UnitedHealthcare agree that such information and records will be considered confidential. and UnitedHealthcare have the right to release any and all records concerning health care services which are necessary to implement and administer the terms of the plan, for appropriate medical review or quality assessment, or as is required to do by law or regulation. During and after the term of the plan, and UnitedHealthcare and its related entities may use and transfer the information gathered under the plan in a nonpersonalized format for commercial purposes, including re and analytic purposes. For complete listings of your medical records or billing statements, recommends that you contact your health care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing requested forms. If you request medical forms or records from UnitedHealthcare, they also may charge you reasonable fees to cover costs for completing the forms or providing the records. Administrative Services UnitedHealthcare may, in its sole discretion, arrange for various persons or entities to provide administrative services in regard to the plan, such as claims processing. The identity of the service providers and the nature of the services they provide may be changed from time to time at their sole discretion. UnitedHealthcare is not required to give you prior notice of any such change, and they are not required to obtain your approval. You must cooperate with those persons or entities in the performance of their responsibilities. Clerical Error If a clerical error or other mistake occurs, that error does not create a right to benefits. These errors include, but are not limited to, providing misinformation on eligibility or benefit coverage or entitlements. The terms of this plan may not be amended by oral statements made by: The plan sponsor The plan administrative committee The claims administrator, or Any other person. In the event an oral statement conflicts with any term of the plan, the plan terms will control. It is your responsibility to confirm the accuracy of statements made by UnitedHealthcare or its designees, in accordance with the terms of this SPD and other plan documents. In some cases, and UnitedHealthcare will designate other persons or entities to request records or information from or related to you, and to release those records as necessary. Our designees have the same rights to this information as does the plan administrator. 93

94 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser California HMO Plan at a Glance Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Kaiser California HMO Plan Under the Kaiser California HMO, benefits for the services described on the following pages are covered only if they are: Kaiser California HMO Plan at a Glance ly necessary The following is an overview of the benefits offered under the Kaiser California HMO plan. For additional details or questions about HMO coverage, please click to see the Evidence of Coverage for Northern California or Southern California. The documents are also available on Gapweb ( > benefits > select U.S. Full-Time Benefits, or contact the plan directly. For, see Claims Administrators and Plan Numbers on page 255. Provided, prescribed, authorized, or directed by a plan provider, and Received from a plan provider within Kaiser s service area, except where otherwise noted for: - Referrals - Kaiser s visiting member program - Emergency care - Emergency ambulance service Important! - Hospice care HMO plans do not allow you to use out-of-network providers. You will not receive benefits if you use a provider or facility outside of the HMO plan s network except for in a life-threatening emergency. - Out-of-area urgent care - Post-stabilization care (described in the Evidence of Coverage). Visit Gapweb ( benefits > select U.S. Full-Time Benefits, or refer to the Evidence of Coverage for Northern California or Southern California for additional information about your benefits, what services are available at each Kaiser facility, and the types of services that are covered and not covered by the plan. You can also visit Your ID Card You will need to present your Kaiser Permanente identification card each time you receive care and services at a Kaiser facility. It s a good idea to carry your card with you at all times. If your card is lost or damaged, please call Member Services at

95 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Features and Covered Services Feature What You Pay Annual Deductible None Annual Out-of-Pocket Maximum $1,500 per person /$3,000 per family Covered Services What You Pay What s Covered Outpatient Services Office Visits (primary and specialty care) $35 co-pay Routine Preventive Care Exams No charge Kaiser California HMO Plan Well-Child Preventive Care Visits No charge Kaiser California HMO Plan at a Glance Family Planning Visits No charge Scheduled Prenatal Care and First Postpartum Visit No charge Kaiser Hawaii HMO Plan Eye Exams (to provide a prescription for eyeglasses) Preventive visit: No charge; Diagnostic visit: $35 co-pay per visit Hearing Exams Preventive visit: No charge; Diagnostic visit: $35 co-pay per visit Other Important Information MVP HMO Plan Allergy Injections $3 co-pay per visit MCS Plan (Puerto Rico) Allergy Testing $35 co-pay per visit Important Plan Notices Immunizations No charge Therapy (physical, occupational, and speech therapy visits) $35 co-pay per visit X-rays, Lab Tests, and Diagnostic Tests $10 co-pay per procedure (Preventive X-rays, screenings, and laboratory tests: No charge); $50 co-pay for CT scans and all MRIs and PET scans Hospital Services Outpatient Surgery $150 co-pay per procedure Inpatient Hospital Stay (room and board, surgery, anesthesia, X-rays, lab tests, and drugs) $500 co-pay per admission Other Services Ambulance Service $100 co-pay per trip Durable Equipment (in accord with Kaiser s formulary guidelines) No charge Emergency Room Visits $150 co-pay per visit (waived if admitted directly to the hospital) External Prosthetic and Orthotic Devices No charge for covered devices 95

96 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Covered Services What You Pay Health Education (for specific conditions) Covered individual health education counseling: No charge Covered health education programs: No charge Home Health Care (up to 100 visits/calendar year) No charge Hospice Care No charge What s Covered Infertility Services 50% co-insurance Skilled Nursing Facility Care (up to 100 days/plan year) No charge Other Important Information Urgent Care Services $35 co-pay per visit Additional Information for UnitedHealthcare Plans Kaiser California HMO Plan Kaiser California HMO Plan at a Glance Kaiser Hawaii HMO Plan Mental Health and Substance Abuse Outpatient Mental Health Individual visits: $35 co-pay per visit/group visits: $17 co-pay per visit Substance Abuse Individual visits: $35 co-pay per visit/group visits: $5 co-pay per visit Inpatient MVP HMO Plan Mental Health $500 co-pay per admission MCS Plan (Puerto Rico) Substance Abuse (detoxification) $500 co-pay per admission Substance Abuse (rehab: transitional residential recovery services) $100 co-pay per admission Important Plan Notices (covered only when obtained through Kaiser) Retail Generic Up to 30-day supply: $15 co-pay per prescription Brand-Name Up to 30-day supply: $35 co-pay per prescription Mail-Order Program Generic Up to 100-day supply: $30 co-pay per prescription Brand-Name Up to 100-day supply: $70 co-pay per prescription Note: This is a summary of the most frequently asked about benefits and their cost sharing amounts. This chart does not describe benefits please click to see the Evidence of Coverage for Northern California or Southern California for more information about what is covered under each benefit (including exclusions and limitations) and additional benefits that are not included in this summary. The documents are also available on Gapweb ( > benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext

97 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan Plan Features Under the Kaiser Hawaii HMO, benefits for the services described on the following pages are covered only if they are: Kaiser Hawaii HMO Plan at a Glance The following is an overview of the benefits offered under the Kaiser Hawaii HMO plan. For additional details or questions about HMO coverage, click here to see the Evidence of Coverage. The document is also is available on Gapweb ( > benefits > select U.S. Full-Time Benefits, or contact the plan directly. For, see Claims Administrators and Plan Numbers on page 255. Kaiser Hawaii HMO Plan Kaiser Hawaii HMO Plan at a Glance MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices ly necessary (with some exceptions) Provided, prescribed, authorized or directed by a plan provider, and Received from a plan provider within Kaiser s service area, except where otherwise noted for: - Referrals - Kaiser s visiting member program - Emergency care Important! HMO plans do not allow you to use out-of-network providers. You will not receive benefits if you use a provider or facility outside the HMO plan s network except for a lifethreatening emergency. - Emergency ambulance service - Hospice care - Out-of-area urgent care. Visit Gapweb ( benefits > select U.S. Full-Time Benefits, or refer to your Kaiser Permanente Member Handbook for additional information about your benefits and the types of covered services that are available from each Kaiser facility some facilities only offer specific types of covered services. You can also visit Your ID Card You will need to present a picture ID and your Kaiser Permanente identification card each time you receive care and services at a Kaiser facility. It s a good idea to carry your card with you at all times. If your card is lost or damaged, please call Member Services at (Oahu) or (Neighbor Islands). 97

98 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Plan Features and Covered Services Feature What You Pay Annual Deductible None Annual Out-of-Pocket Maximum $2,500 per person/$7,500 per family (three or more members) Covered Services What You Pay What s Covered Outpatient Services Office Visits (primary and specialty care) $20 co-pay per visit Other Important Information Routine Preventive Care Exams No charge Kaiser California HMO Plan Well-Child Preventive Care Visits No charge Family Planning Visit $20 co-pay per visit Initial Prenatal Visit $20 per co-pay visit Immunizations No charge Eye Exams (to provide a prescription for eyeglasses) $20 co-pay per visit Kaiser Hawaii HMO Plan Kaiser Hawaii HMO Plan at a Glance MVP HMO Plan Therapy (physical, occupational, and speech therapy visits) $20 co-pay per visit MCS Plan (Puerto Rico) X-rays, Lab Tests, and Diagnostic Tests 10% of applicable charges Important Plan Notices Hospital Services Surgery Outpatient $20 co-pay per visit Inpatient Anesthesia Services No charge Hospital Stay $75 co-pay per day Other Services Ambulance Service 20% of applicable charges Emergency Room Visits $75 co-pay per visit Diabetes Equipment (includes glucose meters, and external insulin pumps) 50% of applicable charges Implanted Internal Prosthetics, Devices, and Aids No charge Home Health Care No charge Hospice Care No charge Skilled Nursing Facility Care (60 days/benefit period) No charge 98

99 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Covered Services What You Pay Mental Health and Substance Abuse Outpatient Mental Health $20 co-pay per visit Substance Abuse $20 co-pay per visit What s Covered Inpatient Mental Health $75 co-pay per day Other Important Information Substance Abuse $75 co-pay per day Kaiser California HMO Plan Kaiser Hawaii HMO Plan Kaiser Hawaii HMO Plan at a Glance MVP HMO Plan MCS Plan (Puerto Rico) Optical You pay all costs greater than a $150 allowance per calendar year. When an optical prescription is filled at a Kaiser Permanente Hawaii optical center, Optical 150 you may use the allowance for prescription glasses lenses/frames/lens treatment OR a prescription contact lens/contact lens exam. (covered only when obtained through Kaiser) Generic $15 co-pay for up to a 30-day supply, or $30 co-pay for a 90-day supply using our mail order program Important Plan Notices Brand-Name Contraceptive Drugs and Devices No charge Mail Order (up to a 90-day consecutive supply) $30 co-pay (two drug co-pays) $15 co-pay for up to a 30-day supply, or $30 co-pay for a 90-day supply using our mail order program Note: This is a summary of the most frequently asked about benefits and their cost sharing amounts. This chart does not describe benefits click here to see the Evidence of Coverage for more information about what is covered under each benefit (including exclusions and limitations) and additional benefits that are not included in this summary. The document is also is available on Gapweb ( > benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext

100 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan MVP HMO Plan Important! MVP HMO Plan at a Glance The following is an overview of the benefits offered under the MVP HMO plan. For additional details or questions about HMO coverage, including what the plan covers and does not cover, please click here to see to the Evidence of Coverage document. The document is also available on Gapweb ( benefits > select U.S. Full-Time Benefits, or contact MVP Health Care at Kaiser Hawaii HMO Plan MVP HMO Plan HMO plans do not allow you to use out-of-network providers. You will not receive benefits if you use a provider or facility outside the HMO plan s network except for a lifethreatening emergency. Under the MVP HMO plan, benefits are covered when delivered, arranged, or authorized by a member s primary care physician. Services that are provided by out-of-network providers are not covered unless determined to be medically necessary and arranged by an MVP physician. MVP HMO Plan at a Glance MCS Plan (Puerto Rico) Important Plan Notices Plan Features and Covered Services Feature What You Pay Plan Year Deductible None Out-of-Pocket Maximum None Covered Services What You Pay Outpatient Services Office Visits Primary care physician: $25 co-pay Specialist: $40 co-pay Preventive Services (including periodic physicals and gynecological exams) No charge Well-Baby and Well-Child Care No charge Initial Pre-natal Visit No charge Immunizations No charge X-rays, Lab Tests and Diagnostic Tests No charge; $40 co-pay for radiology and scans Vision Exam (limited to once every two years) $40 co-pay per visit 100

101 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Covered Services What You Pay Hospital Services Outpatient $75 co-pay per admission Inpatient $500 co-pay per admission¹ and $100 surgery co-pay Other Services What s Covered Advanced Infertility Services Subject to co-pay as noted for medical services Ambulance Service $100 co-pay for true emergency (if not a true emergency, not covered) Other Important Information Chiropractic Care (prescribed by your primary care provider) $40 co-pay per visit Durable Equipment 50% co-insurance Kaiser California HMO Plan Emergency Room Visits $100 co-pay per visit Kaiser Hawaii HMO Plan Home Health Care (60 visit maximum) $25 co-pay per visit MVP HMO Plan Maternity Services (physician and hospital services²) $500 co-pay and $200 delivery co-pay MVP HMO Plan at a Glance Nursery Care No charge MCS Plan (Puerto Rico) Physical Therapy (prescribed by your primary care provider; up to 30 visits per member, per calendar year; combined benefit for outpatient and office Important Plan Notices settings; combined benefit for physical therapy, occupational therapy and Urgent Care Services $40 co-pay per visit speech therapy) $25 co-pay per visit Mental Health and Substance Abuse Outpatient Mental Health (short-term, acute, or crisis intervention) $40 co-pay per visit Substance Abuse (rehabilitation) $40 co-pay per visit Inpatient Mental Health $500 co-pay per admission Substance Abuse (detoxification) $500 co-pay per admission 101

102 UnitedHealthcare Plans Covered Services HRA and HRA Plus Plans What You Pay Out-of-Area Plan Hawaii PPO Plan Retail Pharmacy (30-day supply) $10 generic $30 preferred brand-name Additional Information for UnitedHealthcare Plans $50 brand-name³ Mail Service Pharmacy (90-day supply) What s Covered $25 generic $75 preferred brand-name $125 brand-name³ Other Important Information 1 Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MVP HMO Plan at a Glance MCS Plan (Puerto Rico) Important Plan Notices Co-pay applies to the first admission only per member per plan year. Subject to inpatient hospital co-pays, excluding newborns. 3 Member Adjusted Pricing (MAC): Member pays the difference between generic and brand-name drug cost for any drug that has a generic equivalent. 2 Note: This chart is intended to provide a general outline of MVP coverage. In the event of any conflict between this document and the group or subscriber contract and any pertinent rider(s), contract and riders will be controlling. Benefits may vary by state. Personal comfort items Experimental procedures Cosmetic surgery Exclusions The following care is not covered: Reversal of voluntary sterilization Eye glasses/contact lenses Services by out-of-network providers (unless emergency or authorized by MVP) Routine foot care Custodial care Dental care for adults and TMJ. 102 Employment or insurance physicals

103 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered MCS Plan (Puerto Rico) MCS Plan at a Glance The MCS medical plan is a preferred provider organization (PPO) plan that offers health care through a network of doctors, hospitals and other health care providers. The following is an overview of benefits offered under the MCS medical plan. For additional information on the MCS plan, visit Gapweb ( benefits > select U.S. Full-Time Benefits, or contact MCS at Plan Feature What you pay Other Important Information Plan Year Deductible (For major medical expenses) $100 per person/$300 per family Kaiser California HMO Plan Co-insurance (For major medical expenses) 20% of eligible expense Out-of-Pocket Maximum (For major medical expenses) $1,500 per person/$3,750 per family Lifetime Maximum (For major medical and organ transplant expenses) $2 million per policy year Covered Services What You Pay Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Outpatient Services MCS Plan at a Glance Office Visits Generalist: $8 co-pay per visit Specialist: $10 co-pay per visit Important Plan Notices Sub-specialist: $15 co-pay per visit Hospital Services Inpatient and Outpatient $50 co-pay per admission Other Services Ambulance Service (ground) $75 co-pay per trip and a 4-trip maximum per year Emergency Room Visits (true emergency) Illness: $35 co-pay per visit/accident: No charge Prescription¹ Generic (100-day supply) $5 co-pay per prescription; 15-day supply for acute medications, 30-day supply for maintenance medications Brand-Name (100-day supply) $15 co-pay per prescription; 15-day supply for acute medications, 30-day supply for maintenance medications 1 Specialty and Biotechnology Drugs (30-day supply) 30% co-insurance (maximum $200) per prescription Mail Service Pharmacy $10 co-pay per prescription for a 90-day supply (maintenance medications only) Over-the-Counter Drug $1 co-pay Certain over-the-counter drugs are covered for $1 with a prescription. 103

104 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan Important Plan Notices Maternity Hospital Stays (Newborns and Mothers Health Protection Act) Benefits for Mastectomy-Related Services (Women s Health and Cancer Rights Act) Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection with childbirth. In general, group health plans and health insurance issuers may not: If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed MCS Plan (Puerto Rico) Surgery and reconstruction of the other breast to produce a symmetrical appearance Important Plan Notices Prostheses, and Benefits for MastectomyRelated Services Maternity Hospital Stays Medicare Part D Prescription Drug Coverage Privacy of Health Information Treatment of physical complications of all stages of the mastectomy, including lymphedemas. These benefits will be provided subject to the same deductibles, co-pays and co-insurance applicable to other medical and surgical benefits provided under your plan. For information on WHCRA benefits or details about any mastectomy-related state laws that may apply to your insured medical plan, please refer to the benefit summaries for the medical plan in which you are enrolled. The summaries are available on Gapweb or by contacting your medical plan. 104 Restrict benefits for the length of hospital stay 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). Require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay of up to 48 hours (or 96 hours). For details on any state maternity laws that may apply to your insured medical plan, please refer to the benefit summaries for the medical plan in which you are enrolled. The summaries are available on Gapweb or by contacting your medical plan. Medicare Part D Prescription Drug Coverage The plan administrator has determined that the prescription drug coverage offered as part of the medical benefits is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered creditable coverage. Employees can keep this coverage and not pay a higher premium (a penalty) if they later decide to join a Medicare drug plan. The plan administrator will distribute certificates of creditable coverage to employees upon participation in this plan, during each subsequent Open

105 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Benefits for MastectomyRelated Services Enrollment period, and any time the prescription drug coverage ends or is no longer considered creditable. Privacy of Health Information The receipt, use, and disclosure of protected health information is governed by regulations issued under the Health Insurance Portability and Accountability Act (commonly referred to as HIPAA). In accordance with these regulations, the plan administrator, certain employees working with, and on behalf of, the plan and the plan s business associates may receive, use and disclose protected health information in order to carry out the payment, treatment, and health care operations under the plan. These entities and individuals may use protected health information for such purposes without your authorization. If your protected health information is used or disclosed for any other purpose (other than as specifically required or authorized under HIPAA), the plan must first obtain your written authorization for such use or disclosure. Maternity Hospital Stays Medicare Part D Prescription Drug Coverage Privacy of Health Information 105

106 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Term Definition Addendum Any attached written description of additional or revised provisions to the plan. The benefits and exclusions of this SPD and any amendments thereto shall apply to the addendum except that in the case of any conflict between the addendum and SPD and/or amendments to the SPD, the addendum shall be controlling. Alternate facility A health care facility that is not a hospital and that provides one or more of the following services on an outpatient basis, as permitted by law: Surgical services Emergency health services, or Rehabilitative, laboratory, diagnostic or therapeutic services. Kaiser California HMO Plan An alternate facility may also provide mental health or substance abuse treatment service on an outpatient or inpatient basis (for example, a residential treatment facility). Kaiser Hawaii HMO Plan Amendment Any attached written description of additional or alternative provisions to the plan. Amendments are effective only when distributed by the plan sponsor or the plan administrator. Amendments are subject to all conditions, limitations and exclusions of the plan, except for those that the amendment is specifically changing. Autism spectrum disorders A group of neurobiological disorders that includes Autistic Disorder, Rhett s Syndrome, Asperger s Disorder, Childhood Disintegrated Disorder, and Pervasive Development Disorders Not Otherwise Specified (PDDNOS). Benefits Plan payments for covered health services, subject to the terms and conditions of the plan and any addendums and/or amendments. Body Mass Index (BMI) A calculation used in obesity risk assessment which uses a person s weight and height to approximate body fat. BMI See Body Mass Index (BMI). Cancer Care Support Program The Cancer Care Support Program provides support and resources to UnitedHealthcare members and their covered dependents living with cancer. The program is administered by Alere, an organization that works with UnitedHealthcare to establish eligibility into the program. Cancer Resource Services (CRS) A program administered by UnitedHealthcare or its affiliates that provides: Claims administrator For the HRA, HRA Plus, Hawaii PPO and Out-of-Area Plans, UnitedHealthcare (also known as United HealthCare Services, Inc.) and its affiliates, who provides certain claim administration services. Clinical trial A scientific study designed to identify new health services that improve health outcomes. In a clinical trial, two or more treatments are compared to each other and the patient is not allowed to choose which treatment will be received. MCS Plan (Puerto Rico) Other Important Information Important Plan Notices MVP HMO Plan Specialized consulting services to employees and enrolled dependents with cancer Access to cancer centers with expertise in treating specific forms of cancer even the most rare and complex conditions, and Guidance for the patient on the prescribed plan of care and the potential side effects of radiation and chemotherapy. 106

107 UnitedHealthcare Plans Term Definition Co-insurance The percentage of eligible expenses you are required to pay for certain covered health services. Company Company or company means Congenital anomaly A physical developmental defect that is present at birth and is identified within the first 12 months of birth. Congenital heart disease (CHD) Any structural heart problem or abnormality that has been present since birth. Congenital heart defects may: Kaiser Hawaii HMO Plan Congenital Heart Disease Resource Services A UnitedHealthcare program that provides information to employees or their covered dependents with congenital heart disease, and that offers access to additional centers for the treatment of congenital heart disease. MVP HMO Plan COBRA Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) a federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated. MCS Plan (Puerto Rico) Cosmetic procedures Procedures or services that change or improve appearance without significantly improving physiological function, as determined by the claims administrator. Reshaping a nose with a prominent bump is an example of a cosmetic procedure because appearance would be improved, but there would be no improvement in function, such as breathing. Cost-effective The least expensive equipment that performs the necessary function. This term applies to durable medical equipment and prosthetic devices. Covered health services Health services and supplies that are: HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Important Plan Notices Be passed from a parent to a child (inherited) Develop in the fetus of a woman who has an infection or is exposed to radiation or other toxic substances during her pregnancy, or Have no known cause. Provided for the purpose of preventing, diagnosing or treating sickness, injury, mental illness, substance abuse or their symptoms Included in each medical plan s Plan Options at a Glance and What s Covered Provided to a covered person who meets the plan s eligibility requirements, and Not identified in. The claims administrator maintains clinical protocols that describe the scientific evidence, prevailing medical standards and clinical guidelines supporting its determinations regarding specific services. You can access these clinical protocols (as revised from time to time) on or by calling the number on the back of your ID card. This information is available to physicians and other health care professionals on UnitedHealthcareOnline. Covered person Either the employee or a dependent while enrolled and eligible for benefits under the plan. References to you and your throughout this SPD are references to a covered person. 107

108 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Services that do not require special skills or training and that: Provide assistance in activities of daily living (including, but not limited to, feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring, and ambulating) Do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing, or Do not require continued administration by trained medical personnel in order to be delivered safely and effectively. Deductible The fixed-dollar amount paid each plan year for covered health care services before the co-insurance applies. Under the HRA medical plans, the deductible is offset by the Gap-funded HRA dollars. After the first year, the employee responsibility portion of the deductible may be paid with rollover dollars from your HRA account. Designated facility A facility that has entered into an agreement with the claims administrator or with an organization contracting on behalf of the plan, to provide covered health services for the treatment of specified diseases or conditions. A designated facility may or may not be located within your geographic area. Kaiser Hawaii HMO Plan MVP HMO Plan Definition Other Important Information Important Plan Notices Custodial care What s Covered MCS Plan (Puerto Rico) Term Additional Information for UnitedHealthcare Plans Kaiser California HMO Plan Hawaii PPO Plan To be considered a designated facility, a facility must meet certain standards of excellence and have a proven track record of treating specific conditions. The fact that a hospital is in-network does not mean that it is a designated facility. Domiciliary care Living arrangements designed to meet the needs of people who cannot live independently but do not require skilled nursing facility services. Durable medical equipment (DME) equipment that is: Eligible expenses Used to serve a medical purpose with respect to treatment of a sickness, injury, or their symptoms Not disposable Not of use to a person in the absence of a sickness, injury, or their symptoms Durable enough to withstand repeated use Not implantable within the body, and Appropriate for use, and primarily used, within the home. Expenses that will be considered for reimbursement from a plan. For the UnitedHealthcare plans, UnitedHealthcare is the claims administrator and has the discretion and authority to determine on the plans behalf whether a treatment or supply is a covered health service and how the eligible expense will be covered under the plans. For in-network benefits, you are not responsible for any difference between the eligible expenses and the amount the provider bills, unless you agreed to reimburse the provider for such services. For out-of-network benefits, except for fees that are negotiated by an out-ofnetwork provider and either the claims administrator or one of its vendors, affiliates or subcontractors, you are responsible for paying, directly to the out-of-network provider, any difference between the amount the provider bills you and the amount the plans will pay for eligible expenses. Amounts charged over eligible expenses do not apply towards your deductible or outof-pocket maximum. Eligible expenses are based on either of the following: When covered health services are received from in-network providers, eligible expenses are the contracted rates(s) with that provider. 108

109 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Term Definition Eligible expenses cont. When covered health services are received from out-of-network providers, eligible expenses are based on: Hawaii PPO Plan Additional Information for UnitedHealthcare Plans - Negotiated rates agreed to by the non-network provider and either the claims administrator or one of its vendors, affiliates or subcontractors, at the discretion of the claims administrator. - If rates have not been negotiated, then one of the following amounts: For covered health services other than those services further specified below, eligible expenses are determined based on competitive fees in that geographic area. If no fee information is available for a covered health service, the eligible expense is based on 50% of billed charges, except that certain eligible expenses for mental health services and substance use disorder services are based on 80% of the billed charge. What s Covered Other Important Information For mental health services and substance use disorder services, the eligible expense will be reduced by 25% for covered health services provided by a psychologist and by 35% for covered health services provided by a masters level counselor. Kaiser California HMO Plan Kaiser Hawaii HMO Plan The claims administrator calculates eligible expenses based on available data resources of competitive fees in that geographic area, unless you received services as a result of an emergency or as otherwise arranged through the claims administrator. MVP HMO Plan MCS Plan (Puerto Rico) Percentages and benefits apply only to covered health care supplies and services. You are responsible for all other expenses. Benefits are determined at the time your claim is received. Important Plan Notices These provisions do not apply if you receive covered health services from a non-network provider in an emergency or as otherwise arranged by the claims administrator. In that case, eligible expenses are the amounts billed by the provider, unless the claims administrator negotiates lower rates. For certain covered health services, you are required to pay a percentage of eligible expenses in the form of a co-pay and/or co-insurance. Eligible expenses are subject to the claims administrator s reimbursement policy guidelines. You may request a copy of the guidelines related to your claim from the claims administrator. IMPORTANT NOTICE: Non-network physicians and providers may bill you for any difference between the physician s or provider s billed charges and the eligible expense described above. Emergency A serious medical condition or symptom resulting from injury, sickness or mental illness, or substance abuse that: Arises suddenly, and In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health. Emergency health services Health care services and supplies necessary for the treatment of an emergency. 109

110 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Term Definition Experimental or investigational services, surgical, diagnostic, psychiatric, substance abuse, or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications, or devices that, at the time UnitedHealthcare and make a determination regarding coverage in a particular case, are determined to be any of the following: Hawaii PPO Plan Additional Information for UnitedHealthcare Plans Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use Subject to review and approval by any institutional review board for the proposed use (devices which are FDA-approved under the Humanitarian Use Device exemption are not considered to be experimental or investigational), or The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight. What s Covered Other Important Information Kaiser California HMO Plan Exceptions: If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and may, at their discretion, consider an experimental or investigational service to be a covered health service. Before such consideration, UnitedHealthcare and must determine that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition, and that the service would be provided under standards equivalent to those defined by the National Institutes of Health. Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Explanation of benefits (EOB) A statement provided by UnitedHealthcare to you, your physician, or another health care professional that explains: Gender identity disorder A disorder characterized by the following diagnostic criteria: Home health agency A program or organization authorized by law to provide health care services in the home. The benefits provided (if any) The allowable reimbursement amounts Deductibles Co-insurance Any other reductions taken The net amount paid by the plan, and The reason(s) why the service or supply was not covered by the plan (if applicable). A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex) Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex The disturbance is not concurrent with a physical intersex condition, and The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 110

111 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan MCS Plan (Puerto Rico) Important Plan Notices Definition An institution, operated as required by law, which: Is primarily engaged in providing health services on an inpatient basis for the acute care and treatment of sick or injured individuals. Care is provided through medical, mental health, substance abuse, diagnostic, and surgical facilities, by or under the supervision of a staff of physicians, and Has 24-hour nursing services. A hospital is not primarily a place for rest, custodial care, or care of the aged and is not a skilled nursing facility, convalescent home or similar institution. MVP HMO Plan Hospital What s Covered Kaiser Hawaii HMO Plan Term Additional Information for UnitedHealthcare Plans Kaiser California HMO Plan Hawaii PPO Plan Other Important Information HRA dollars For the HRA medical plans, the amount allocates to your health reimbursement account depending on your coverage category. Injury Bodily damage other than sickness, including all related conditions and recurrent symptoms. In-network provider A doctor, dentist, hospital or other practitioner who has a contract with a health plan to provide health care services at network negotiated rates. In-network benefits How benefits are paid for covered health services provided by an in-network provider. Inpatient rehabilitation A hospital (or a special unit of a hospital that is designated as an inpatient rehabilitation facility) that provides physical facility therapy, occupational therapy, and/or speech therapy on an inpatient basis, as authorized by law. Inpatient stay An uninterrupted confinement following formal admission to a hospital, skilled nursing facility or inpatient rehabilitation facility. Intensive outpatient treatment A structured outpatient mental health or substance use disorder treatment program that may be free-standing or hospitalbased that provides services for at least three hours per day, two or more days per week. Lifetime maximum benefit The most the plan will pay for benefits during the entire period you are enrolled in that particular plan. The plan does not impose any lifetime or annual limits on the value of essential health benefits. Medicaid A federal program administered and operated individually by participating state and territorial governments that provides medical benefits to eligible low-income people needing health care. Medicare Government-provided health insurance primarily for people age 65 and older. This includes Parts A, B, C, and D of the insurance program established by Title XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended. Mental health services Covered health services for the diagnosis and treatment of mental illnesses. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a covered health service. Mental health and substance use disorder (MH/SUD) administrator The organization or individual designated by who provides or arranges mental health and substance use disorder treatment services under the plan. 111

112 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Term Definition Mental illness Mental health or psychiatric diagnostic categories listed in the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders, unless they are not covered by your plan. Neonatal Resource Services (NRS) A program administered by UnitedHealthcare or its affiliates that provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to help manage NICU admissions. Open Enrollment The period of time, determined by, during which eligible employees may enroll themselves and their dependents under the plan. Orthotics Devices that straighten or change the shape of a body part, including, but not limited to, cranial banding and some types of braces. Out-of-network benefits How benefits are paid for covered health services provided by out-of-network providers. Out-of-network provider A doctor, dentist, hospital or other practitioner who does not have a contract with a -provided health plan. Out-of-pocket maximum The most you will pay in a plan year for eligible health care services, in addition to your employee contributions. Under the HRA medical plans, the amount of the out-of-pocket maximum includes the deductible, which is offset by the Gap-funded HRA dollars. Unless otherwise noted, expenses for co-pays, prescription drugs, non-covered expenses and amounts that exceed an eligible expense do not count toward the out-of-pocket maximum. Partial hospitalization/ day treatment A structured ambulatory program, free-standing or hospital-based, that provides services for at least 20 hours per week. Personal Health Support Programs provided by UnitedHealthcare that focus on prevention, education, and closing the gaps in care designed to encourage an efficient system of care for you and your covered dependents. Some services require notifying Personal Health Support in advance to avoid having your benefits reduced. Personal Health Support Nurse The primary nurse that may be assigned to you if you have a chronic or complex health condition. If a Personal Health Support Nurse is assigned to you, this nurse will call you to assess your progress and provide you with information and education to manage your condition. Physician Any doctor of medicine or doctor of osteopathy who is properly licensed and qualified by law. Other Important Information Kaiser California HMO Plan Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist or other provider who acts within the scope of his or her license will be considered on the same basis as a physician. The fact that a provider is described as a physician does not mean that benefits for services from that provider are available to you under the plan. Plan administrator or its designee. Plan sponsor Pregnancy care Prenatal care, postnatal care, childbirth and care to treat any complications associated with pregnancy. 112

113 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Term Definition Preventive care services aimed at early detection and intervention. Preventive care services focus on wellness, health promotion, and other activities that reduce the likelihood of illness or injury. Primary Care Physician (PCP) A physician in general practice or who specializes in pediatrics, family practice, or internal medicine, who has been selected by the covered individual from the list of primary care physicians in the plan directory. Some HMO plans require a member to choose a PCP and to always see the PCP for a referral to a specialist. Private duty nursing Nursing care that is provided to a patient on a one-on-one basis by licensed nurses in a home setting when any of the following are true: Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan Important Plan Notices MCS Plan (Puerto Rico) No skilled services are identified Skilled nursing resources are available in the facility The skilled care can be provided by a home health agency on a per visit basis for a specific purpose, or The service is provided to a covered person by an independent nurse who is hired directly by the covered person or his/ her family. This includes nursing services provided on a home-care basis, whether the service is skilled or non-skilled independent nursing. Provider A health care professional or facility operating as required by law. Residential treatment facility A licensed facility operating 24-hours per day that provides a program of effective mental health services or substance use disorder services treatment, and that meets all of the following requirements: It is established and operated in accordance with applicable state law for residential treatment programs It provides a program of treatment under the active participation and direction of a physician and approved by the mental health/substance use disorder administrator It has or maintains a written, specific, and detailed treatment program requiring full-time residence and full-time participation by the patient, and It provides at least the following basic services in a 24-hour per day, structured milieu: Room and board Evaluation and diagnosis Counseling, and Referral and orientation to specialized community resources. A residential treatment facility that qualifies as a hospital is considered a hospital. Reconstructive procedure A procedure performed to address a physical impairment where the expected outcome is restored or improved function. The primary purpose of a reconstructive procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive procedures include surgery or other procedures that are associated with an injury, sickness, or congenital anomaly. The primary result of the procedure is not changed or improved physical appearance. The fact that a person may suffer psychologically as a result of the impairment does not classify surgery or any other procedure done to relieve the impairment as a reconstructive procedure. 113

114 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Definition Semi-private room A room with two or more beds. The additional cost of a private room is covered only when a private room is necessary in terms of generally accepted medical practice, or when a semi-private room is not available. Sickness Physical illness, disease or pregnancy. The term sickness as used in this SPD does not include mental illness or substance use disorder, regardless of the cause or origin of the mental illness or substance use disorder. Skilled care Skilled nursing, teaching and rehabilitation services when: They are delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome and provide for the safety of the patient A physician orders them They are not delivered for the purpose of assisting with activities of daily living, including, but not limited to, dressing, feeding, bathing, or transferring from a bed to a chair They require clinical training in order to be delivered safely and effectively, and They are not custodial care, as defined in this section. Kaiser California HMO Plan Kaiser Hawaii HMO Plan Important Plan Notices Term Other Important Information MCS Plan (Puerto Rico) MVP HMO Plan Skilled nursing facility A nursing facility that is licensed and operated as required by law, including a skilled nursing facility that is part of a hospital for purposes of the plan. Specialist physician A physician who has a majority of his or her practice in areas other than general pediatrics, internal medicine, obstetrics/ gynecology, family practice, or general medicine. Spinal treatment Detection or correction, by manual or mechanical means, of bone or joint dislocation(s) (subluxation) in the body to remove nerve interference or its effects. The nerve interference must be the result of, or related to, distortion, misalignment or subluxation of, or in, the vertebral column. Substance use disorder services Covered health services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association, unless those services are specifically excluded. Total disability For the purposes of the medical plans, a total disability means an employee s inability to perform all substantial job duties because of physical or mental impairment, or a dependent s inability to perform the normal activities of a person of like age and gender. 114

115 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Term Definition Transitional care Mental health services/substance use disorder services that are provided through transitional living facilities, group homes and supervised apartments that provide 24-hour supervision that are either: Hawaii PPO Plan Sober living arrangements such as drug-free housing, alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug-free environment, and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn t offer the intensity and structure needed to assist the covered person with recovery. Supervised living arrangements which are residences such as transitional living facilities, group homes and supervised apartments that provide members with stable and safe housing and the opportunity to learn how to manage their activities of daily living. Supervised living arrangements may be utilized as an adjunct to treatment when treatment doesn t offer the intensity and structure needed to assist the covered person with recovery. Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan Unproven services MVP HMO Plan Health services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature. Well-conducted randomized controlled trials are two or more treatments compared to each other, with the patient not being allowed to choose which treatment is received. Well-conducted cohort studies from more than one institution are studies in which patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group. MCS Plan (Puerto Rico) Important Plan Notices UnitedHealthcare has a process by which it compiles and reviews clinical evidence with respect to certain health services. From time to time, UnitedHealthcare issues medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at Please note: If you have a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare may, at its discretion, consider an otherwise unproven service to be a covered health service for that sickness or condition. Prior to such a consideration, UnitedHealthcare must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that sickness or condition. The decision about whether such a service can be deemed a covered health service is solely at UnitedHealthcare s discretion. Other apparently similar promising but unproven services may not qualify. Urgent care Treatment of an unexpected sickness or injury that is not life-threatening but requires outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering, such as high fever, a skin rash or an ear infection. 115

116 UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Term Definition Urgent care center A facility that provides urgent care services, as previously defined in this section. In general, urgent care centers: Do not require an appointment Are open outside of normal business hours so you can get medical attention for minor illnesses that occur at night or on weekends, and Provide an alternative if you need immediate medical attention but your physician cannot see you right away. Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices 116

117 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Prescription Drug Plan for UnitedHealthcare Plans If you are enrolled in the HRA, HRA Plus, Hawaii PPO, or Outof-Area plan, you automatically have coverage for prescription drugs through Express Scripts. Express Scripts administers the prescription drug coverage for these medical plans and has a large network of chain and independent pharmacies across the country. When a prescription order or refill is issued by a physician or other provider, you pay a co-pay or co-insurance when you have your prescription filled at an in-network pharmacy. If you are enrolled in an HMO plan, your prescription drug coverage is provided through the HMO. About Express Scripts Express Scripts provides you access to: Local pharmacies: A network of nearly 60,000 participating retail pharmacies throughout the United States and its territories. Home Delivery Services: For your long-term medications, such as those used to treat high blood pressure or high cholesterol, you can access convenient mail-order service with possible savings. Express Scripts specialist pharmacists: The Home Delivery Service from Express Scripts has specialist pharmacists who can help you manage the long-term medications used to treat specific chronic conditions. Online resources: Go to for useful health and benefit information, along with online pharmacy services. Register on the website by clicking Create online account and entering the Member ID number listed on your Express Scripts prescription drug ID card. Important definitions and phrases can be found in Terms You Should Know on page 129. It s a good idea to take a minute to look up a term or phrase you do not know so you can better understand how your plan works. Express Scripts Member Services: Representatives are available 24 hours a day, 7 days a week (except Thanksgiving and Christmas). Pharmacists are also available around the clock for consultation. If you are a Puerto Rico employee, your prescription drug coverage is provided through MCS. Prescription Drug ID Cards Express Scripts will provide you with a prescription drug ID card. Present your ID card when filling a prescription at a participating retail pharmacy. If you need additional or replacement ID cards, please contact Express Scripts Member Services or visit to request a new card or print a temporary card. 117

118 About Express Scripts Member Services Id Cards Visit the Express Scripts website, to view plan and co-pay/co-insurance information, for details on prescription medications, locate a participating pharmacy near you, and manage your mail order prescriptions. If you have questions, call Express Scripts Member Services at This number is also listed on your Express Scripts prescription drug ID card. Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization My Rx Choices Infertility Pharmacy Benefits My Rx Choices : An easy way to lower your out-of-pocket prescription costs. Covered Expenses Benefit Determinations Your benefit includes the My Rx Choices prescription savings program, which is designed to help you find potential savings on prescription drugs that you or your covered family members take on an ongoing basis. Your doctor knows which medications are right for you but may not know how much they cost. My Rx Choices provides you with available lower-cost options so that you and your doctor can make the most informed decisions based on health and cost. No prescription is ever changed without your doctor s approval. Simply visit and register on the website. Have your new member ID number and a recent prescription number handy. 118

119 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Your Prescription Drug Plan Coverage Prescription Drug Benefit Highlights The co-pay/co-insurance information for your prescription drug plan is shown below. Your prescription drug benefit provides coverage only at participating retail pharmacies and through the Home Delivery Pharmacy Services. For additional information about your prescription drug plan, call Express Scripts Member Services toll-free at or visit Drugs Requiring Authorization Infertility Pharmacy Benefits Type of drug Express Scripts network pharmacies only Covered Expenses Benefit Determinations You pay Retail (31-day supply) Generic $10 co-pay Preferred brand-name 30%; $30 minimum per prescription $90 maximum per prescription Non-preferred brand-name 45%; $45 minimum per prescription $135 maximum per prescription Mail order (90-day supply) Generic $25 co-pay Preferred brand-name 30%; $75 minimum per prescription $225 maximum per prescription Non-preferred brand-name 45%; $ minimum per prescription $ maximum per prescription 119 Generic Substitution If you purchase a brand-name drug when a generic equivalent is available, you will pay a higher out-of-pocket cost. You will pay the difference between the full cost of the brand-name drug and the generic drug, plus the generic co-pay. This additional cost will apply even if your doctor has indicated Dispense As Written (DAW) on your brand prescription, and regardless of whether you fill your prescription at a participating retail pharmacy or through the Home Delivery Pharmacy Service from Express Scripts. To find out if there s a generic equivalent for a brand-name drug you are taking, visit and select My Rx Choices. You will be able to enter the name of your medication, and My Rx Choices will provide you with personalized cost-saving opportunities specific to your prescriptions and prescription drug plan. If you are new to the Express Scripts website, you will need to register, so have your member ID number and a recent prescription number handy. You can also call Member Services toll-free at If special circumstances require you to take a brand-name drug instead of its generic equivalent, you or your doctor can request a coverage review for medical necessity by calling Express Scripts toll-free at Formulary A formulary is a list of brand-name and generic medications that are preferred by your plan. Typically, an independent group of doctors and pharmacists has reviewed this list to help ensure that it includes medications for most medical conditions that are treated on an outpatient basis. You will usually pay a lower co-pay/co-insurance for generic and brand-name medications that are on the formulary.

120 Member Services FDA-approved generics are safe and effective. Generic drugs may have unfamiliar names, but they are safe and effective. Generic drugs and their brand-name counterparts: My Rx Choices Have the same active ingredients, and Prescription Drug Plan Coverage Are manufactured according to the same strict federal regulations. About Express Scripts Id Cards Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Generic drugs have the same strength, purity, and quality as the brand-name alternatives. Prescriptions filled with generic drugs cost less under s prescription drug program. For more information about the formulary, visit or contact Express Scripts Member Services at How Your Prescription Drug Plan Works Retail Pharmacy Program Prescriptions and refills dispensed at a retail pharmacy are filled for up to a 31-day supply. The amount you pay for each purchase or refill depends on whether you obtain generic or brand-name drugs and whether you use a retail pharmacy that participates in the Express Scripts retail pharmacy network. For an outline of your co-pays/co-insurance, please see Prescription Drug Benefit Highlights on page 119. How to Purchase Retail Prescriptions At a Participating Retail Pharmacy: When you purchase your prescriptions through a participating retail pharmacy, simply present your prescription drug ID card and pay the applicable amount. You don t have to file any claim forms. At a Non-Participating Pharmacy: When you purchase your prescriptions at an out-of-network pharmacy, you pay the full cost of your prescription. There is no reimbursement for prescriptions purchased at a non-participating pharmacy. Important! Coordination-of-benefits (COB) provisions do not apply to the prescription drug plan. When a prescription drug is packaged or designed in a manner that provides more than a consecutive 31day supply, the co-pay or co-insurance will reflect the number of days dispensed. You may obtain up to three cycles at one time of oral contraceptives at a participating retail pharmacy if you pay the co-insurance for each cycle supplied. The Express Scripts retail pharmacy network is a national network comprised of nearly 60,000 retail pharmacies. The network includes most major chains, discount, grocery, and independent pharmacies. To find a local participating pharmacy, log on to and click Locate a pharmacy or contact Member Services. 120

121 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Mail Order Program through the Express Scripts Home Delivery Pharmacy Filling prescriptions through mail order is the most cost-effective option for members taking long-term medications (such as those used to treat high blood pressure or high cholesterol) on a regular basis. The Express Scripts Home Delivery Pharmacy provides up to a 90-day supply of medication, delivered directly to your home or other requested location, postage paid for standard delivery. In order to fill your prescription through the Home Delivery Pharmacy, mail your prescription, order form, and payment to the address on the order form. Or, you may also ask your doctor to fax your prescription to Express Scripts Easy Rx Fax line at Your medication will usually be delivered within eight days of receiving your order. To order refills, call the automated refill system at 800.4REFILL ( ) or visit Refills are normally delivered more quickly. If you are a first-time visitor to the site, have your member ID number and a recent prescription number available to register. To ensure timely delivery, place your orders at least two weeks in advance. If you have any questions concerning your order, or if you do not receive your medication within the designated timeframe, please contact Express Scripts Member Services. If a new medication has been prescribed for you to take immediately, ask your doctor to issue two prescriptions: One prescription for a 14-day supply should be written and filled at your local participating retail pharmacy and the second should be written for up to a 90-day supply and sent to the Express Scripts Home Delivery Pharmacy. 121 When to Refill You will be able to refill your retail and mail-order prescriptions when you have used 75% of the medication you have on hand. For example, for a 31-day supply, you should request a refill no sooner than the 23rd day of the supply, based on when after the prescription was filled. For a 90-day supply, you should request a refill no sooner than the 67th day of the supply. If you request a refill early at a retail pharmacy, the pharmacist will automatically receive a message saying that you are refilling too soon. However, the retail pharmacist can still dispense the medication if he or she feels it is appropriate. If you request a refill early through mail order, Express Scripts will hold your request until the 67th day of the current supply before dispensing. Supplemental Discount Program Your prescription drug benefit includes a feature that offers you a discount on prescription medications not covered by your plan. To take advantage of these discounts, order your noncovered prescriptions through the Express Scripts Home Delivery Pharmacy using the same mail-order form and envelope you normally would use. Be sure to include the full payment for your discounted medications when you send in your order so it can be processed. You can check the prices of these medications by visiting the Express Scripts website at You can make your payments by check, money order, or credit card. Remember, this feature is already part of your prescription drug benefit. You do not have to sign up to get these discounts. Please note that medications with quantity limits do not apply. Members who take advantage of the discounts will pay a $5 handling fee for each non-covered prescription ordered.

122 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Mail-Order Balance Your plan allows you to maintain a balance of up to $100 on your mail-order account. This amount is known as your account limit or floor limit, and Express Scripts will bill you up to this limit. When ordering prescriptions through the Express Scripts Home Delivery Pharmacy, be sure to check your outstanding balance. You can view a summary of your account online by visiting the Express Scripts website at If your outstanding balance reaches the $100 limit, Express Scripts will hold your orders until the balance has been paid. Orders held for more than seven days because of outstanding balances will be mailed back to you unfilled. You will need to reorder the medication after you pay the balance. To avoid potential delays, please include your payment with each prescription order. You can pay for your mail-order prescriptions by check, e-check, money order or credit card. If you would like to use a credit card for your mail-order prescriptions, you must provide your payment information online at To register to pay by e-check, you must contact Express Scripts Member Services by calling Lowering Your Out-of-Pocket Costs To maximize your benefit, ask your physician to write your prescription order or refill for a 90-day supply, with refills when appropriate. You are charged the mail order co-pay or co-insurance for each prescription order or refill from the mail order service, regardless of the number of days supply that is written on the order or refill. So, be sure your physician writes your mail order or refill for a 90-day supply, not a 31-day supply with three refills. 122 Specialty Medications Specialty medications are drugs that typically require injection or special handling and are used to treat complex conditions. Whether they re administered by a health care professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service. Conditions and therapies for which specialty medications are typically used include: Age-related macular degeneration Immune deficiency Alpha-1 antitrypsin deficiency Iron chelation therapy Anemia Lysosomal storage disorders Asthma Multiple sclerosis Cancer Neutropenia Chronic kidney disease Noninfectious uveitis Crohn s disease Osteoarthritis Cystic fibrosis Osteoporosis Deep vein thrombosis Parkinson s disease Chronic kidney disease Psoriasis Growth hormone deficiency Pulmonary arterial hypertension Hemophilia Respiratory syncytial virus Hepatitis C Rheumatoid arthritis Hereditary tyrosinemia Thrombocytopenia Infertility Homocystinuria

123 About Express Scripts Accredo Express Scripts Specialty Pharmacy Id Cards Important information for those who use specialty medications provides access to the enhanced services and expertise of Accredo Health Group, Express Scripts specialty pharmacy, which can provide convenient delivery of your specialty medication. If you are currently using a retail pharmacy to obtain specialty medications that are available through Accredo, you may transfer those prescriptions to Accredo. Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations By ordering your specialty medications through Accredo, you can receive: Toll-free access to specialty-trained pharmacists and nurses 24 hours a day, 7 days a week Delivery of your medications within the United States on a scheduled day, Monday through Friday, at no additional charge Most supplies, such as needles and syringes, provided with your medications Safety checks to help prevent potential drug interactions Refill reminders Health and safety monitoring Up to a 31-day supply of your specialty medication for just one co-pay. For more information about Accredo or to order your specialty medications, call Member Services at To get started using Accredo, call the number on the back of your prescription drug ID card or log in to your account at If you are a first-time visitor, have your member ID number and a recent prescription number handy to register. To learn more about specialty medications and services, visit Out-of-Network Pharmacies Are Not Covered Remember, prescriptions filled at an out-of-network pharmacy are not covered. Supply Limits Some prescription drugs are subject to supply limits that may restrict the amount dispensed per prescription order or refill. To determine if a prescription drug has been assigned a maximum quantity level for dispensing, visit or call Express Scripts Member Services at Note: Some products are subject to additional supply limits based on criteria that the plan administrator and the claims administrator have developed, subject to periodic review and modification. The limit may restrict the amount dispensed per prescription order or refill and/or the amount dispensed per month s supply. Drugs Requiring Authorization When Certain Medications Require Prior Authorization or Express Scripts Approval Express Scripts is required to review prescriptions for certain medications with your doctor before they can be covered. This is known as coverage management. This prior authorization review uses clinical guidelines that are reviewed and approved by an independent group of doctors and pharmacists. Coverage Management Programs The three coverage management programs are outlined below, with a partial list of medications that will need to be reviewed by Express Scripts in order for them to be covered by your plan. For more information about coverage reviews and prior authorization, call Express Scripts Member Services at

124 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Prior authorization some medications require that you obtain approval through a coverage review before the medication can be covered. The coverage review process will allow Express Scripts to obtain more information about your specific course of treatment (information that is not available on your original prescription) in determining whether a given medication qualifies for coverage. Those medications include: Select antineoplastic agents Select intranasal steroids Select hypnotic agents. For example, if you or your covered family members are taking a sleep aid, please be advised that you may not receive more than a 60-day supply within a 90-day period without a coverage review from Express Scripts and your doctor. Select antipsoriatic agents. Qualification by history the following is a partial list of medications that may also require a coverage review based on: Whether certain criteria are met, such as age, sex or condition, and/or Whether an alternate therapy or course of treatment has failed or is not appropriate. In either of these instances, Express Scripts pharmacists will review the prescription to ensure that all criteria required for a certain medication are met. If the criteria are not met, a coverage review will be required. Examples of these medications include: Tazorac Tretinoin. Quantity management to promote safe and effective drug therapy, certain covered medications may have quantity restrictions. These quantity restrictions are based on manufacturer or clinically approved guidelines and are subject to periodic review and change. These medications include: Select antihypertensives Select antihistamines Example Member fills a 30-day supply of Ambien on May 1 Member refills a 30-day supply of Ambien on June 1 Member has exhausted the allowable quantity for this 90-day period and would not be eligible to receive an additional quantity until August 1. Coverage Review Process You can check to see if your medication requires prior authorization (coverage review) by calling Express Scripts Member Services at If your medication requires a coverage review, you or your doctor may start the review process by calling Express Scripts toll-free at , weekdays from 8:00 a.m. to 9:00 p.m. Eastern Time. At an in-network retail pharmacy: When a coverage review is necessary, Express Scripts automatically notifies the pharmacist, who in turn tells you that the prescription needs to be reviewed for prior authorization. You or your doctor may start the review process by calling Express Scripts toll-free at , 8:00 a.m. to 9:00 p.m. Eastern Time, Monday through Friday. Select antidepressants 124 Select diabetic agents

125 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Express Scripts contacts your doctor, requesting more information regarding the prescription. After receiving the necessary information, Express Scripts notifies you and the doctor, confirming whether or not coverage has been authorized. If coverage is authorized, you simply pay your normal co-pay/ co-insurance for the medication. If coverage is not authorized, you will be responsible for the full cost of the medication. If appropriate, you can talk to your doctor about alternatives that may be covered. Covered Expenses Through the Express Scripts Home Delivery Pharmacy: If you are filling a prescription through mail order and a coverage review is required, Express Scripts contacts your doctor to request more information regarding the prescription. After receiving the necessary information, Express Scripts notifies you and your doctor, confirming whether or not coverage has been authorized. Benefit Determinations If coverage is authorized, you receive your medication and simply pay your normal co-pay/co-insurance for the medication. If coverage is not authorized, Express Scripts will send you a notification in the mail, along with your original prescription if it was mailed to the Home Delivery Pharmacy. 125 Infertility Pharmacy Benefits To be eligible for this benefit, you must have one year of service with and be enrolled and participating in the Reproductive Resource Services (RRS) program before seeking treatment. Infertility services must be provided at an RRS Center of Excellence to receive coverage. See page 69 for more information. If you meet the qualifications, you may be eligible for a separate prescription drug benefit for infertility administered through Express Scripts, with a lifetime maximum benefit of $2,500. To enroll in the RRS program, call , weekdays, 8:00 a.m. to 5:00 p.m. Central Time. Covered Expenses Your plan provides coverage for: Federal legend prescription drugs, unless otherwise indicated Drugs requiring a prescription under the applicable state law Insulin, needles and syringes if included on prescription, and Compound medications, of which at least one ingredient is a federal legend drug. Compounding for specialty prescriptions is available through the Accredo Pharmacy.

126 About Express Scripts Id Cards Member Services My Rx Choices Prescription Drug Plan Coverage The items in the charts below are covered at no cost to members when filled with a prescription from your doctor. Immunizations are generally administered in a doctor s office but can also be administered through the pharmacy where available. Use the pharmacy register when paying for the over-the-counter items. Covered item Eligible members Covered immunizations Recommended ages Contraceptives Women through age 50 (generic and single-source branded products only) covered under Rx including oral, transdermal, intravaginal contraceptives, diaphragms, cervical caps, implantable contraceptives Hepatitis A Anyone age 1 year or older Hepatitis B No age or administration restriction Hepatitis B and Haemophilus No age or administration restriction Rotavirus Children from birth to 12 months of age Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Aspirin (to prevent cardiovascular events) Men ages 45 to 79 years and women ages 55 to 79 years Diphtheria, Tetanus, Pertusis (DtaP) Anyone less than 7 years of age Fluoride Children 6 months through 5 years old Tetanus and Tdap Anyone age 7 years or older Pneumococcal Folic Acid Women of child-bearing age (through age 50) Pneumovax: Anyone 2 years or older Prevnar 13: No age or administration restriction Iron Supplements Children ages 6 to 12 months who are at risk for iron deficiency anemia Polio Children from birth to 18 years of age Influenza (A, B and H1N1) No age or administration restriction Smoking Cessation Men and women over 18 who use tobacco products. Zyban, Nasal, Chantix, over-the-counter nicotine patches and gum. MMR, Varicella Anyone age 1 year or older Meningococcal Anyone age 2 years or older Human papillomavirus HPV4 for anyone age 9 through 26 years old HPV2 for females only age 9 through 26 years old Zoster Anyone age 60 years or older Haemophilus No age or administration restriction Travel Vaccines/Other: Immunizations for Thyphoid, Yellow fever, Anthrax, Japanese encephalitis, and Rabies No age or administration restriction Benefit Determinations Vitamin D Men and women over 65 who are at increased risk for falls 126

127 About Express Scripts Under the Prescription Drug Plan Id Cards No payment will be made under any portion of the plan for: Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations A medication that can be purchased without a prescription order; these are commonly called over-the-counter (OTC) drugs Available over-the-counter medications that do not require a prescription order or refill by federal or state law before being dispensed, unless the plan administrator has designated overthe-counter medication as eligible for coverage as if it were a prescription drug and it s obtained with a prescription order or refill from a physician Prescription drugs that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent Certain prescription drugs that the plan administrator has determined are therapeutically equivalent to an over-thecounter drug. Such determinations may be made up to six times during a calendar year, and the plan administrator may decide at any time to reinstate benefits for a prescription drug that was previously excluded under this provision. Medications for any condition, injury, sickness, or mental illness arising out of, or in the course of, employment for which benefits are available under any workers compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received Prescription drugs for which payment or benefits are provided or available from the local, state, or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law Therapeutic devices or appliances, support garments and other non-medical devices 127 Durable medical equipment (prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered) Investigational or experimental drugs, including compounded medications for non-fda approved use Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a prescription order or refill and is covered by your prescription drug plan Compounded drugs that are available as a similar commercially available prescription drug. (Compounded drugs that contain at least one ingredient that requires a prescription order or refill are covered as non-preferred brand-name.) Hair growth stimulants Drugs prescribed to remove or reduce wrinkles in the skin Drugs for smoking cessation not prescribed by your doctor or covered under the plan Nutritional supplements Vitamins, except for the following which require a prescription: - Prenatal vitamins - Vitamins with fluoride - Single entity vitamins. Ostomy supplies Dental fluoride products Biologicals/Vaccines/Immunization agents Plasma/Blood Products (except hemophilia factors) Allergy serums

128 Member Services Any prescription filled in excess of the number specified by the doctor or any refill dispensed after one year from the doctor s original order My Rx Choices Non-federal legend drugs Prescription Drug Plan Coverage Medications with cosmetic implications Benefit Highlights Drugs for which coverage management approval is required but is not received About Express Scripts Id Cards Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations Pharmaceutical products for which benefits are provided in the medical portion of the plan Medications dispensed by an out-of-network pharmacy Medications dispensed outside of the United States, except in an emergency The amount dispensed (days supply or quantity limit) that exceeds the supply limit Medications prescribed, dispensed or intended for use during an inpatient stay Medications prescribed for appetite suppression, and other weight loss products Replacements of previously dispensed prescription drug products that were lost, stolen, broken or destroyed Prescription drugs, including new prescription drugs or new dosage forms, that determines do not meet the definition of a covered health service Medications typically administered by a qualified provider or licensed health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. Infertility medication that exceeds the $2,500 lifetime benefit limit 128 Unit dose packaging of prescription drugs, and Drugs used for conditions and/or at dosages determined to be experimental or investigational, or unproven, unless Gap Inc. has agreed to cover an experimental or investigational, or unproven treatment. Benefit Determinations Determinations on prescription drug benefits will be made by Express Scripts in accordance with the terms of your plan. Obtaining Claim Forms Prescription drug claim forms are available on Gapweb ( benefits. Submitting Claim Forms The prescription drug claims administrator is Express Scripts. You only need to file a claim form when you use a network pharmacy but do not present your Express Scripts ID card. You must attach the pharmacy receipt for prescription drugs that shows the prescription number and the name of the doctor who issued the prescription. Your prescription drug claim form must be completely filled out, or it will be sent back to you. Send your completed form and receipts to: Express Scripts P.O. Box Lexington, KY Claim Denials and Appeals For information on the types of claims that may be filed as well as the process for appealing denied claims please see Claims and Appeals Procedures on page 228.

129 About Express Scripts Id Cards Term Definition Brand-name A medication that is marketed and sold under a unique, trademark-protected name. A single-source drug is a brandname drug that has patent protection and is available from only one manufacturer. A multi source drug is a brandname drug for which the patent has expired, and multiple manufacturers now offer that same medication as a generic equivalent. Co-pay/Co-insurance The portion of the cost of the claim that must be paid by the member. Date of service Date on which a prescription is filled or dispensed. Infertility Pharmacy Benefits Days supply The number of days payable by the plan for the dispensed drug. Covered Expenses Direct claim The member pays 100% of the prescription drug cost at the time of purchase and then submits a paper claim for reimbursement. Federal legend drug A medication that requires a prescription; Federal Legend is printed on the label. Formulary A list of commonly prescribed medications approved by the FDA that have been selected based on their clinical safety and opportunities for savings in some cases. An independent Pharmacy and Therapeutics committee updates this list regularly, based on continuous evaluation of medications. Contact Express Scripts at to determine if the brand-name drug you are taking is on the formulary. You can also locate this information at You may pay a higher price for non-preferred drugs (those not listed as preferred on the formulary) than you would for preferred drugs (those listed as preferred on the formulary). Generic A medication that is generally sold under the name of its active ingredients the chemicals that makes it work rather than under a brand-name and is typically much less expensive than its brand-name counterpart. Member Services My Rx Choices Prescription Drug Plan Coverage Benefit Highlights Formulary How Your Plan Works Drugs Requiring Authorization Benefit Determinations Generic equivalent drugs are approved by the U.S. Food and Drug Administration (FDA) and contain the same active ingredients and are the same in safety, strength, performance, quality, and dosage form as their brand-name counterparts. Generic alternative drugs are FDA approved generic medications whose active ingredients are different from those in another brand-name drug. You may be taking a brand-name drug that does not have a generic equivalent. However, there may be a different generic drug that can be used to treat the same condition as your current brand-name drug. In-network pharmacy A retail or mail order pharmacy that has: Entered into an agreement with the claims administrator to dispense prescription drugs to covered persons Agreed to accept specified reimbursement rates for prescription drugs, and Been designated by the claims administrator as an in-network pharmacy. 129

130 About Express Scripts Term Definition Member Services Maintenance medication A medication that is taken regularly to treat an ongoing condition, such as diabetes, high blood pressure or asthma. My Rx Choices Multi-source (brand) drug A brand-name medication that has an FDA-approved generic equivalent available. Prescription Drug Plan Coverage Out-of-network claims Claims processed by pharmacies that do not participate in the plan s pharmacy network. Benefit Highlights Out-of-network pharmacy A retail pharmacy that does not have an agreement with Express Scripts for this plan to dispense prescription drugs to participants. Over-the-counter (OTC) medication A medication that does not require a prescription. Prescription drug A medication, product or device that has been approved by the Food and Drug Administration and that can, under federal or state law, only be dispensed using a prescription order or refill. Prescription drug cost The rate the claims administrator has agreed to pay its in-network pharmacies, including a dispensing fee and any applicable sales tax, for a prescription drug dispensed at an in-network pharmacy. Prescription order or refill The directive to dispense a prescription drug issued by a duly licensed health care provider whose scope of practice permits issuing such a directive. Therapeutic class A group or category of prescription drugs with similar uses and/or actions. Therapeutically equivalent When prescription drugs can be expected to produce essentially the same therapeutic outcome and toxicity. Usual and Customary (U&C) charge The usual fee that a pharmacy charges individuals for a prescription drug without reference to reimbursement to the pharmacy by third parties. The Usual and Customary charge includes a dispensing fee and any applicable sales tax. Id Cards Formulary How Your Plan Works Drugs Requiring Authorization Infertility Pharmacy Benefits Covered Expenses Benefit Determinations 130

131 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Plans Dental offers two dental plan options through Delta Dental: the basic Dental plan and the Dental Plus plan. Both options offer care through Delta Dental s network of dental providers, who have agreed to specially negotiated, discounted rates. If you choose a dentist from one of Delta Dental s two provider networks (PPO or Premier), you will receive the highest level of benefits from the plan. Your out-of-pocket costs will be lowest with a Delta Dental PPO dentist, and there are 168,000 PPO dental offices nationwide. You can also visit a Delta Dental Premier dentist these providers are outside of the Delta PPO network, but you will still enjoy user-friendly claims administration, cost protections and other Delta Dental advantages, plus have access to more than 251,000 dental offices nationwide. The maximum amount that the plan will pay out each year, or the annual plan year maximum, is slightly lower for Premier dentists. If you see a provider who doesn t belong to any of Delta Dental s networks, it s called out-of-network care and your benefit levels are lower. Important definitions and phrases can be found in Terms You Should Know on page 139. It s a good idea to take a minute to look up a term or phrase you do not know so you can better understand how your plan works. Your Dental Coverage Both Delta Dental plan options cover many of the same eligible expenses, but their costs differ: The basic Dental plan has a lower monthly payroll contribution, but you pay more in co-insurance when you receive care. The Dental Plus plan has a higher monthly payroll contribution, but you pay less in co-insurance. Note that orthodontia is only covered by the Dental Plus plan. You may elect to enroll yourself and your eligible dependents in either plan option as long as you and your dependents enroll in the same dental plan. See Dental Plans at a Glance on the following page for details. You may elect dental coverage independently of medical and vision coverage. 131

132 Dental Dental Plans at a Glance Your Dental Coverage The features described below apply to both dental plans, unless otherwise noted. Dental Plans at a Glance Plan Features PPO Network Premier Network Out-of-Network 1 Plan Year (July 1 June 30) Deductible Family deductible is cumulative Deductible amounts do not carry over from one plan year to the next You pay: $50 (individual) $200 (family) You pay: $50 (individual) $200 (family) You pay: $50 (individual) $200 (family) Per Person Plan Year Maximum The maximum amount payable by the plan for covered services received in a plan year Dental plan: $1,100 Dental Plus plan: $2,200 Dental plan: $1,000 Dental Plus plan: $2,000 Pre-Determination of Benefits A service you can request from you dentist to find out in advance what the plan will cover before the expense is incurred Encouraged for all services expected to exceed $300 Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information If two or more of your family members are involved in the same accident and the resulting dental expenses could have been applied to the deductible, the deductible will be waived for these expenses if they equal or exceed the deductible amount. This waiver applies only to the expenses resulting from the accident. Plan pays after deductible (unless noted) Type of Service PPO Network Diagnostic Services: Two oral exams per plan year. Oral exams include office visits for observations and specialist consultations, or any combination of the above. Full mouth X-rays (one every five years under ANY Delta Dental plan) Panoramic films when taken individually (one every five years) Bitewing X-rays (two per plan year through age 17, one per plan year for age 18 and over) Diagnostic casts Biopsy/tissue exams Emergency treatment Consultation by a specialist Preventive Services: Routine cleaning of teeth (max two per plan year) Fluoride treatment (two per plan year through age 14) Space maintainers Pregnancy Benefit: One additional oral exam and either one additional routine cleaning or one additional periodontal scaling and root planing per quadrant (see Basic Services benefit) 132 Premier Network 100% deductible does not apply Out-of-Network 1 90% deductible does not apply

133 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Plan pays after deductible (unless noted) Type of Service PPO Network Premier Network Out-of-Network 1 Basic Services Fillings (amalgam, synthetic, plastic or direct resin restorations for the treatment of cavities) - Synthetic, plastic, or direct resin restorations covered on the front teeth (anteriors) and covered at the amalgam rate for the back teeth - Amalgam will be covered for the back teeth (posteriors). You may request synthetic, plastic, or direct resin restorations for the back teeth, but the plan will only cover the cost of amalgam and you will be responsible for the difference. Oral surgery (e.g., extractions) Sealants (acrylic, plastic or composite) used to seal developmental grooves and pits for purposes of preventing decay. Sealant benefits include the application of sealants only to permanent first molars (through age 8) and second molars (through age 15) without decay, without restorations and with the occlusal surface intact. Sealant benefits do not include the repair or replacement of a sealant on any tooth within two years of its application. Endodontics (e.g., root canal therapy) Periodontic cleaning (max two per plan year). You may be eligible for an additional periodontal cleaning if you are pregnant or have diabetes. Injections of antibiotic drugs Dental plan: 65% Dental Plus plan: 80% Dental plan: 60% Dental Plus plan: 80% Dental plan: 50% Dental Plus plan: 70% Major Services Crowns, inlays, onlays, and cast restorations necessary to treat cavities that cannot be directly restored with other means (one per five years) Construction/repair of fixed bridges, partial dentures, and complete dentures necessary to replace missing, natural teeth Initial installation of a bridge or denture (covered only if it replaces teeth that were lost while covered under the plan) Replacement of prosthodontic appliance (one per five years) unless it is determined that the appliance cannot be made serviceable Standard partial or complete denture (plan will pay a percentage up to a maximum allowance) Dental implants (prosthetic appliances) placed into or on the bone of the upper or lower jaw to retain or support dental prosthesis. The following limitations apply to coverage for implants: - Implants are covered only if a conventional fixed or removable prosthesis cannot provide clinically acceptable service and you will derive significant greater benefit from an implantborne prosthesis. - Implant procedures are not covered unless the dentist requests and receives pre-determination of benefits from Delta Dental. A second opinion may be required from a dentist at a location selected by Delta Dental before pre-determination will be granted. - Implant removal is limited to one for each tooth during the enrollee s lifetime whether provided under Delta Dental or any other dental care plan. 50% %

134 Dental Plan pays after deductible (unless noted) Type of Service Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information 1 PPO Network Premier Network Out-of-Network 1 Myofascial Pain Dysfunction (MPD) and Temporomandibular Joint Disorder (TMJ) Lifetime maximum of $1,500 per person Covered services include: temporary repositioning appliance, occlusal guard, occlusal adjustment, and removable metal overlay stabilizing appliance Covered services must be authorized in advance by Delta Dental plan will not pay for the repair or replacement of any appliance furnished in whole or in part as MPD-TMJ benefits 50% 40% Orthodontia Lifetime maximum of $1,500 per person Adult and child orthodontia If orthodontic treatment is begun before the patient becomes eligible for coverage, payments made by Delta Dental will begin with the first payment due to the dentist following the employee s eligibility date Dental plan: Not covered Dental Plus plan: 50% Dental plan: Not covered Dental Plus plan: 40% Accident Benefits Plan includes dental accident coverage that has a separate plan year maximum - Dental plan: $1,000 separate contract year maximum - Dental Plus plan: $2,000 separate contract year maximum Dental accident coverage includes services needed as a result of an accident and used within 180 days of the accident. It does not cover any accident that occurred before your eligibility in the Delta Dental plans. The services are subject to the same co-insurance percentages, limitations, and exclusions as under your regular dental plan. 100% Coverage subject to Reasonable & Customary (R&C) limits. Amounts charged over the R&C limit are your responsibility. If you are enrolled in a UnitedHealthcare medical plan and need to fill a prescription from your dentist, present your Express Scripts plan ID card to any pharmacy in the Express Scripts network. See Prescription Drug Plan on page 117 for details. If you are enrolled in a HMO medical plan or are not covered by a medical plan, prescription drugs prescribed by your dentist will be covered through the dental plan. You must pay for the prescription and then submit a claim to Delta Dental for reimbursement. 134

135 Dental Under the Dental Plans Your Dental Coverage The dental plans cover treatment by a dentist for covered services, subject to plan limits and exclusions. Benefits are limited to the applicable percentages of your dentist s fees or allowances, and are not covered if they have resulted from an occupational accident. Following are examples of dental expenses that are not covered by the plans: Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Services for injuries covered by any workers compensation or employers liability laws, or services that are paid by any federal, state or local government agency, except Medi-Cal benefits Services for reconstructive purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, and upper and lower jaw malformations Services for congenitally missing teeth and teeth that are discolored or lacking enamel Treatment which restores tooth structure that is worn, treatment which rebuilds or maintains chewing surfaces that are damaged because the teeth are out of alignment or occlusion, or treatment which stabilizes the teeth. Examples of such treatment are equilibration and periodontal splinting. Any single procedure, bridge, denture, or other prosthodontic service that was started before you were eligible for the plan Replacement of existing restoration for any purpose other than active tooth decay Premedication or analgesia Experimental, investigational, or unproven services are not covered by the plan. These services are defined as dental, surgical, diagnostic, or other dental care services, technologies, supplies, treatments, procedures, drug therapies or devices that are determined to be: Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use - Subject to review and approval by any institutional review board for the proposed use - The subject of an ongoing clinical trial that meets the definition of a phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight, or - Not demonstrated through prevailing peer-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed. An experimental, investigational, or unproven service may be covered under this plan to treat a life-threatening illness or condition if, Delta Dental or any other review organization that may designate determines that the service: - Is proved to be safe with promising efficacy - Is provided in a clinically-controlled re setting, and - Uses a specific re protocol that meets standards equivalent to those defined by the National Institutes of Health. Charges by a hospital or other surgical treatment facility, and any additional fees charged by the dentist for treatment in any such facility

136 Dental Plans at a Glance Anesthesia, except for that given by a dentist for covered oral surgery procedures and select endodontic and periodontal procedures dentist whenever you can. A participating Delta dentist will file the claim for you with Delta, and you won t have to pay any charges over the contract rate. Intravenous sedation Questions About Service from a Delta Dentist If you have questions about the services you receive from a participating Delta dentist, you should first discuss the matter with your dentist. If you continue to have concerns, call Delta s Quality Review department at If appropriate, Delta can arrange for you to be examined by one of its consulting dentists in your area. Dental Your Dental Coverage Additional Plan Information Extraoral grafts (grafting tissues from outside the mouth to tissue inside the mouth) TMJ other than as specified in Dental Plans at a Glance on page 132. Vision Services or supplies furnished by a family member Your Vision Coverage Charges by the dentist for completing dental forms Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Charges for broken appointments Instruction for oral care such as hygiene or diet Services not performed by a dentist except those performed by a licensed dental hygienist which are supervised and billed by a dentist for cleaning and scaling of teeth or fluoride treatments. reserves the right to add to or amend this list from time to time by resolution of the Global Benefits Committee under the authority granted to the Committee by the Board of Directors of Additional Plan Information Pre-existing Condition Exclusions There are no pre-existing condition exclusions. If You Live in Delaware, Indiana, Louisiana, North Carolina or South Carolina Delta Dental s network of participating dentists is not yet widely available in your state. You may continue to use any dentist for your dental care, and the amount the plan will pay for your care will not be reduced if you use a non-participating dentist. However, there are still advantages to using a participating Delta 136 Second Opinions Delta obtains second opinions through regional consultant members of its Quality Review committee who conduct clinical examinations, prepare objective reports of dental conditions, and evaluate treatment that is proposed or has been provided. Delta will authorize such an examination before treatment when it is necessary to make a benefits determination in response to a dentist s request for a pre-determination of treatment cost. Delta will also authorize a second opinion after treatment if you have a complaint regarding the quality of care provided. Delta will notify you and the treating dentist when a second opinion is necessary and appropriate, and direct you to the Regional Consultant selected by Delta to perform the clinical examination. When Delta authorizes a second opinion through a Regional Consultant, the plan will pay for all examination or consultation charges. You may otherwise obtain second opinions about treatment from any dentist you choose, and claims for the examination may be submitted to Delta for payment. The plan will pay such claims in accordance with the benefits of the plan.

137 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Coordination of Benefits If you or your dependents have other group dental coverage, benefits from the dental plans will coordinate with the other plan s coverage. For information about s terms regarding Coordination of Benefits, please see Coordination of Benefits on page 225. Extended Dental Coverage If you or any covered dependent received treatment for any covered dental expense during the 30 days before the date your coverage under the plan ended, any work in progress that is completed within 90 days after coverage ends may be considered for reimbursement. Accessibility and Services for After-Hours and Urgent Care If you or a family member has special needs, you should ask your dentist about accessibility to their office or clinic at the time you call for an appointment. Your dentist will be able to tell you if their office is accessible, taking into consideration the specific requirements of your needs. Routine or urgent care may be obtained from any licensed dentist during his or her normal office hours. Delta does not require prior authorization before seeking treatment for urgent or afterhours care. You may plan in advance for treatment for urgent, emergency, or after-hours care by asking your dentist how you can contact him or her in the event you or a family member may need urgent care treatment or treatment after normal business hours. Filing a Complaint If you have any questions about the services received from a Delta dentist, we recommend that you first discuss the matter with your dentist. If you continue to have concerns, you may call or write to Delta Dental. If you have a question or complaint regarding the denial of dental services or claims, the policies, procedures and 137 operations of Delta, or the quality of dental services performed by a Delta dentist, you may call Delta Dental toll free at or visit Obtaining Claim Forms Dental claim forms are available on Gapweb or by contacting Delta Dental s Customer Service Center. Submitting Claims for Non-Participating Dentist Services The claims administrator is Delta Dental. If you visit a participating Delta dentist, you do not need to file a claim form. If you visit an out-of-network dentist, you are responsible for filing a claim. If you visit an out-of-network dentist, you are responsible for paying any charges and Delta will reimburse you according to the plan benefits. Payments made to you are not assignable; in other words, Delta will not pay out-of-network dentists directly. Orthodontia Claims After Delta processes your initial orthodontic claims, the first payment of 50% of the approved treatment plan amount will be made. The remaining 50% will be paid 12 months later. Calculation of orthodontic benefits continues to be based on the all-inclusive total treatment plan amount and is subject to deductibles (if any), appropriate co-payment percentages, and a patient s lifetime orthodontic maximum. The claim must include: Banding date Amount of down payment Monthly payment amount Description of service Estimated treatment length

138 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Dual coverage information (including the amount paid by the primary carrier and a copy of the Explanation of Benefit statement), and Delta Dental of California P.O. Box Sacramento, CA Appliance name used to control harmful habit (only for claims submitted for a harmful habit appliance). How and When Claims Are Paid All payments will be made to you as soon as Delta Dental receives satisfactory proof of your incurred expenses and payments for dental services, except in the following cases: Completing Your Claim Forms Complete the employee portion of the form Have your provider complete the provider portion of the form Send the form and bills to the address shown on the form Make sure the bills and the claim form include the following information: Your name and Social Security number Additional Plan Information Company name () Group number 600 (Delta Dental) or 6600 (Delta Dental Plus) Diagnosis Delta Dental will send an Explanation of Benefits (EOB) to you. The EOB will explain how Delta Dental considered each of the charges submitted for payment. Any benefits continued for your eligible dependents after your death will be paid to one of the following: Date the services or supplies were incurred Specific services or supplies provided. Your surviving spouse A bill or cash receipt for prescription drugs must also show the prescription number and the name of the dentist who issued the prescription. Claims should be submitted within 12 months after the date the expenses are incurred. Claims submitted after the 12-month period may not be considered for payment. Delta Dental will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested. Send your completed form and bills/receipts to Delta Dental at: If Delta Dental pays benefits directly to the network provider. These payments will satisfy Delta Dental s obligation to the extent of the payment. Patient s name 138 If you have financial responsibility under a court order for a dependent s dental care, Delta Dental will make payments directly to the provider of care, or Your eligible child who is not a minor, if there is no surviving spouse A provider of care who makes charges to your eligible dependents for covered services and supplies, or The legal guardian of your eligible dependents. Benefit Determinations or Appealing Denied Claims For information on the types of claims that may be filed as well as the process for appealing denied claims please see Claims and Appeals Procedures on page 228.

139 Dental Your Dental Coverage Term Definition Anesthesia Local anesthesia means the administration of specific agents to achieve the loss of conscious pain response in a specific location of the body. General anesthesia means the administration of specific agents to render the patient completely unconscious and without conscious pain response. Additional Plan Information Anesthetic A drug that produces loss of feeling or sensation either generally or locally. Appliance A device used to provide a functional or a therapeutic (healing) effect. Bitewing X ray An X ray showing exposed portions of teeth, used primarily for early detection of hidden decay between teeth. Bridge, bridgework Fixed bridge is a non-removable replacement for a natural tooth or teeth, and is cemented to natural teeth which are used as abutments on either side. Removable bridge is a partial denture normally held by clasps to natural teeth, permitting removal as desired. Vision Plus Plan at a Glance Cavity A portion of a tooth destroyed by decay requiring filling or more extensive treatment. Plan Limits and Exclusions Co-insurance The percentage of the reasonable and customary portion of covered dental expenses for which you and the plan share responsibility for payment after you have paid the deductible, if applicable. Crown A dental restoration usually covering the whole exposed portion of a tooth. It is most often made of porcelain, gold, or acrylic and frequently used in bridgework or to restore a badly broken or decayed tooth. Dentist An individual licensed to practice dentistry by the governmental authorities who have jurisdiction over the licensing and practice of dentistry, in the locality where the service is rendered. As used in this plan, the term dentist also includes a licensed physician, authorized by license to perform the particular dental service rendered. Denture A removable replacement for natural teeth. Full denture is a denture replacing all teeth in an upper or lower jaw. Partial denture is a denture replacing some, but not all, of the upper or lower teeth. Eligible expenses The reasonable and customary expenses eligible for reimbursement under the plan. Eligible expenses include only those expenses incurred when a service is performed by or under the direction of a dentist, that is essential for the necessary care of the teeth, and that starts and is completed while the person is covered. Endodontics The treatment of diseases within the root of a tooth, primarily root canal therapy. Extraction The removal of a natural tooth. Filling The material inserted in a tooth to fill a cavity. Fluoride A substance used in preventing tooth decay. Impaction A tooth partly or wholly buried under the gum by bone or tissue. Ineligible expenses Dental expenses that are not eligible for reimbursement under the plan. ly necessary Services or supplies required to diagnose or treat a patient in accordance with standards of good dental practice. This includes both the frequency and duration of treatment, as established by appropriate dental associations. Dental Plans at a Glance Vision Your Vision Coverage Additional Plan Information 139

140 Dental Your Dental Coverage Dental Plans at a Glance Term Definition Oral surgery Surgery of the oral cavity, including teeth, tongue, and throat. It may be dental or non-dental in nature. If dental in nature, the surgery costs are covered by a dental plan and the hospital costs (if inpatient) are normally covered by a medical plan. If non-dental in nature, the costs are normally covered by a medical plan. Orthodontics The branch of dentistry primarily concerned with the detection, prevention, and correction of abnormalities in the positioning of the teeth in their relationship to the jaws (commonly, teeth straightening or repositioning). Periodontics The treatment of diseases of the gum and tissue around the teeth. Pre-determination An estimate of the amount Delta Dental will pay for a service, assuming you are eligible and meet all of the requirements of the plan at the time the treatment is completed. Additional Plan Information Vision In order to receive pre-determination, your dentist must send an Attending Dentist s Statement to Delta Dental listing the proposed treatment. Delta Dental will send your dentist a Notice of Pre-determination, which estimates how much of the treatment costs Delta Dental will pay and how much you will have to pay. Your dentist should return the statement to Delta Dental for payment when the treatment has completed. Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Computations are estimates only and are based on what would be payable on the date the notice is issued. Payment will depend on your eligibility and your remaining annual maximum when completed services are submitted to Delta Dental. Additional Plan Information Prophylaxis The mechanical cleaning of teeth to remove plaque and tartar. Prosthetics The artificial replacement of natural teeth (bridges and dentures). Pulp The soft tissue inside the crown and roots of a tooth, composed of nerves, blood vessels, and other tissues. This is the part of the tooth in which root canal therapy is done. Reasonable & Customary (R&C) limit When you receive care from an out-of-network provider, the plan pays out-of-network charges based on a standard range of fees for services in your geographic area. This is a Reasonable & Customary (R&C) limit. If your out-of-network provider charges more than the R&C limit, you are responsible for paying that amount out of your pocket. Restoration Any inlay, crown, bridge, partial denture, or complete denture that restores or replaces loss of tooth structure, teeth, or oral tissue. The term applies to the end result of repairing and restoring or reforming the shape, form, and function of part or all of a tooth or teeth. Root canal therapy (endodontic therapy) The treatment of a tooth having a damaged pulp that is usually performed by completely removing the pulp chamber and root canals, and filling these spaces with scaling material. Surface One of the four sides of a chewing area of a tooth. Temporomandibular Joint Disorder (TMJ) A disorder involving the joint linking the jawbone and the skull. Topical The painting of the surface of teeth as in fluoride treatment, or application of a cream-like anesthetic formula to the surface of the gum. 140

141 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Vision Your Vision Coverage offers two vision plan options: the basic Vision plan and the Vision Plus plan, which are administered by Vision Service Plan (VSP ). Eligible employees are automatically enrolled in the basic Vision plan. There is no cost to you for this plan, which pays for one eye exam every 12 months with a VSP network doctor. If you visit a non-vsp doctor, your eye exam will be reimbursed up to $50, and you will be responsible for any remaining amount. The Vision plan covers only employees. To cover dependents, you must enroll in the Vision Plus plan. You can find a VSP network doctor in your area at or by contacting VSP Member Services at When you make an appointment with a VSP network doctor, let them know that you have VSP coverage and the doctor will obtain benefit authorization directly from VSP. There are no ID cards issued, and claim forms are not required if you visit VSP network doctors. You pay only the applicable co-pays, if any, to a VSP network doctor for services covered by the plans. VSP will pay the doctor directly for the remainder of eligible charges. If you receive services from a non-vsp provider, you are responsible for paying the provider in full and then submitting an itemized bill to VSP. Search on Gapweb or contact VSP Member Services at to obtain a claim form. 141 For additional vision benefits, you can choose to enroll yourself and your eligible dependents in the Vision Plus plan, and you pay for the coverage. This plan helps cover the cost of eyewear such as prescription glasses or contact lenses. If you enroll your dependents in this plan, it also provides them with one eye exam every 12 months. You have the choice of visiting a VSP network doctor or a non-vsp provider. If you use a VSP network doctor, covered services are provided at a higher benefit level, and you will have lower out-of-pocket costs. You can also receive higher coverage for certain services from retail chains affiliated with VSP. If you receive services at Costco or any other affiliate provider, you will receive higher coverage for certain services. In most cases, you will not need to fill out a claim form.

142 Dental Your Dental Coverage Dental Plans at a Glance For details on plan coverage and providers you can use, see the table below. Vision Plus Plan at a Glance VSP Providers Eye Exam Costco1 Other Affiliate Providers2 Non-VSP Provider Covered 100%; no co-pay Up to $50 reimbursement Lenses Covered 100% after $25 co-pay3 1 set every 12 months Vision Includes: Glass or plastic single vision, lined bifocal, lined trifocal, or lenticular prescription lenses After $25 co-pay3 reimbursed up to: Your Vision Coverage Polycarbonate prescription lenses are covered in full for eligible children Additional Plan Information 1 every 12 months $50 for single vision $75 for bifocal Vision Plus Plan at a Glance $100 for trifocal Plan Limits and Exclusions $125 for lenticular $80 for progressives Additional Plan Information Lens Discounts Guaranteed pricing saves members an average of 35-40% Costco discount pricing Guaranteed pricing saves members an average of 35-40% NA Frames Covered 100% after $25 co-pay up to $1503 Covered 100% after $25 co-pay up to $703 Covered 100% after $25 co-pay up to $1503 Up to $70 reimbursement after $25 co-pay1 1 set every 12 months 20% off amount above allowance Contact Lenses Covered 100% up to $150 (instead of eyeglasses) 15% off contact lens services, excluding materials 1 set every 12 months 1 20% off amount above allowance Covered 100% up to $150 Up to $150 reimbursement Covered 100% up to $150 15% off contact lens services, excluding materials Not all Costco eye doctors are affiliated with VSP. Contact VSP to confirm the doctor is an affiliate provider before receiving services. 2 Other affiliated providers include Visionworks, WisconsinVision, RxOptical, Cohen s Fashion Optical and more. Contact VSP for a complete list. 3 One $25 co-pay for eyeglass lenses and frames. To find a VSP provider, Costco, or other affiliate provider near you, call or visit 142

143 Dental Plan Limits and Exclusions UV (ultraviolet) protected lenses. Your Dental Coverage Certain benefits covered under the Vision and Vision Plus plans are subject to plan limits: If you are a VSP member but do not notify your VSP network doctor about your coverage, your claim for reimbursement will only be paid at the out-of-network level. Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information The Vision Plus plan covers one set of contacts or eyeglass lenses every 12 months. Under the Vision Plans If you elect contact lenses, you will be eligible for a frame 12 months after the last date of obtaining the contact lenses. This rule also applies to your eligible dependents. Orthoptics or vision training and any associated supplemental testing, plano (non-prescription) lenses, or two pairs of glasses in lieu of bifocals Cosmetic extras such as designer frames, lens coating, or tinted lenses will cost you extra. If you use a VSP network doctor, you will pay the VSP discounted price for these cosmetic extras. If you are using a non-vsp provider, you will pay the retail price. Replacement of lenses and a frame furnished under this plan that are lost or broken, except at the normal intervals These plans are designed to cover visual needs rather than cosmetic eyewear. If you select any of the following extras, the plan will pay the basic cost of the allowed lenses, and you will be responsible for any additional cost for the options, unless the extra is defined in the schedule of benefits: or surgical treatment of the eyes Costs for securing eyewear such as lenses and a frame under the Vision plan Corrective vision treatment such as, but not limited to, RK and PRK laser surgery, other than access to discounts as stated in the Laser Vision Correction Discount section on the next page. Blended lenses Additional Plan Information Contact lenses (except as noted in the schedule of benefits) Prescription Glasses Discount If you visit a VSP network doctor, the Vision Plus plan offers: Oversize lenses Photochromic lenses; tinted lenses except Pink #1 and Pink #2 Progressive multifocal lenses The coating of the lens or lenses 30% off unlimited additional pairs of prescription glasses when purchased on the same day as an eye exam from the same doctor who provided the exam. 30% off unlimited non-prescription sunglasses and prescription sunglasses when purchased on the same day as an eye exam from the same doctor who provided the exam. If you wear contact lenses, you can purchase a pair of non-prescription sunglasses at the 30% discounted rate when purchased on the same day as your eye exam. The laminating of the lens or lenses A frame that costs more than the plan allowance Certain limitations on low vision care Cosmetic lenses Optional cosmetic processes 143

144 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information If you return to the VSP network doctor after the day of your VSP eye exam (and within 12 months) you will receive a 20% discount off additional pairs of glasses. You will also receive up to 35 40% savings on lens extras, such as scratch resistant and anti-reflective coatings and progressives, from a VSP network doctor. For additional information, visit or contact VSP Member Services at Contact Lens Exam and Lens Discount The Vision Plus plan offers a $150 allowance that applies to the cost of your contact lens exam (evaluation and fitting) and your contacts. If you visit a VSP network doctor, you will also receive a 15% discount off the cost of your contact lens exam. Your contact lens exam is performed in addition to your routine eye exam. Learn more from your VSP network doctor, visit or contact VSP Member Services at Laser Vision Correction Discount As a VSP member, you also receive discounted rates on laser vision correction surgery including PRK, LASIK, and Custom LASIK which could add up to hundreds of dollars in savings. Discounts typically average 15% off the contracted laser center s usual and customary price. VSP discounts may not apply to laser center promotional programs however, if the laser center is offering a temporary price reduction, VSP members will receive 5% off the promotional price. The most you will pay is $1,500 per eye for PRK, $1,800 per eye for LASIK or $2,300 per eye for Custom LASIK. (While the laser vision correction screening with your doctor is free, if you have a pre-operative exam and do not proceed with the surgery, your VSP network doctor may charge a discounted exam fee up to $100.) 144 Low Vision Benefit The Vision Plus plan includes a special low-vision benefit if you or a covered family member have severe visual problems that are not correctable with regular lenses. This benefit is subject to the following limitations: Prior authorization is required. When a VSP network doctor suspects a low-vision condition, he or she will request advanced approval from VSP before beginning treatment for you. VSP may authorize supplemental testing by the doctor to determine the nature of the problem and propose a treatment plan to VSP. The supplemental testing is paid up to $125 by the Vision Plus plan. VSP must approve the treatment plan or benefits will not be paid. You will pay a portion of the cost. For approved treatment plans, VSP will pay 75% of the cost. You will be responsible for the remaining 25%. The maximum benefit is $1,000 every two years. This $1,000 maximum includes the cost of the supplementary testing. If you receive low-vision treatment from a non-vsp provider, the plan will pay benefits as described above but you will have to pay the full fee to the provider. VSP will reimburse you only the amount it would have paid to a VSP network doctor for the same services. You will be responsible for any expenses not reimbursed by VSP. Coordination of Benefits If you or your dependents have other vision coverage, benefits from the vision plans will coordinate with the other plan s coverage. See Coordination of Benefits on page 225.

145 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information Filing a Complaint You can file a complaint regarding a service or claim payment to VSP either verbally or in writing. Call VSP Member Services at , Monday through Friday, 5:00 a.m. to 8:00 p.m. Pacific Time. VSP Member Services can provide you with a form or take your complaint over the phone. Grievance forms are also available at a VSP doctor s office, and complaints may be filed in writing to: VSP Complaint and Grievance Unit P.O. Box Sacramento, CA Upon receiving a verbal or written complaint, VSP will respond, in writing, to acknowledge receipt and/or disposition of the grievance within five calendar days. All complaints will be resolved to the enrollee within 30 calendar days, and VSP keeps all grievances filed and related responses on file for seven years. Group number (Vision plan) or (Vision Plus plan) Patient s name, date of birth, address and phone number, and Relationship to covered VSP member (e.g., self, spouse, partner, child ). Claims should be submitted within 12 months after the date the expenses are incurred. Claims submitted after the 12-month period may not be considered for payment. VSP will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested. Send your completed form and bills/receipts to VSP at: VSP P.O. Box Sacramento, CA You may also sign on to select the Out-of-Network Reimbursement Form and follow the instructions. Obtaining Claim Forms A claim form for reimbursement of out-of-network vision expenses is available on Gapweb ( benefits or by contacting VSP s Member Services. How and When Claims Are Paid All payments will be made to you as soon as VSP receives satisfactory proof of your incurred expenses and payments for vision services, except in the following cases: Submitting Claim Forms You do not need to file a claim form when visiting a VSP network doctor. If you visit a non-vsp provider, you are responsible for paying the doctor and filing a claim, then VSP will reimburse you. When submitting a claim to VSP, you must include the following: If you have financial responsibility under a court order for a dependent s vision care, VSP will make payments directly to the provider of care Provider s bill, including a detailed list of the services received Your name, phone number, address and Social Security number If VSP pays benefits directly to the network doctor, or If you request in writing that payments be made directly to a provider (you have this option when completing the claim form). Company name () 145

146 Dental Your Dental Coverage Dental Plans at a Glance Additional Plan Information These payments will satisfy VSP s obligation to the extent of the payment. A VSP WellVision Savings Statement is available to you at The Savings Statement explains how VSP considered each of the charges submitted for payment. If Your Claim Is Denied For information on the process for appealing denied claims, please see Claims and Appeals Procedures on page 228. Vision Your Vision Coverage Vision Plus Plan at a Glance Plan Limits and Exclusions Additional Plan Information 146

147 Important Plan Notices Benefits for MastectomyRelated Services Maternity Hospital Stays Medicare Part D Prescription Drug Coverage Privacy of Health Information Important Plan Notices offers medical, vision, prescription drug and dental benefits to eligible international assignees through Cigna Global Health Benefits. To be eligible for these expatriate benefits, your assignment must be one year or longer outside your home location, and you will be eligible for these benefits at the start of your assignment. If you are eligible for expatriate benefits, the Global Mobility team will send you a package with enrollment forms and additional information about Cigna Global Health Benefits coverage. If you have questions about this coverage or how to enroll, contact the Global Mobility team at [email protected]. Note: Please click here to see the policy document for a description of coverage and exclusions. The document is also available on Gapweb ( benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext Benefits for Mastectomy-Related Services (Women s Health and Cancer Rights Act) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses, and Treatment of physical complications of all stages of the mastectomy, including lymphedemas. These benefits will be provided subject to the same deductibles, co-pays and co-insurance applicable to other medical and surgical benefits provided under this plan. For information on WHCRA benefits or details about any mastectomy-related state laws that may apply to your insured medical plan, please refer to the benefit summaries for the medical plan in which you are enrolled. The summaries are available on Gapweb or by contacting your medical plan. 147

148 Important Plan Notices Benefits for MastectomyRelated Services Maternity Hospital Stays Medicare Part D Prescription Drug Coverage Privacy of Health Information Maternity Hospital Stays (Newborns and Mothers Health Protection Act) Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection with childbirth. In general, group health plans and health insurance issuers may not: Restrict benefits for the length of hospital stay 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). Require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay of up to 48 hours (or 96 hours). Privacy of Health Information The receipt, use and disclosure of protected health information is governed by regulations issued under the Health Insurance Portability and Accountability Act (HIPAA). In accordance with these regulations, the plan administrator, certain employees working with, and on behalf of, the plan and the plan s business associates may receive, use and disclose protected health information in order to carry out the payment, treatment, and health care operations under the plan. These entities and individuals may use protected health information for such purposes without your authorization. If your protected health information is used or disclosed for any other purpose (other than as specifically required or authorized under HIPAA), the plan must first obtain your written authorization for such use or disclosure. For details on any state maternity laws that may apply to your insured medical plan, please refer to the benefit summaries for the medical plan in which you are enrolled. The summaries are available on Gapweb or by contacting your medical plan. Medicare Part D Prescription Drug Coverage The plan administrator has determined that the prescription drug coverage offered as part of the medical benefits is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered creditable coverage. Employees can keep this coverage and not pay a higher premium (a penalty) if they later decide to join a Medicare drug plan. The plan administrator will distribute certificates of creditable coverage to employees upon participation in this plan, during each subsequent Open Enrollment period, and any time the prescription drug coverage ends or is no longer considered creditable. 148

149 Your EAP Coverage Eligibility and Enrollment Dependent Care Services Legal/Financial Services Using Your EAP Benefits Confidentiality Additional Information (EAP) Your EAP Coverage The EAP is a free and confidential counseling service to help you, your household members and dependents resolve personal issues. provides this benefit in partnership with Magellan Behavioral Health*. Through this program, experienced, licensed mental health professionals (including psychologists, clinical social workers, marriage, family and child counselors) are available to help you with: Employees classified as full-time, their household members and dependents are eligible for s EAP benefits. You are automatically enrolled in the EAP when you become a new benefits-eligible employee or change your status from part-time to full-time. To participate, simply call the dedicated number at 888.EAP.4GAP ( ). Eligibility and Enrollment Marital, family or relationship problems Dependent Care Services Stress, anxiety or depression EAP dependent care services include: Adolescent behavior problems Consultation and information services helping educate you on a wide range of parent, senior, child and work/life issues. Alcoholism or drug dependency Conflicts at work or at home (occupational issues, balancing work and life, etc.) Eating disorders Stress from financial or legal difficulties. Your EAP benefits include up to eight free counseling sessions per problem per year, as clinically appropriate, with licensed professionals. The EAP can also provide you with resources and referrals for a wide range of topics, including child care, elder care, adoptions, legal and financial services, and much more. * Services in California are provided through Magellan Health Services of California Employer Services. Resource and referral services helping you identify care concerns, locate convenient resources and services, provide availability updates, and assist you to evaluate service quality. You can receive a full range of resource materials that may include tip sheets, brochures, signature guides, and CDs or cassettes. The EAP also provides full life cycle consultation, information and resources for all stages of life (including prenatal, infant, toddler, school-age, teen, retirement and seniors), assisting you in the following areas: Pregnancy planning, adoption assistance and infertility Childcare centers, kindergarten and preschools In-home nannies, babysitters and au pairs Parenting Teen internship and volunteer programs College services (including pre-college, college, and adult college re-entry) 149

150 Your EAP Coverage Vocational training, distance learning and career counseling Legal/Financial Services Eligibility and Enrollment Middle adulthood lifestyle changes Senior housing, in-home supports and services, retirement residences, skilled nursing facilities and hospice care Legal and financial consultations are also available to you and your family through the EAP legal and financial services at or Being a grandparent Legal services include: Confidentiality Companion caregivers, respite care Legal consultation and referral services for personal legal issues Additional Information Special needs, ranging from care for newborns to assistance for developmentally challenged adults One free initial office or telephone legal consultation with a network attorney lasting a maximum of 60 minutes per separate legal matter. If additional representation/consultation services are required, you will receive a preferred rate reduction of 25% from the attorney s normal hourly rate. Dependent Care Services Legal/Financial Services Using Your EAP Benefits Retirement planning Community services, transportation, legal consultations and volunteering Meal services. Work/life consultants offer referrals from a continuously updated nationwide resource database. To make sure your needs are met, you will be encouraged to call back to request further information on the same or other topics if your situation changes or the need arises. An Important Note About EAP Dependent Care Services The final decision about your dependent care arrangements is up to you. Referrals given by the EAP in connection with dependent care services are not endorsements or guarantees for the programs or providers to which you are referred. You are encouraged to discuss any concerns about resources with an EAP counselor. 150 Mediation services through the Early Intervention Program, which provides informal resolution for personal problems and, in certain circumstances, workplace issues. Financial services include: Information and planning tools for household budgeting, retirement planning, education funding, debt management, estate planning, and leasing versus buying Unlimited free telephone consultations with a financial counselor for routine financial matters one free initial in-person consultation with a local financial consultant is also available for more complex financial planning issues. If additional face-to-face financial counseling services are required, the financial consultant will tell you his or her fee for services. Personalized reports such as a pre-retirement analysis or a college funding analysis are available through local financial consultants at no cost to you.

151 Your EAP Coverage Eligibility and Enrollment Dependent Care Services Legal/Financial Services Using Your EAP Benefits You can also access a free online legal and financial resource center at The website is not meant to replace the counsel and advice of licensed professionals, but is designed to provide information and resources. The site includes a legal library, a financial library, and several online tools, including financial calculators. Confidentiality Additional Information An Important Note About the EAP s Legal/ Financial Services The EAP does not include advice on issues regarding your program of benefits, employees, providers, or attorneys. It does not cover matters relating to your job or business concerns. This program does not provide advice on any matter that is frivolous, harassing, or otherwise would be a violation of ethical rules. Using Your EAP Benefits The EAP phone lines are staffed 24 hours a day, seven days a week. If you are calling in a crisis situation, you will be able to speak to a counselor immediately. If you are calling for nonemergency counseling, a trained EAP staff member will help you with referrals to find a local, licensed counselor near your work or home. Your counselor will meet with you to assess your problem and, depending on the severity, either provide brief counseling or refer you to longer-term or specialized treatment outside of the EAP. You can always contact the EAP at any time if you are having trouble making an appointment with your counselor or are not satisfied with your counselor. 151 EAP information, educational materials and self-help strategies are also available online at Brief counseling is outpatient counseling that is problem-focused, emphasizes skills and strengths, and encourages the recipient to practice new behaviors. Brief counseling involves setting goals that can be achieved in a one- to five-month period using the interpretation, suggestions and framework the counselor provides. As appropriate, you or your household members and unmarried children may receive counseling alone or together with members of your family. covers in full all costs for the counseling sessions you receive through the EAP. There are no co-pays, co-insurance or deductible payments for EAP services. However, if your counselor determines that a referral for longer-term or specialized services would be appropriate, you will be responsible for paying for those services. If you are enrolled in a UnitedHealthcare medical plan, you may have coverage for these sessions. You will need to call UnitedHealthcare to receive authorization to continue to see your counselor and ensure your counselor will be covered by your insurance. Under the EAP The EAP does not provide any of the following: Evaluations required by any state or federal judicial officer or other governmental official or agency mandating that you, your household member or your unmarried child undergo counseling Court-mandated counseling, evaluations or recommendations to be used in child custody proceedings, child abuse proceedings, criminal proceedings, workers compensation proceedings, or legal actions of any kind

152 Your EAP Coverage Eligibility and Enrollment Dependent Care Services Legal/Financial Services Using Your EAP Benefits Confidentiality Additional Information Evaluations for fitness-for-duty determinations or excuses for leaves of absence or time off care, including services for a condition that requires psychiatric treatment (for example, a psychosis) Inpatient treatment Services that are not available from providers not identified by the EAP for your particular problem Psychological, psychiatric, neurological, educational or IQ testing Remedial and social skills education services, such as evaluation or treatment of learning disabilities, learning disorders, academic skill disorders, language disorders, mental retardation, motor skill disorders or communication disorders, behavioral training or cognitive rehabilitation Medication or medication management Examinations and diagnostic services in connection with obtaining employment or a particular employment assignment, admission to or continuing in school, securing any kind of license (including professional licenses), or obtaining any kind of insurance coverage Confidentiality The EAP maintains strict confidentiality about the services they provide. They will not share information concerning your involvement in the EAP without your written permission unless life, safety or national security is seriously threatened, or the law requires disclosure. Information about your participation will not be given to If you have been referred for a work performance problem, the EAP will confidentially inform the manager who referred you whether you attend the EAP session and whether you cooperate with the counseling plan, but only with your written permission. Additional Information About the EAP For California Employees: Evidence of Coverage and Disclosure If you are a employee living in California, you can find additional information about the terms of your EAP benefits by accessing the Evidence of Coverage and Disclosure Form available on Gapweb ( benefits. Testimony in legal proceedings or creation of records for legal proceedings or other preparation for legal proceedings Guidance on workplace issues when you, your household member or your unmarried child sues, or threatens to sue, Acupuncture Biofeedback or hypnotherapy. 152

153 Health Care FSA Eligibility Enrollment There are two types of (FSAs): How the Health Care FSA Works Health Care FSA Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Dependent (Day) Care FSA. These are separate accounts and you may enroll in one or both to help you reduce your taxes. Details on each type of Flexible Spending Account, including eligibility and enrollment, eligible expenses and maximum contributions, are outlined in this chapter. Puerto Rico employees are not eligible to participate in FSAs. Eligible Expenses Ineligible Expenses Health Care Flexible Spending Account (FSA) Using Your Dependent (Day) Care FSA Although your health plans typically cover most of your health care expenses, there are still some costs that are not covered and that you must pay for out of your own pocket. The Health Care FSA lets you set aside tax-free dollars to pay for certain health care expenses for you and your eligible dependents. When Coverage Ends With a Health Care FSA, you can set aside a portion of your regular income from each paycheck to pay for eligible out-of-pocket health care expenses for you and your dependents, such as:, dental or vision deductibles, co-insurance and co-pays Eyeglasses, contact lenses and contact lens supplies Orthodontia Prescription drugs When you enroll in a Health Care FSA, you decide how much you want to contribute for the plan year. Pre-tax deductions are then taken from every paycheck and put into your Health Care FSA. This lowers your taxable income and reduces the amount of taxes you pay for the year. Your tax savings can really add up. When you have health care expenses that you pay out of your own pocket, you can use a plan-provided Health Care Spending MasterCard to pay for the expenses or submit claims to UnitedHealthcare, the Health Care FSA plan administrator, to request reimbursement from your account. Important: The Health Care FSA does not replace your medical plan, but you can use it to pay for eligible out-of-pocket health care expenses not covered by any of your health insurance plans with tax-free money. Eligibility You are eligible to participate in the Health Care FSA even if you do not enroll in a medical plan. Your Health Care FSA can be used to pay for certain health care expenses for you and your eligible dependents. Your eligible dependents are those whom you claim as dependents on your federal income tax return for the calendar year in which the expense is incurred; they do not need to be enrolled in a medical plan. Important: Due to tax laws, Puerto Rico employees are not eligible to participate in the Health Care FSA. Laser eye surgery. 153

154 Health Care FSA Enrollment Eligibility You can enroll in a Health Care FSA when you first become eligible for benefits, during each annual Open Enrollment or if you experience a life event (see page 10). Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Important: You must enroll in the Health Care FSA each year to participate. The election you make in one plan year does not automatically carry over to the next, so it s important to re-enroll during each Open Enrollment to continue participation in your Health Care FSA. If you elect to increase or decrease your contribution amount during the plan year based on a qualifying life event, your new election will be effective on the first day of the month following the date of your qualifying life event, or on the first of the month if the event occurs on that day. Please note: If you attempt to enroll after June 1, you may not be allowed to add this coverage through the enrollment tool, since there are a limited number of payroll deductions left in the plan year ending June 30. Contact Employee Services at , ext , if you have questions about enrolling during this timeframe. You will have the opportunity to enroll in the Health Care FSA for the next plan year, which starts on July 1. How the Health Care FSA Works Here s how the Health Care FSA works: The Health Care FSA runs on a plan year (July 1 June 30), not a calendar year Before you enroll, estimate how much you spend each year on out-of-pocket health expenses. When you enroll, you choose how much of your pay you wish to contribute You can contribute a minimum of $150 up to a maximum of $2,500 for the plan year - Your contributions will be credited to your Health Care FSA through pre-tax payroll deductions taken in equal amounts from each paycheck remaining in the plan year. It s important to plan carefully, because any unused funds in your Health Care FSA at the end of the plan year will be forfeited in accordance with IRC regulations. If you are considered a highly compensated employee (HCE) as defined by the IRS, your maximum allowable Health Care FSA contribution election may be reduced, as described below. Note: Health Care FSA Contributions Cannot Cover Dependent Care Expenses If you contribute to a Health Care FSA, those funds cannot be used to reimburse you for dependent care expenses, which would be covered under a Dependent (Day) Care FSA. The two accounts are separate, and the funds in each account cannot be used for the expenses eligible under the other account. For the Health Care FSA, you should carefully estimate your health care expenses for the upcoming plan year, since federal tax law requires that you forfeit any unused funds remaining in your account at the end of the plan year. Special Rules for Highly Compensated Employees (HCEs) The Health Care FSA defines an HCE as any employee in the top 25% of employees ranked by salary (including bonuses) in the previous calendar year.

155 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends In return for favorable tax treatment, current IRC regulations require the Health Care FSA plan to pass certain participation tests. These non-discrimination tests are designed to ensure a fair mix of participation in the plan among employees at various income levels. To pass these tests, the contributions of HCEs may be limited. If the test results are not favorable, it may be necessary to lower the amount that HCEs can contribute to their account for the plan year. The IRS periodically determines the definition of an HCE, and this information is subject to change. Currently, an HCE s annual contribution amount is not additionally limited and they can elect up to the annual contribution maximum of $2,500. Employees on a Leave of Absence If you participate in the Health Care FSA and take a leave of absence from, you may be eligible to continue participating in and submitting claims toward your Health Care FSA. Your contributions will be deducted from your pay if you are on a paid leave of absence. If you are on an unpaid leave, any missed contributions will be deducted from your pay when you return to work. When you return to work from your leave, the amount you contribute per pay period will be adjusted to account for missed deductions. Changing Your Contribution Elections While you are allowed to change your contribution election during each Open Enrollment period, IRS regulations do not permit you to stop or change the amount you contribute to your Health Care FSA during the plan year, unless you experience a qualifying life event (see page 10). Your requested contribution election must be consistent with the type of qualifying life event you experience. Important: If you elect to increase or decrease your goal amount based on a life event, your new amount will be effective the first 155 day of the month following the event, or on the first of the month if the event occurs on that day. Eligible Health Care FSA Expenses Only expenses that are incurred while you are participating in the Health Care FSA may be reimbursed from your account. In addition, expenses that are incurred during one plan year cannot be reimbursed during another plan year. An expense is considered incurred when services are provided, not when you are billed or when you pay for eligible services. You may use your contributions to your Health Care FSA for a number of eligible expenses not paid for by your health insurance plans. To be eligible for reimbursement under the Health Care FSA plan, the health care expenses must be incurred: For medical care, as defined in Section 213(d) of the Internal Revenue Code. Eligible expenses are amounts paid for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body, including prescription drugs. While you are participating in the Health Care FSA, and During the plan year (July 1 to June 30). Below is a partial list of the types of health care expenses eligible for reimbursement from your Health Care FSA. Generally, eligible health care expenses are those for which you could have claimed a tax deduction on an itemized federal income tax return. Eligible Health Care Expenses General Examples Co-pays, co-insurance and deductible amounts Routine physical exams Lab and X-rays performed for medical reasons Birth control items prescribed by your doctor

156 Health Care FSA Childbirth classes Eligibility Breast pumps and other lactation devices Enrollment How the Health Care FSA Works For additional information on eligible expenses, please visit Gapweb ( benefits, review IRS Publication 502 at or contact UnitedHealthcare at If you are enrolled in a UnitedHealthcare medical plan, you may also visit their website at Cardiac rehabilitation classes Eligible Expenses Drug abuse treatment centers Ineligible Expenses Sterilization, unless prohibited by law Using Your Health Care FSA Other qualified 213(d) medical expenses not covered by your health insurance plans. When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Vision Expenses Routine eye examinations Ineligible Expenses Laser eye surgery Eligible Expenses Eye glasses Ineligible Expenses Contact lenses, including all necessary supplies and equipment. Using Your Dependent (Day) Care FSA When Coverage Ends You cannot be reimbursed through your Health Care FSA for any expenses paid by any other medical, dental or vision plan. Expenses reimbursed by your Health Care FSA cannot be included as a deduction or credit on your income tax return. Hearing aids and repairs You cannot receive reimbursement from your Health Care FSA for any expense that is not considered tax-deductible by the IRS or not considered an eligible medical care item. Examples of ineligible expenses include: Cost and repair of special telephone equipment for the deaf. Non-prescription drugs, with the exception of insulin Dental Expenses Co-pays, co-insurance and deductible amounts Expenses incurred for cosmetic surgery or other similar procedures, unless the procedure is necessary to improve deformities directly related to a congenital condition, a personal injury or a disfiguring disease Hearing Expenses Routine hearing examinations Preventive care Exams, cleanings, X-rays, root canals and bridges Tooth whitening Dentures and fillings. Expenses for custodial care in a nursing home Co-pays, co-insurance and deductible amounts Insurance premiums, including Medicare Part B premiums, longterm care premiums, and other payments or contributions for health coverage (such as contributions for coverage under an employer-sponsored group health plan or HMO or other health plan) Costs for covered prescription drugs. 156 Important: There are certain expenses that are listed as deductible in IRS Publication 502, but cannot be reimbursed by the Health Care FSA because of IRS rules (e.g., insurance premiums).

157 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Expenses incurred for general good health (such as vitamins and other dietary supplements, soap, or toothpaste) co-pays or co-insurance, as well as for prescription drugs, dental expenses and vision expenses. Expenses incurred before the effective date of enrollment in your Health Care FSA. If you are enrolled in an HRA plan, your Health Care Spending MasterCard cannot be used at a medical provider s office since there are no co-pays, and UnitedHealthcare manages the claims process to use your health reimbursement account (HRA) funds first before using your FSA account. HRA plan members can use the Health Care Spending MasterCard for prescription drugs, dental expenses and vision expenses if the card is accepted by those providers. Important: The above descriptions of eligible and ineligible expenses are not complete and can change at any time without notice. If you have a question about whether or not an expense is eligible, contact UnitedHealthcare at Using Your Health Care FSA When you have an eligible health care expense, you can use your Health Care FSA to pay for the expense, or to reimburse yourself if you have paid for the expense out of your own pocket. Once you enroll in a Health Care FSA, you have access to the full amount of your annual contribution, even if you have not yet contributed the full amount through your payroll deductions, minus any reimbursements you have already received. Your Health Care Spending MasterCard When you first enroll in the Health Care FSA, you will automatically receive a Health Care Spending MasterCard in the mail from UnitedHealthcare, our Health Care FSA plan administrator. This card looks like a credit card with the UnitedHealthcare logo, and provides you with a convenient way to access funds from your Health Care FSA. You and your covered dependents can use your Health Care Spending MasterCard at approved locations that accept MasterCard to pay for eligible expenses. All drug stores are required to take Health Care Spending Cards visit to check which drug stores in your area are compliant. If you are enrolled in the Hawaii PPO, Out-of-Area, or an HMO plan, you can use your Health Care Spending MasterCard for 157 Remember: Be sure to activate the card as soon as you receive it. Review all information sent to you, including the terms and conditions. Sign the back of the card and then call the toll-free number on the activation sticker on the card and follow the voice prompts to complete the activation process. Additional cards sent to you for your dependents are to be signed by them. Only one phone call is necessary to activate all cards. Your card will be ready to use one business day after your call. At the start of the July 1 plan year, your card will be ready to use on July 2. You can use this card to pay for certain out-of-pocket health care expenses, such as prescription drug co-pays and eligible over-the-counter medical items. Over-the-counter drugs are not eligible for a reimbursement without a prescription. The card is programmed with your personal account information, including the amount available under your Health Care FSA. Use your card to pay for eligible expenses at the time of service, up to the amount available from your account. You do not have to submit a claim for reimbursement. You will have access to funds up to the yearly amount you elected less any amounts already used.

158 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works If you enroll in the Health Care FSA or Dependent (Day) Care FSA, you will receive only one card that will work for both plans, with the activity tracked separately for each account. Important: On the last day of the plan year, access to remaining funds in your Health Care Spending MasterCard ends at midnight Eastern Time. If you are in a different time zone and lose access to funds in your Health Care Spending MasterCard before midnight, you will need to submit a manual claim form to request reimbursement. You may choose to use your Health Care Spending MasterCard for mail order prescriptions or for eligible over-the-counter (OTC) supplies and materials by going to an online pharmacy at Drugstore.com via Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Please note If you activate your card prior to the plan effective date, you cannot use your card until the plan effective date. Qualified Locations and Providers The Health Care Spending MasterCard may be used at any approved provider with a Point-of-Service (POS) bankcard terminal that accepts MasterCard or your Health Care Spending MasterCard number can be entered online or on an order form, similar to using a credit card number. You can even use your Health Care Spending MasterCard to pay for a bill you receive in the mail if the provider accepts MasterCard. Examples of qualified locations and providers include dental offices and vision care providers. 158 Please note You may be able to use your Health Care Spending MasterCard to pay for prescribed OTC medicines if you take your OTC prescription to a pharmacist to be filled and have a prescription number assigned. Or you may purchase prescribed OTC medicines using another form of payment, such as cash or a personal credit card. If it is an eligible expense under your plan, you can manually submit for reimbursement. Non-prescribed OTC medicines are not an eligible expense subject to reimbursement. Getting Reimbursed from Your Health Care FSA If you pay for eligible health care expenses out of your own pocket, you can complete an FSA/HRA claim form to receive a reimbursement from your Health Care FSA by check or direct deposit to your bank account. Instructions for direct deposit are located at Submitting a Claim Form You can submit a request for reimbursement from your Health Care FSA at any time throughout the plan year. You will be reimbursed for eligible expenses as long as the amount requested is at least $25, except for the last month s reimbursement. To request a reimbursement from your Health Care FSA: Complete an FSA/HRA claim form for the expenses you or your eligible dependent(s) incurred. The form is available on Gapweb ( benefits.

159 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Attach proof of the expenses incurred such as a bill, invoice, itemized receipt, or an explanation of benefits (EOB) from any group medical/dental plan under which you are covered. An EOB will be required if the expenses are for services usually covered under group medical or dental plan (e.g., charges by surgeons, doctors and hospitals). In such cases, an EOB will verify what your out-of-pocket expenses were after payments under other group medical/dental plans. Retain copies of the request form and supporting documentation for your records. Send your completed claim form to: UnitedHealthcare Health Care Account Service Center P.O. Box El Paso, TX Fax: Toll-free fax: Important: If you and your eligible dependents are enrolled in a UnitedHealthcare medical plan option, all eligible medical expenses will be automatically reimbursed from your Health Care FSA and you will not be required to submit a claim form. Employees participating in the Health Care FSA who are called to active military service may elect a taxable cash distribution from their unused Health Care FSA. If you participate in the Health Care FSA and are called to active military duty (by reason of being a member of the reserves) for a period of at least 180 days, you may elect a reservist distribution from your Health Care FSA. A reservist distribution is a lump sum taxable cash distribution that equals the excess (if any) of: Your pre-tax contributions during the calendar year as of the date of the call or order to military duty, less the amount of reimbursements made from the Health Care FSA for eligible expenses incurred during the year as of the date of the call or order to military duty. It is your responsibility to ensure that the reimbursement request has been received by UnitedHealthcare. 159 Heroes Earnings Assistance and Relief Tax (HEART) Act You may elect a reservist distribution any time after the date of your order to active military duty and before April 1 following the year in which your order occurred. To request a reservist distribution, you must call your local Human Resources representative. Once you receive a reservist distribution, your participation in the Health Care FSA will end. You may participate again in the Health Care FSA if you later become an eligible employee.

160 Eligible Expenses Receive Your FSA Dollars Faster With Direct Deposit Instead of receiving a check for reimbursement from the Health Care FSA, you can choose to have your Health Care FSA dollars directly deposited into your checking account. To activate this feature: Ineligible Expenses Log on to Using Your Health Care FSA Click on Claims and Accounts on the menu bar Health Care FSA Eligibility Enrollment How the Health Care FSA Works When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Click on Direct Deposit under the Member Actions section of the left navigation bar. September 30 Deadline for Requesting Reimbursement For expenses incurred during the plan year (July 1 to June 30), your FSA claim form must be postmarked on or before September 30 following the end of the plan year and received by UnitedHealthcare. Use or Lose In accordance with IRC regulations, unclaimed amounts left in your Health Care FSA account after September 30 following the plan year will be forfeited. These amounts cannot be paid to you or carried forward to the next plan year. Coverage for all employees covered by the Health Care FSA ends at midnight on the earliest of: The last day of the month in which your employment with Gap Inc. ends The last day of the month in which you become ineligible, or 160 When Health Care FSA Coverage Ends The date the plan terminates. You may submit claims for reimbursement of eligible health care expenses that were incurred during the plan year (July 1 to June 30) before your termination date. The deadline for submitting claims is September 30 following the end of each plan year. You may continue coverage under the Health Care FSA, through COBRA, if your employment with ends, or you are no longer eligible.

161 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Dependent (Day) Care Flexible Spending Account (FSA) Important: Due to tax laws, Puerto Rico employees are not eligible to participate in the Dependent (Day) Care FSA. If you rely on babysitters, dependent care providers or home health care nurses to care for your dependents so that you and your spouse can work, look for work or your spouse can attend school full-time, a Dependent (Day) Care FSA may help you save money. Qualifying Individuals for Dependent (Day) Care FSA Expenses The Dependent (Day) Care FSA provides reimbursement for the eligible expenses of qualifying individuals who are, in general, your tax dependents and who: With a Dependent (Day) Care FSA, you can set aside a portion of your paycheck to pay for eligible dependent care expenses (inside or outside your home), including: Rely primarily on you for their support, and Day care Eligible Expenses Before or after school care Ineligible Expenses Day camp Using Your Dependent (Day) Care FSA When Coverage Ends Elder care. When you enroll in a Dependent (Day) Care FSA, you decide how much you want to set aside for the plan year (July 1 to June 30). Pre-tax deductions are then taken from every paycheck and put into your Dependent (Day) Care FSA. This lowers your taxable income and reduces the amount of taxes you pay for the year. Since the money you put into your Dependent (Day) Care FSA is never taxed, your tax savings can really add up. When you have dependent care expenses, you pay for them first and then submit a claim to UnitedHealthcare, the FSA claims administrator, to request reimbursement from your account. Live with you most of the time Are under age 13, or Are physically or mentally unable to care for themselves, regardless of age. This could include care for a disabled spouse or for parents living with you that you are able to claim as dependents on your tax return. Special rules apply to children of divorced or separated parents. You can find more information in IRS Publication 503, available at Important: The dependent care expenses of domestic partners and their children are not considered eligible for reimbursement through this plan unless they can be claimed as dependents on your income tax returns. See Eligible Dependent (Day) Care FSA Expenses on page 164 for more information. Important: Keep in mind that you cannot use money in this account to pay for your dependents health care expenses. Their health care expenses may be eligible for coverage under a Health Care FSA, which is a wholly separate account. 161

162 Health Care FSA Enrollment Eligibility You can enroll in a Dependent (Day) Care FSA when you first become eligible for benefits, during each annual Open Enrollment or if you experience a life event (see page 10). Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Important: You must enroll in the Dependent (Day) Care FSA each year to participate. The election you make in one plan year does not automatically carry over to the next plan year, so it s important to re-enroll during each Open Enrollment period to continue participation. If you elect to increase or decrease your contribution amount during the plan year based on a life event, your new election will be effective on the first day of the month following the date of your life event, or on the first of the month if the event occurs on that day. Please note: If you attempt to enroll after June 1, you may not be able to add this coverage through the enrollment tool, since there are a limited number of payroll deductions left in the plan year ending on June 30. Contact Employee Services at , ext , if you have questions about enrolling during this timeframe. You will have the opportunity to enroll for the next plan year, which starts on July 1. How the Dependent (Day) Care FSA Works Here s how the Dependent (Day) Care FSA works: The Dependent (Day) Care FSA runs on a plan year (July 1 June 30), not a calendar year. - You can contribute a minimum of $300 up to a maximum of $5,000 ($2,500 if married and filing taxes separately) for the plan year. If you are a highly compensated employee (HCE), you will be limited to a maximum contribution of $1,200 for the plan year, as described on the following page. - Your contributions will be credited to your Dependent (Day) Care FSA through pre-tax payroll deductions taken in equal amounts from each paycheck remaining in the plan year. It s important to plan carefully, because any unused funds in your Dependent (Day) Care FSA at the end of the plan year will be forfeited in accordance with IRC regulations. Dependent (Day) Care FSA Contributions Cannot Cover Health Care Expenses! If you contribute to a Dependent (Day) Care FSA, those funds cannot be used to reimburse you for your dependents health care expenses, which might be covered under a Health Care FSA. The two accounts are separate, and the funds in each account cannot be used for the expenses eligible under the other account. For the Dependent (Day) Care FSA, you should carefully estimate your dependent care expenses for the upcoming plan year, since federal tax law requires that you forfeit any unused funds remaining in your account at the end of the plan year. Before you enroll, estimate how much you will spend on dependent care expenses during the plan year. When you enroll, you choose how much of your pay you wish to contribute. 162

163 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment Annual Contribution Rules Your maximum annual contribution to the Dependent (Day) Care FSA depends on your marital and income tax filing status. For single participants, the maximum contribution is generally $5,000 per year. For married participants, the maximum contribution is generally $5,000 per year if filing tax returns jointly, and $2,500 per year if filing separately. See the chart below for details. Note: Spouses who both work may contribute no more than $5,000 per year per couple to the Dependent (Day) Care FSA, regardless of where they work. How the Dependent (Day) Care FSA Works If you are You may contribute the lesser of Eligible Expenses Single $5,000, or your annual income Married, filing a joint tax return $5,000, or your annual income, or your spouse s annual income Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Married, filing separate tax returns $2,500, or your annual income, or your spouse s annual income Married and your spouse is physically or mentally incapable of caring for him/ herself or is a full-time student for at least 5 calendar months per year $250 per month (up to $3,000 per year) for one qualifying dependent; or $500 per month (up to $5,000 per year) for two or more qualifying dependents It is important that you estimate your dependent care expenses carefully, as you will forfeit any contributions you do not claim for reimbursement. 163 Special Rules for Highly Compensated Employees (HCEs) In return for favorable tax treatment, current IRC regulations require the Dependent (Day) Care FSA to pass certain participation tests. These non-discrimination tests are designed to ensure a fair mix of participation in the plan among employees at various income levels. To pass these tests, the contributions of HCEs may be limited. If the test results are not favorable, it may be necessary to lower the amount that HCEs can contribute to their account for the plan year. The IRS periodically determines the definition of an HCE. This information is subject to change. Currently an HCE is any employee who earned a salary of $115,000 or more while on the payroll in the previous calendar year. This amount may change from year to year in accordance with IRC regulations. Salary may include your regular earnings, bonus pay, PTO pay, and pre-tax amounts contributed for benefits in the previous calendar year. Currently, employees who meet the definition of an HCE are limited to an annual maximum contribution of $1,200 toward their Dependent (Day) Care FSA. Annual Maximum Contribution Limits for the Calendar Year and the Plan Year The Dependent (Day) Care FSA plan is governed by IRS regulations and is subject to both plan year (July 1 to June 30) and calendar year (January 1 to December 31) limits. Currently, the IRS annual maximum contribution for Dependent (Day) Care FSA for the calendar year is $5,000. If you elect the annual maximum of $5,000 for the plan year, your contributions may be adjusted to ensure that you do not exceed the $5,000 annual IRS maximum contribution for the calendar year. The annual IRS maximum takes priority over the $5,000 plan year annual maximum. If you meet the $5,000 IRS maximum for the calendar year, your payroll

164 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends deductions will automatically stop. When the new calendar year starts, payroll will resume your deductions. Efforts to prevent you from exceeding your IRS calendar maximum contribution may reduce your plan year annual maximum. This rule also applies to the HCEs who are limited to an annual maximum contribution of $1,200. Employees on a Leave of Absence If you participate in a Dependent (Day) Care FSA and take a leave of absence from, your participation in the plan will end the day before your leave of absence begins. Expenses you incur for dependent care while you are on a leave of absence are not considered eligible expenses and will not be reimbursed from your Dependent (Day) Care FSA. You will have 30 calendar days from your return-to-work date to re-enroll in the plan by completing the Dependent (Day) Care Flexible Spending Account election form on Gapweb ( benefits. Your prior contributions will not automatically begin upon your return to work. The new plan year amount you elect to contribute for a Dependent (Day) Care FSA will be effective the first of the month on or following your return-to-work date and will be deducted from each paycheck in equal amounts based on the number of remaining pay periods in the plan year. Changing Your Contribution Elections While you are allowed to change your contribution election during each Open Enrollment period, IRS regulations do not permit you to stop or change the amount you contribute to your Dependent (Day) Care FSA during the plan year, unless you experience a life event. Your requested contribution election change must be consistent with your life event. 164 Eligible Dependent (Day) Care FSA Expenses The primary purpose of the Dependent (Day) Care FSA is to provide assistance for the well-being and protection of one or more eligible dependents so that you can work. Dependent care expenses must meet the statutory requirements of Internal Revenue Code Section 129. More information about eligible expenses also can be found in IRS Publication 503. Generally, expenses listed in IRS Publication 503 are eligible expenses under the Dependent (Day) Care FSA. Some examples of work-related eligible expenses are: In-home services provided by a babysitter Services provided by a housekeeper or maid, if that person is responsible for the care of an eligible dependent during the day Services provided by a day care facility for children, including summer day camp (the facility must be licensed if it provides care for more than six individuals who do not normally reside there) Services provided by a day care facility for adults (the facility must be licensed if it provides care for more than six individuals who do not normally reside there), and Care provided outside your home (if the eligible dependent is over age 13, he or she must be unable to care for himself or herself and spend at least eight hours per day in your home). For additional information on eligible expenses, please visit Gapweb ( benefits, review IRS Publication 503 at or contact UnitedHealthcare at If you are enrolled in a UnitedHealthcare medical plan, you may also visit their website at

165 Health Care FSA Ineligible Expenses Eligibility Examples of ineligible Dependent (Day) Care FSA expenses include: Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends Payments to any individual who is your or your spouse s dependent under the age of 19 at the end of the calendar year in which the expense is incurred or paid Expenses for which you have claimed the dependent care tax credit under Internal Revenue Code Section 21 Expenses incurred before you became a participant in the Dependent (Day) Care FSA Amounts paid to provide food, clothes or education (certain exceptions may apply) Services outside your home at a camp where your child, disabled spouse or dependent stays overnight Educational expenses for eligible children in kindergarten or above, and Expenses incurred for care of your domestic partner or domestic partner s child who may not be claimed as your tax dependents. Expenses submitted for reimbursement to the Dependent (Day) Care FSA must meet IRC regulations. If your dependent care expenses are not clearly eligible, the claims administrator may ask you to submit additional information to help determine whether the reimbursement is allowed. In some cases, you may need a statement from your tax advisor verifying that the expense in question is eligible for reimbursement. If your spouse has no earned income, you cannot use a Dependent (Day) Care FSA unless your spouse is physically or mentally incapable of caring for himself or herself, is looking for work or is a full-time student for at least five months during the plan year. 165 You are responsible for making sure all expenses submitted for payment under the Dependent (Day) Care FSA are eligible for reimbursement. Using Your Dependent (Day) Care FSA When you have an eligible dependent care expense, you can use your Dependent (Day) Care FSA to pay for the expense, or to reimburse yourself if you have paid the expense out of your own pocket. Once you enroll in a Dependent (Day) Care FSA, you have access only to the amount that you have contributed so far in the plan year. Your Health Care Spending MasterCard When you first enroll in the Dependent (Day) Care FSA, you will automatically receive a Health Care Spending MasterCard in the mail from UnitedHealthcare, our Dependent (Day) Care FSA claims administrator. This card looks like a credit card with the UnitedHealthcare logo, and provides you with a convenient way to access funds from your Dependent (Day) Care FSA. You can use your Health Care Spending MasterCard with approved providers who accept MasterCard to pay for eligible expenses. Remember: Be sure to activate the card as soon as you receive it. Review all information sent to you, including the terms and conditions. Sign the back of the card and then call the toll-free number on the activation sticker on the card to complete the activation process. Additional cards sent to you for your dependents are to be signed by them. Only one phone call is necessary to activate all cards. Your card will be ready to use one business day after your call, but cannot be used until after the first payroll deduction after July 1 of that plan year.

166 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Eligible Expenses Ineligible Expenses Using Your Health Care FSA When Coverage Ends Dependent (Day) Care FSA Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends You can use this card to pay for eligible dependent care expenses as long as the provider or facility accepts MasterCard The card is programmed with your personal account information, including the amount available under the Dependent (Day) Care FSA. Use your card to pay for eligible expenses at the time of service, up to the balance in your account. You do not have to submit a claim for reimbursement. You will have access to funds up to the amount you have actually contributed to the plan to-date. If you enroll in the Health Care FSA and the Dependent (Day) Care FSA, you will receive only one card that will work for both plans with the activity tracked separately for each account. Important: On the last day of the plan year, access to remaining funds in your Health Care Spending MasterCard ends at midnight, Eastern Time. If you are in a different time zone and lose access to funds in your Health Care Spending MasterCard before midnight, you will need to submit a manual claim form to request reimbursement. Some employees may be eligible to claim a dependent care tax credit on their federal income tax return. This credit is available for the same types of expenses as the Dependent (Day) Care FSA. However, the IRS requires that the dependent care tax credit be reduced dollar-for-dollar by the amount reimbursed under a Dependent (Day) Care FSA. In other words, you cannot use expenses reimbursed through the Dependent (Day) Care FSA to claim the tax credit. For more information about how the dependent care tax credit works, see IRS Publication 503. In addition, because each employee s situation is different, you may want to consult with a tax advisor before deciding whether to use the tax credit or the Dependent (Day) Care FSA. Getting Reimbursed From Your Dependent (Day) Care FSA If you pay for eligible dependent care expenses out of your own pocket, you can complete an FSA/HRA claim form to receive a reimbursement from your Dependent (Day) Care FSA by check or direct deposit to your bank account. Instructions for direct deposit are located at Submitting a Claim Form You can submit a request for reimbursement from your Dependent (Day) Care FSA at any time throughout the plan year. You will be reimbursed for eligible expenses as long as the amount requested is at least $25, except for the last month s reimbursement. Only amounts you have actually contributed to the account are available for reimbursement. If you request reimbursement for more than what you have in your account, you will receive only the amount in your account. As additional deposits are made to your account, outstanding reimbursements will be processed automatically. To request a reimbursement from your Dependent (Day) Care FSA: 166 Dependent Care Tax Credit vs. Dependent (Day) Care FSA Complete an FSA/HRA claim form for the expenses you or your eligible dependent(s) incurred. The form is available on Gapweb ( benefits.

167 Health Care FSA Eligibility Enrollment How the Health Care FSA Works Attach copies of your receipts that show the following: When Dependent (Day) Care FSA Coverage Ends - Day care provider s name, address, and Social Security or tax identification number Coverage for all employees covered by the Dependent (Day) Care FSA ends at midnight on the earliest of: - Dates of service Ineligible Expenses - Dependent s name The last day of the month in which your active employment with ends, including termination Using Your Health Care FSA - Amount paid. The day before you begin a leave of absence Eligible Expenses When Coverage Ends Retain copies of your claim form and receipts for your records The last day of the month in which you become ineligible, or Dependent (Day) Care FSA Send your completed claim form to: UnitedHealthcare Health Care Account Service Center P.O. Box El Paso, TX The date the plan terminates. Enrollment How the Dependent (Day) Care FSA Works Eligible Expenses Ineligible Expenses Using Your Dependent (Day) Care FSA When Coverage Ends All contributions stop when your pay stops, including when you are on a leave of absence. If you would like to participate in the Dependent (Day) Care FSA when you return from a leave, you must re-enroll within 30 days from your return to work date. Fax: Toll-free fax: It is your responsibility to ensure that the reimbursement request has been received by UnitedHealthcare. September 30 Deadline for Requesting Reimbursement For expenses incurred during the plan year (July 1 to June 30), your FSA/HRA Claim Form must be postmarked on or before September 30 following the end of the plan year and received by UnitedHealthcare. You may submit claims for reimbursement of eligible dependent care expenses that were incurred during the plan year, including expenses incurred within the same plan year after your termination date. The deadline for submitting claims is September 30 following the end of each plan year. Use or Lose In accordance with IRC regulations, unclaimed amounts left in your Dependent (Day) Care FSA account after September 30 following the plan year will be forfeited. These amounts cannot be paid to you or carried forward to the next plan year. 167

168 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance The following section is a summary of your benefits. For further details, please see the Minnesota Life Certificates of Insurance posted on Gapweb. s Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance plans are designed to provide financial assistance to your family in the event of your injury or death. offers eligible employees the following plans, provided through Minnesota Life Insurance Company: The Basic Life Insurance plan pays benefits to your designated beneficiary if you die while you are a covered employee of Gap Inc. Basic Life coverage is guaranteed up to $2 million with no evidence of insurability (EOI) or proof of good health required. Basic Life provides you with Basic Life Insurance coverage at no cost to you, equivalent to your annual base pay. For Directors and above, the Basic Life Insurance benefit equals three times your annual base pay. Supplemental Life You may increase your life insurance coverage by purchasing Supplemental Life Insurance in amounts equal to one, two, three, or four times your annual base pay. You pay for this extra insurance through payroll deductions. The maximum amount of life insurance coverage you may carry through the Basic Life and Supplemental Life plans combined is $2 million. Dependent Life If you have a spouse, domestic partner or children, you may also purchase Dependent Life Insurance. Spouse and domestic partner coverage is available in increments of $5,000, $10,000, $25,000, $50,000, $75,000, and $100,000, but cannot exceed 50% of your Basic Life Insurance amount. You can also elect Dependent Life Insurance for your Child(ren) in the amount of $10,000 per child. Basic Life Insurance You are automatically enrolled for coverage in the Basic Life Insurance plan, which is 100% paid for by : Eligible employees through the Management level One times your annual base pay Employees at Director level and above Three times your annual base pay. Coverage amounts are rounded to the nearest $100 and subject to a minimum of $5,000 and a maximum of $2 million. Taxable Life Insurance If your basic group life insurance coverage is more than $50,000, the premium value of the amount in excess of $50,000 is taxed as ordinary income. The taxable amount is generally based on IRS tables that estimate the relative benefit value of the excess insurance. AD&D You can purchase additional coverage for yourself and your family through the AD&D plan. This coverage provides a benefit if you die in an accident or suffer certain accidental injuries, such as loss of an eye or limb. Termination of Coverage 168

169 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Supplemental Life Insurance Changing Your Coverage You may increase your life insurance coverage by purchasing Supplemental Life Insurance in the following amounts, rounded to the nearest $100: See Making Changes on page 10 for information on changing your benefit elections during Open Enrollment or if you experience a life event during the plan year. One times your annual base pay If you didn t enroll in Supplemental Life Insurance when you were first eligible, you may apply to add this coverage if you experience a life event or during Open Enrollment. However, you may be required to provide evidence of insurability (EOI) to Minnesota Life. In addition to completing an EOI form, you may be required to have a physical examination or to submit additional medical information. If you are requesting a reinstatement of previous coverage that has been terminated, you will need to provide EOI to Minnesota Life. Visit Gapweb ( benefits to make changes to your Supplemental Life Insurance coverage. Two times your annual base pay Three times your annual base pay Changing Your Coverage Four times your annual base pay. Additional Life Insurance Plan Information Like Basic Life, the Supplemental Life Insurance plan pays benefits to your designated beneficiary if you die while you are a covered employee of The maximum amount of life insurance coverage you may carry under both the Basic Life and Supplemental Life combined is $2 million. Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Waiver of Premium If you are under age 60 and become totally and permanently disabled, you may be eligible for a premium waiver after nine months of total disability. Once proof of your disability is reviewed and approved, your Basic and Supplemental Life Insurance coverage may be continued without payment of premiums during the uninterrupted continuance of the total and permanent disability, but not beyond attainment of age 65. Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability Termination of Coverage 169

170 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Dependent Life Insurance Child(ren) Coverage You may purchase Dependent Life Insurance coverage for your eligible dependents, including your spouse or domestic partner and children. The plan pays a benefit to you if a dependent dies while covered by the plan. You can elect Dependent Life Insurance without electing Supplemental Life Insurance. You may purchase Dependent Life Insurance coverage for your children. The benefit amounts are $500 between birth and age 14 days, and $10,000 for children over age 14 days. Spouse or Domestic Partner Coverage Changing Your Coverage For spouse or domestic partner coverage, you may purchase coverage in the following amounts: Additional Life Insurance Plan Information $5,000 Enrolling $10,000 How Benefits Are Paid $25,000 Benefits Reduction Rule $50,000 Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits $75,000 $100,000. The amount of your spouse or domestic partner life insurance coverage cannot be more than 50% of your own coverage amount under Basic Life Insurance. Evidence of insurability (EOI) is required if you elect spouse or domestic partner coverage in any amount greater than $25,000. If you previously waived coverage and elect any amount during a life event or Open Enrollment, EOI is required (except in the event of a marriage or start of domestic partnership). Changing Your Coverage See Making Changes on page 10 for information on changing your benefit elections during Open Enrollment or if you experience a life event during the plan year. If you didn t elect Dependent Life Insurance when you were first eligible to do so, you may apply to add this coverage for your eligible dependents if you experience a life event or during Open Enrollment. However, you will be required to provide EOI to Minnesota Life. In addition to completing an EOI form, your eligible dependent may be required to have a physical examination or to submit additional medical information. If you are requesting a reinstatement of previous coverage that has been terminated, you may need to provide EOI to Minnesota Life. Visit Gapweb ( benefits to make changes to your Dependent Life Insurance coverage. Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability Termination of Coverage 170

171 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Additional Life Insurance Plan Information Enrolling in the Life Insurance Plans The cost of Basic Life Insurance is 100% paid by, and you are automatically enrolled effective your eligibility date. You pay for the cost of Supplemental Life Insurance and Dependent Life Insurance through payroll deductions, and you may enroll in these plans when you first become eligible, if you experience a life event, or during Open Enrollment although you may be required to provide evidence of insurability (EOI), depending on the level and amount of insurance. If you enroll in Supplemental Life Insurance and/or Dependent Life Insurance, you should verify that appropriate deductions are being taken from your pay a few weeks after you enroll. If deductions aren t being taken, please notify Employee Services immediately. Your coverage may be jeopardized if deductions aren t being taken and your coverage is not considered paid by Minnesota Life. How Benefits Are Paid The Basic and Supplemental Life Insurance plans pay benefits to your designated beneficiary if you die while you are a covered employee of Any amount payable to a beneficiary will be paid to those you name. Unless you state to the contrary, if more than one beneficiary is named, they will share on equal terms. If a named beneficiary dies before you, his or her share will be payable in equal shares to any other named beneficiaries who survive you. You may name one or multiple beneficiaries who would share benefits, and you may change your beneficiary at any time on Gapweb ( benefits. Dependent Life Insurance pays a benefit to you, the employee, if a dependent dies while covered by the plan. Beneficiaries Important! If you and your spouse or domestic partner are both employees, you cannot have both Life Insurance as an employee and also be covered by Dependent Life Insurance through your spouse or domestic partner. In addition, no person may be covered as a dependent of more than one employee. Benefits Reduction Rule All benefit amounts for Basic, Supplemental, and Dependent Life Insurance for your spouse or domestic partner are reduced by 33.33% when he or she reaches age 70. At age 75, benefit amounts are reduced by another 33.33% of the original benefit amount. Age-related benefit reductions will apply the first day of the month of the insured employee s 70th and 75th birthdays. Actively-at-Work Provision If you are ill or injured and away from work on the date your coverage would take effect, the coverage will not take effect until you return to full-time work for one full day. This rule also applies to any increases made to your coverage. Accelerated Benefit If you or a covered dependent has a terminal condition while covered by the life insurance plans, you may apply to cash out the life insurance coverage in advance for up to 100% of its value. For this purpose, a terminal condition is defined as a condition caused by sickness or accident which directly results in a life expectancy of 12 months or less. The minimum amount of coverage that the terminally ill insured person must have is $10,000 and the maximum is $1 million. You may also apply to receive a partial accelerated benefit, which leaves the insured s remaining coverage in force, but that remaining coverage must be at least $25,000. Portability Termination of Coverage 171

172 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability To apply for the accelerated benefit, complete an application form, available from Employee Services, and send it with a physician s statement to Minnesota Life. bill you for the policy. It s important to note that the premium rate on your portable policy will be higher than the rate you paid for coverage as an active employee. For more information about the accelerated benefit feature, please see the Minnesota Life Certificates of Insurance posted on Gapweb ( benefits. Portability coverage will not be available to employees if any of the following applies: How to Continue or Convert Your Life Insurance Coverage You have converted your insurance to an individual life policy Portability Your Supplemental and Dependent Life Insurance plans are portable meaning you can elect to continue your coverage if you leave You are eligible to continue your Life Insurance if you no longer meet the eligibility requirements of this plan for any of the following reasons: You terminate employment, including retirement You are no longer in a class eligible for insurance You are on a leave or layoff, or You are no longer eligible for insurance due to an amendment to the group policy, and the total number of insured members under the group policy who lose eligibility due to that amendment is less than 25%. Your insured spouse or domestic partner is eligible to continue Dependent Life Insurance coverage if he or she no longer meets the eligibility requirements of the group policy due to legal separation, divorce, dissolution of the partnership, your death, or if you take a 100% accelerated benefit. Portable life insurance is issued without medical questions. You must request portable life insurance within 31 days of your termination or change in employment status. Minnesota Life will You are over 70 years of age You are an employee and you were not actively-at-work due to sickness or injury on the date immediately preceding your portability date You are a spouse/domestic partner and are totally disabled and unable to work, or The group life policy with Minnesota Life terminates. The minimum amount of insurance that can be continued on your life is $10,000. The maximum amount of insurance that can be continued for an insured under age 65 is the amount of insurance that was in force on the insured s portability date, but not more than $500,000 for an employee or $150,000 for a spouse/domestic partner. For an insured who is age 65 or older on his or her portability date, the amount will not be more than $325,000 for an employee or $97,500 for a spouse/domestic partner. When an insured reaches age 65, the amount of insurance continued under this benefit will reduce to 65% of the amount of insurance in force on the day before he or she turns age 65. Portable coverage will terminate on the first to occur of: The insured s 70th birthday The date the insured again meets the eligibility requirements of the plan Termination of Coverage 172

173 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit In the case of a child or spouse/domestic partner who is insured with portable coverage, the date your spouse/domestic partner or child is no longer eligible, or The end of a 31-day period following the date the required premium contribution is due and not paid. If you become disabled while covered under the Group Life Insurance plan and you qualify for a medical leave of absence you may receive up to 52 weeks of company-paid Basic Life coverage and have the option of continuing your employeepaid Supplemental Life coverage. After you have been out on a medical leave of absence for 52 weeks, will terminate your coverage, unless you are eligible for the waiver of premium benefits described on page 169. When your life insurance coverage ends, you will have the option to convert the group policies to individual plans (see Conversion below). Benefit Amounts Conversion You may convert your life insurance coverage to an individual policy if all or part of your coverage under the group policy terminates. You may convert up to the full amount of your terminated insurance if the coverage ends for any of the following reasons: Description of Coverage You move from one eligible class to another Additional Benefits You are no longer in an eligible class Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability The group policy is terminated, or The group policy is changed to reduce or terminate your insurance. You do not have the right to convert your coverage if your coverage under this group policy terminates due to a failure to make, when due, the required premium contributions. You may convert your insurance to any type of individual policy of life insurance customarily issued by Minnesota Life for purposes of conversion, except term insurance. The individual policy will not include any supplemental benefits such as any disability benefits, accidental death and dismemberment benefits, or accelerated benefits. You can convert your insurance by applying for an individual policy and paying the first premium within 31 days after your Life Insurance terminates. Evidence of insurability (EOI) will not be required. The individual policy takes effect 31 days after your Gap Inc. Life Insurance policy coverage ends. Termination of Coverage Coverage for all persons covered by Life Insurance ends at midnight on the earliest of: The last day of the month in which your employment with Gap Inc. ends. For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) becomes ineligible. For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July 31. However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. The date the plan(s) terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). Termination of Coverage 173

174 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Accidental Death & Dismemberment (AD&D) Insurance However, one may elect Employee and the other Employee & family. You may enroll in and pay for Accidental Death & Dismemberment (AD&D) Insurance to supplement your other insurance coverage. The AD&D plan pays benefits to you if you sustain a major injury or to your designated beneficiary if you die as the result of an accident while you are a covered employee of You may choose to cover yourself and/or your eligible dependents under the plan. Description of Coverage Benefit Amounts If you choose to elect AD&D coverage, you can select any one of the following benefit amounts for yourself or your dependents: Benefit Amounts The benefit you or your beneficiaries receive under the AD&D plan depends on the type of loss you experience, as shown in the following table. Accidental death or dismemberment means that the insured person s death or dismemberment results directly from an accidental injury that is unintended, unexpected and unforeseen. The injury must occur while the insured s coverage is in force, and the resulting death or dismemberment must occur within 365 days after the date of the injury and while coverage is still in force. Type of Loss Amount of Insurance $25,000 $200,000 Life 100% Accelerated Benefit $50,000 $250,000 Both hands or both feet 100% Continue or Convert Coverage $75,000 $300,000 Sight in both eyes 100% Termination of Coverage $100,000 $400,000 Speech and hearing 100% $125,000 $500,000 One hand and one foot 100% One foot and sight in one eye 100% One hand and sight in one eye 100% Quadriplegia (total paralysis of both arms and legs) 100% Paraplegia (total paralysis of both legs) 75% Sight in one eye 50% Speech or hearing 50% One hand or one foot 50% Hemiplegia (paralysis of one arm and one leg on the same side of the body) 50% Thumb and finger of one hand 25% Actively-at-Work Provision Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability Termination of Coverage 174 $150,000 After you or your covered spouse/domestic partner reach age 70, your AD&D coverage will be reduced by a percentage, as summarized in the following table: At Age Benefit Reduction 70 30% 75 55% 80 70% 85 85% If both you and your spouse or domestic partner are employees, you cannot both elect Employee & family coverage.

175 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage A loss is defined as follows: Loss of hands or feet means complete severance at or above the wrist or ankle joints Loss of sight, speech or hearing means the entire and irrecoverable loss of sight, speech or hearing that cannot be corrected by medical or surgical treatment or by artificial means Loss of thumb and finger means complete severance of both the thumb and finger at or above the metacarpophalangeal joints, and Loss of use, without severance, of a limb (e.g., paralysis). A benefit is not payable for both loss of thumb and finger on one hand and the loss of one hand or injury to the same hand as a result of any one accident. Benefits payable for all losses due to any one accident will never exceed the maximum amount covered by the plan. No more than one payment will be made for the same loss or paralysis of the same limb. Accidental Death & Dismemberment (AD&D) Insurance Dependent Coverage You can insure yourself only, or yourself and your dependents under the AD&D plan. Benefits for your dependents are based on the following table: Dependents Covered Amount of Insurance* Spouse or domestic partner (as part of family coverage that includes children) 50% of employee s full amount of insurance Spouse or domestic partner (that does not include children) 60% of employee s full amount of insurance Each child (as part of family coverage that includes a spouse or domestic partner) 15% of employee s full amount of insurance Each child (that does not include a spouse or domestic partner) 20% of employee s full amount of insurance * The maximum amount of insurance for a spouse/domestic partner is $300,000. The maximum amount of insurance for each child is $100,000. Additional Benefits Unless stated otherwise, additional benefits are payable to the same beneficiaries who receive the AD&D benefits, and are paid in addition to any AD&D benefits. Airbag Benefit If an insured person dies as a result of a covered accident that occurs while he or she is driving or riding in a private passenger car, an additional benefit of 5% of the amount payable (subject to a maximum of $12,500), will be paid, as long as: Benefit Amounts Description of Coverage Additional Benefits The seat in which the insured person was seated was equipped with a properly installed airbag at the time of the accident Additional AD&D Plan Information The private passenger car is equipped with seatbelts Actively-at-Work Provision A seatbelt was in proper use by the insured at the time of the accident as certified in the official accident report or by the investigating officer, and Continuation Clause Beneficiaries Portability Termination of Coverage 175

176 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability At the time of the accident, the driver of the private passenger car was a licensed driver and was not intoxicated, impaired, or under the influence of alcohol or drugs. or 1% of the difference between the insured person s amount of insurance and the amount of any benefits paid under the loss schedule for the same accident. Airbag means a passive restraint device in a vehicle that inflates upon collision to protect an individual from injury or death. The benefit will be paid monthly until the earliest of the following: Seatbelt means a properly installed seatbelt (or child restraint if the insured person is a child), lap and shoulder restraint, or other restraint approved by the National Highway Traffic Safety Administration or any successor governmental agency. The date the insured person recovers such that he or she is no longer in a coma A private passenger car means a validly registered four-wheeled private passenger car or policyholder-owned car, jeep, pickup truck or van, including a sport utility vehicle (SUV), that is not licensed commercially or being used for racing, acrobatic or stunt driving. Brain Damage Benefit If an insured person sustains and is diagnosed by a licensed physician as having traumatic brain injury (TBI) as a result of and within 60 days of a covered accidental injury, and such TBI damage has lasted for a minimum of 12 consecutive months, the AD&D plan will pay a benefit equal to 100% of the insured s amount of insurance, minus the amount of any other benefits paid under the loss schedule for the same accident. The insured must be hospitalized due to TBI for at least seven days within the first 60 days following the accident. This benefit will be paid in a lump sum during the 13th month following the date of the accident if TBI continues longer than 12 consecutive months. Coma Benefit If an insured person lapses into a coma as a result of and within 30 days of a covered accidental injury, and the coma has lasted for a minimum of 31 days, the AD&D plan will pay a benefit equal to the lesser of 1% of the insured person s amount of insurance, The date of the insured person s death. If an accidental death payment is due under the plan, the amount of the payment will be reduced by the amount of insurance paid under the coma benefit, or The end of the 11th month for which the benefit is payable. If the insured person remains in a coma after this benefit is payable for 11 straight months, then a lump-sum payment will be made, equal to the insured person s amount of insurance, minus the amount of the 11 monthly payments and any other benefits paid under the loss schedule for the same accident. Coma means a state of profound unconsciousness with no evidence of appropriate responses to stimulation. The insured person must be confined in a medical facility and diagnosed as comatose by a licensed physician. Disappearance Benefit If an insured person s body has not been found after one year from the date the conveyance in which he or she was traveling disappeared, exploded, sank, became stranded, made a forced landing, or was wrecked, it will be presumed that the insured has died as a result of accidental injury that was unintended, unexpected and unforeseen. The death will be considered a covered loss under this plan. Termination of Coverage 176

177 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Exposure Benefit If an insured person is unavoidably exposed to the elements due to a covered accident and suffers a loss that is included in the list of covered losses as a result of the exposure, the AD&D plan will cover the loss. Rehabilitative Physical Therapy Benefit If an insured person suffers an injury that results in a covered loss, the plan will pay an additional benefit for rehabilitative physical therapy that is prescribed by the attending physician or surgeon. The rehabilitative expenses must be incurred within two years of the date of the covered accident. The benefit will be equal to the lesser of 10% of the insured person s amount of insurance or $10,000. Seatbelt Benefit If an insured person dies as a result of a covered accident that occurs while he or she is driving or riding in a private passenger car, the plan will pay an additional accidental death benefit equal to 10% of the amount payable due to the insured person s death, subject to a maximum of $25,000, as long as: The private passenger car was equipped with seatbelts A seatbelt was in proper use by the insured at the time of the accident as certified in the official accident report or by the investigating officer, and At the time of the accident, the driver of the private passenger car was a licensed driver and was not intoxicated, impaired, or under the influence of alcohol or drugs. For a definition of the term seatbelt, please see Airbag Benefit on page 175. Beneficiaries Portability Child Care Benefit If you die as a result of a covered accident and you are survived by your spouse or domestic partner and one or more children, the plan will pay additional benefits to reimburse your surviving spouse or domestic partner for child care expenses for your children who were enrolled for licensed child care at the time of your death. The benefit for each child per year will be the lesser of 5% of your amount of insurance, $5,000, or incurred child care expenses. Child Dismemberment Double Benefit If a covered child receives bodily injuries which result in a covered loss, the amount payable will be twice the amount of the child s amount of coverage, subject to a maximum amount of $200,000. If a covered child sustains more than one covered loss from a single accident, then Minnesota Life will pay the double benefit amount only for the largest amount to which the child is entitled. Common Accident Benefit If both you and your covered spouse or domestic partner die from covered accidental injuries sustained in a common accident, your spouse or domestic partner s accidental death benefit will be increased to an amount equal to 100% of your amount of insurance, provided however, when added to your amount of insurance, the combined benefit is not more than $1 million. Common accident means the same accident or separate accidents that occur within the same 24-hour period. Education Benefit If you die as a result of a covered accident and you are survived by your spouse or domestic partner and one or more children, Minnesota Life will pay an education benefit, in an amount equal to 10% of your amount of insurance, not to exceed $20,000 Termination of Coverage 177

178 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information per eligible child per year. Benefits will be paid for up to four consecutive years of enrollment per eligible child provided that at the time of your death, the eligible child is enrolled as a full-time student at an accredited post-secondary educational institution and is under age 23 or the child was at the 12th grade level and enrolls as a full-time student at a post-secondary educational institution within 365 days of the covered accident. The benefit will be paid to your spouse or domestic partner, if living, otherwise to or on behalf of the eligible children. Extended Dependents Insurance Benefit If you die as a result of a covered accident and you are survived by your spouse or domestic partner and/or one or more children, such dependents insurance will be continued in force for a period of 24 months from the date of your death, without further payment of premiums. Spouse or Domestic Partner Training Benefit If you die as a result of a covered accident and you are survived by your spouse or domestic partner, Minnesota Life will pay a training benefit to the surviving spouse or domestic partner provided that the spouse or domestic partner: Is not working for wage or profit on the date of such an accident, and Within 365 days after the date of such an accident, enrolls as a full-time student in an accredited educational institution or an institution of vocational training for the purpose of preparing for full-time employment. Actively-at-Work Provision The benefit will be equal to the lesser of: Continuation Clause 10% of your amount of insurance Beneficiaries $15,000, or The costs incurred for the education or training within the first year following the date of your death. Proof of the costs will be required before benefits are paid. Under the AD&D Plan The plan will not pay the AD&D benefit where the insured person s death or dismemberment results from any of the following: Suicide or attempted suicide, whether sane or insane Intentionally self-inflicted injury or any attempt at self-inflicted injury, whether sane or insane Participation in or attempt to commit a crime, assault or felony Bodily or mental infirmity, illness or disease or surgical treatment, including diagnostic procedures Alcohol, drugs (unless administered upon the advice of a physician), poisons, gases or fumes, voluntarily taken, administered, absorbed, inhaled, ingested or injected, Bacterial infection, other than infection occurring simultaneously with, and as a result of, the accidental injury Travel or flight in or on any vehicle used for aerial navigation including getting in, out, on or off such a vehicle, if the insured is: - Riding as a passenger in any aircraft not intended or licensed for the transportation of passengers - Acting as a pilot or a crew member of any aircraft, unless riding as a passenger - Riding as a passenger in a non-chartered aircraft that is owned, leased, operated or controlled by the eligible employee s employer Portability Termination of Coverage 178

179 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit - A student taking a flying lesson, unless riding as a passenger Beneficiaries - Hang gliding, or You can add or change beneficiaries as long as your coverage is in force, you have not assigned the ownership of your insurance to someone else, and Minnesota Life has written consent of all irrevocable beneficiaries (if any). You can add or change your beneficiary information on Gapweb ( benefits. - Parachuting, except when the injured has to make a parachute jump for self-preservation. War or any act of war, whether declared or undeclared Accident occurring while the insured is serving on full-time active duty for more than 30 days in any Armed Forces (Reserve or National Guard active duty for training is not excluded). Additional AD&D Plan Information Actively-at-Work Provision If you are ill or injured and away from work on the date your coverage would take effect, the coverage will not take effect until you return to full-time work for one full day. This rule also applies to an increase in your coverage. Continue or Convert Coverage Continuation Clause Termination of Coverage If you are not actively-at-work due to sickness, injury, leave of absence or temporary layoff, your AD&D insurance may be continued for yourself, your insured spouse or domestic partner, and/or his or her insured children. Insurance will be deemed to continue until terminated by discontinuance of premium payments, written request or any other applicable termination provisions. Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Insurance continued for non-medical leave of absence or temporary layoff may not be continued beyond 12 months from the last day you were actively-at-work. Actively-at-Work Provision Portability Your AD&D insurance is portable you can elect to keep your coverage if you leave You are eligible to continue your AD&D insurance if you no longer meet the eligibility requirements of this plan due to any of the following: You terminate employment, including retirement You are no longer in a class eligible for insurance or you are on a leave or layoff, or You are no longer eligible for insurance due to an amendment to the group policy, and the total number of insured members under the group policy who lose eligibility due to that amendment is less than 25%. An insured spouse/domestic partner is eligible to continue insurance if he or she no longer meets the eligibility requirements of the group policy due to legal separation, divorce, dissolution of the domestic partnership or your death. Portability coverage will not be available if any of the following applies: You are over 70 years of age You are an employee and you were not actively at work due to sickness or injury on the date immediately preceding your portability date Continuation Clause Beneficiaries Portability Termination of Coverage 179

180 Basic Life Insurance Taxable Life Insurance You are a spouse/domestic partner and are totally disabled and unable to work, or Supplemental Life Insurance The group life policy with Minnesota Life terminates. Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision The minimum amount of insurance that can be continued under this benefit on your life is $10,000. The maximum amount of insurance that can be continued for an insured under age 65 is the amount of insurance that was in force on the insured s portability date, but not more than $500,000 for an employee or $150,000 for a spouse/domestic partner. For an insured who is age 65 or older on his or her portability date, the amount will not be more than $325,000 for an employee or $97,500 for a spouse/ domestic partner. When an insured reaches age 65, the amount of insurance continued under this benefit will reduce to 65% of the amount of insurance in force on the day before he or she turns age 65. Accelerated Benefit Portable coverage will terminate on the first to occur of: Continue or Convert Coverage The insured s 70th birthday Termination of Coverage Accidental Death & Dismemberment (AD&D) Insurance Benefit Amounts Description of Coverage Additional Benefits Additional AD&D Plan Information Actively-at-Work Provision Continuation Clause Beneficiaries Portability Termination of Coverage 180 The date the insured again meets the eligibility requirements of the plan In the case of a child or spouse/domestic partner who is insured with portable coverage, the date your spouse/domestic partner or child is no longer eligible, or The end of a 31-day period following the date the required premium contribution is due and not paid. Termination of Coverage Coverage for all persons covered by Accidental Death & Dismemberment (AD&D) Insurance ends at midnight on the earliest of: The last day of the month in which your employment with Gap Inc. ends. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) becomes ineligible. - For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. The date the plan(s) terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). When coverage ends, you may be able to convert your AD&D Insurance without evidence of insurability (EOI) to an individual policy if you apply for conversion and pay your first premium within 31 days of the termination of your coverage(s). Obtaining Claim Forms To obtain a claim form, contact Minnesota Life at Written notice of injury on which an AD&D claim may be based must be sent to Minnesota Life within 30 days after the accident. Proof of loss must be furnished to Minnesota Life within 90 days after the date of loss.

181 Basic Life Insurance Taxable Life Insurance Supplemental Life Insurance Waiver of Premium Changing Your Coverage Dependent Life Insurance Spouse or Partner Coverage Child(ren) Coverage Changing Your Coverage Additional Life Insurance Plan Information Enrolling How Benefits Are Paid Benefits Reduction Rule Actively-at-Work Provision Accelerated Benefit Continue or Convert Coverage Termination of Coverage Payment of Benefits Minnesota Life will pay the death benefit after receiving written proof that you died while insured under the plan, or an AD&D benefit after receiving written proof that a covered person has died or suffered a covered dismemberment as a result of a covered accidental injury. All payments by Minnesota Life are payable from the insurer s home office. AD&D benefits will be paid in a single sum. Minnesota Life will pay interest on the benefit from the date of the covered person s death or dismemberment until the date of payment. Life Insurance benefits will be paid in a single sum or by any other method agreeable to the insurer and the beneficiary. Minnesota Life will pay interest on the death benefit from the date of the covered person s death until the date of payment. Additional AD&D Plan Information If there is no eligible beneficiary, or if you do not name one, we will pay the death benefit to: Actively-at-Work Provision Your lawful spouse if living, otherwise Benefit Amounts Description of Coverage Additional Benefits Continuation Clause Beneficiaries Portability Your brothers and sisters in equal shares, if living, otherwise The personal representative of your estate. Benefit Determinations and Appealing Denied Claims For information on the types of claims that may be filed as well as the process for appealing denied claims please see Claims and Appeals Procedures on page 228. Minnesota Life will pay death benefits to your beneficiary or beneficiaries. All other benefits will be payable to you, if living, otherwise to your estate. If there is more than one beneficiary, each will receive an equal share, unless you have requested another method in writing. To receive the death benefits, a beneficiary must be living at the time of your death. In the event a beneficiary is not living at the time or your death, that beneficiary s portion of the death benefit will be equally distributed to the remaining surviving beneficiaries. In the event of the simultaneous deaths of you and a beneficiary, the death benefit will be paid as if you survived the beneficiary. Accidental Death & Dismemberment (AD&D) Insurance Your parents in equal shares, if living, otherwise Your natural or legally adopted Child(ren) in equal shares, if living, otherwise Termination of Coverage 181

182 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Benefits If you become ill or injured and aren t able to work, provides both short-term and long-term disability benefits that replace a portion of your wages if you are deemed to be eligible by the plan. There are two Short-Term (STD) plans and two Long-Term (LTD) plans available to you: STD and STD Plus s STD plans may provide eligible employees with an income for up to 180 days when you are unable to work due to a non-occupational injury or illness, including the birth of a child. The STD Plus plan pays a higher percentage of base wages tax-free during your disability than the basic STD plan. LTD and LTD Plus s LTD plans may provide eligible employees with income protection during an illness or while recovering from an accident after your STD has expired. The LTD Plus plan pays a higher percentage of base wages during your disability (tax-free) than the basic LTD plan. Sedgwick Claims Management Services (Sedgwick CMS), Inc. administers disability claims for the STD and STD Plus plans. You can find more information about your STD or STD Plus benefits or claims on Gapweb, ( benefits, or contact Sedgwick CMS directly at The LTD and LTD Plus plans are administered by CIGNA. You can find more information about your disability benefits or claims on Gapweb ( benefits. 182 Important definitions and phrases can be found in Terms You Should Know on page 192. It s a good idea to take a minute to look up a term or phrase you do not know so you can better understand how your plan works. Short-Term (STD) STD Plan The basic STD plan benefits are paid by They replace 60% of your covered earnings for up to 180 days if you cannot work because of a non-occupational illness or injury, including pregnancy or the birth of a child. These benefits are subject to federal, FICA, state and, if applicable, city taxes. There is a sevenconsecutive-day unpaid waiting period before your benefits begin, except in the case of pregnancy. If you have paid time off (PTO) available, you may use it during the waiting period. STD benefits will be offset by any state disability benefits available to you. You are automatically enrolled in the basic STD plan if you are a fulltime, benefits-eligible employee. STD Plus Plan The STD Plus plan pays 65% of your covered earnings tax-free for a maximum of 180 calendar days if you cannot work because of a non-occupational illness or injury, including pregnancy or the birth of a child. You need to enroll in this plan and pay the premium, which covers the cost of increasing your coverage from 60% of your covered earnings (paid by through the basic STD plan) to 65%. Your premium amount will depend on your salary and will be deducted from your regular paycheck.

183 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison While your benefits received under this plan are tax-free, you will need to pay taxes on the premiums that pays for your basic STD coverage. You pay these taxes up front (called imputed income) and the amount is based on your tax bracket. STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Note: Your Rights Under the California Paid Family Leave Plan You may be eligible for the California Paid Family Leave partial wage replacement if your leave is to care for a qualified dependent or family member with a serious medical condition or to bond with a new child. To obtain a form, call 877.BE.THERE. For more information, visit the California Employment Development Department s website at STD and STD Plus Comparison Plan Features STD STD Plus Employee contributions No Yes (paid by ) Waiting period Seven consecutive days or first day of hospital confinement if sooner (may use PTO); no waiting period for pregnancy Benefit 60% of covered 65% of covered earnings (taxable) earnings (tax-free) Maximum benefit None Minimum benefit None Duration of benefit 180 days of paid benefits while disabled. You will be asked to periodically provide proof of continuing disability. 183 STD and STD Plus Plan Provisions Successive Periods of If you are ill or injured and unable to work after receiving benefits under this plan during more than one period, your successive periods of disability will be determined as follows as long as you earn less than 80% of your covered earnings: If your two consecutive periods of disability are due to the same cause or condition* and are separated by less than 14 calendar days after you return to work at your regular occupation with, they will be considered the same period of disability. A new waiting period will not be required, and the first and second portions of the period will count toward the benefit maximum. If your two consecutive periods of disability are due to the same cause or condition* and are separated by 14 or more calendar days after you return to work at your regular occupation with, they will be considered two separate periods of disability. A new elimination period and a new benefit maximum will be applied. * If the second period of disability is found to be unrelated to the cause or condition of a previous disability, it will be considered a separate period of disability. A new waiting period and benefit maximum will be applied. Maximum Length of Benefit Payments During any one disability period, the maximum benefit payable by the STD plan will be the earliest of the following: 180 days of disability payments A determination by the claims administrator, Sedgwick CMS, that a disability no longer exists Your failure to cooperate in a medical examination required by Sedgwick CMS within 22 days following a written request by them

184 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Your failure to provide information requested in writing by Sedgwick CMS for the purpose of determining whether you are entitled to benefits under the plan. Failure to provide such information within 30 days following such a request will constitute a refusal. The date you start employment with another employer or are self-employed while claiming benefits under this plan, without the prior approval of the claims administrator, Sedgwick CMS The date employment is offered to you by that accommodates the limitations imposed by your disability Compulsory no-fault automobile insurance Any -sponsored or -funded pension or retirement plan, government pension, or railroad (RRA) pension Recoveries resulting from acts of a third party, and the portion of a settlement or judgment, minus associated costs, of a lawsuit that compensates for your loss of earnings, or Benefits from any employment that began after the onset of your disability. Your death. If you are eligible for but fail to apply for or elect any of the benefits above that would reduce the plan benefit, the claims administrator will estimate the benefit that would have been paid had you received such benefits and reduce your disability benefit from this plan by that amount. The duration of benefits under the plan will run concurrently with any benefits you may be eligible for under any federal, state or local mandated leaves of absence. Limitations and Exclusions You will not be entitled to disability benefits if your disability results directly or indirectly from any of the following: Reduction of Benefits If you receive any of the following benefits while receiving a disability benefit under the STD plans, the benefits you receive may be reduced accordingly at the discretion of the claims administrator, Sedgwick CMS: An intentionally self-inflicted injury while sane or insane, suicide or attempted suicide A sickness or injury to which a contributing cause was your commission or attempted commission of a felony, or your engagement in an illegal occupation State disability benefits (if you work in California, Hawaii, New Jersey, New York, Puerto Rico or Rhode Island) see StateMandated Benefits on page 190 A sickness or injury due to your active participation in war or any act of war, declared or undeclared, insurrection, rebellion or riot Any sick leave or salary continuation from or its subsidiaries, including, but not limited to, wages for part-time or light duty work, paid time off (PTO) and holiday pay Revocation, restriction or non-renewal of a license, permit or certification necessary for you to perform the duties of your occupation, solely due to injury or sickness The date you are no longer receiving appropriate care for your disability, or Benefits for loss of income due to unemployment or disability under any law or compulsory government program 184

185 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Cosmetic surgery or a surgical procedure that is not medically necessary but benefits will be paid if your disability is caused by your donating an organ in a non-experimental organ transplant procedure. No benefits are payable: To you if you are incarcerated in any federal, state, or municipal penal or corrections institution, jail, medical facility, public or private hospital, or in any other place because of a criminal conviction of a federal, state or municipal law or ordinance. You also may not receive benefits if you committed a crime and are disabled due to a sickness or injury caused by, or arising out of the commission of, arrest, investigation, or prosecution of any crime that results in a felony conviction. To you if you willfully, for the purpose of obtaining benefits, either make a false statement or representation, with actual knowledge of the falsity thereof, or withhold a material fact in order to obtain benefits under this plan Pre-Existing Condition Limitation If you do not enroll in the STD Plus plan when you are first eligible and later enroll during a subsequent Open Enrollment, the STD Plus plan will not pay for benefits for any period of disability (including pregnancy) caused or contributed to by, or resulting from, a pre-existing condition. A pre-existing condition means any injury or sickness for which you incurred expenses, received medical treatment, care or services, including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a physician within three months before your most recent effective date of insurance. The pre-existing condition limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of disability that begins after you are covered for at least 12 months or after your most recent effective date of insurance, or the effective date of any added or increased benefits. For any sickness or injury that is work-related, or during any period of disability for which benefits are paid or payable under any workers compensation or occupational disease law To you if you are earning 80% or more of your covered earnings, except in the situation where you are working a partial schedule as part of the return-to-work process 185

186 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Long-Term (LTD) Note: Do Not Forget Your PTO LTD Plan The basic LTD plan benefits are paid by They replace 55% of your base wages (minus income you receive from other sources) rounded to the nearest dollar, up to a maximum benefit of $25,000 per month. You are automatically enrolled in the basic LTD plan when you are a full-time, benefits-eligible employee. Like the STD plan, your LTD plan benefits are subject to federal, FICA, and state taxes; read on to learn about the LTD Plus tax-free option. Important: Transitioning from Short-Term to Long-Term Sedgwick CMS and CIGNA will partner to transition your case from Short-Term to Long-Term. You will be contacted by CIGNA when your claim transitions. You may use accrued paid time off (PTO) hours to cover your pay during any unpaid portion of your leave, or to supplement disability benefits that make up less than 100% of your wages. To request PTO pay throughout your leave of absence, call Employee Services at , ext LTD and LTD Plus Comparison Plan Features LTD Employee contributions No (paid by ) Yes Waiting period 180 days Benefit 55% of monthly covered earnings (taxable) Maximum benefit $25,000 per month Minimum benefit The greater of $100 or 10% of your monthly benefit before any reductions for other income benefits Duration of benefit Generally, up to age 65 while disabled. Refer to Maximum Length of Benefit Payments on page 188 for specifics. LTD Plus Plan The LTD Plus plan pays a monthly benefit of 65% of your base wages, rounded to the nearest dollar, tax-free to a maximum benefit of $25,000 per month. You need to enroll in this plan and pay a premium, which covers the cost of increasing your coverage from 55% of your wages (paid by through the basic LTD plan) to 65%. Your premium amount will depend on your salary and age, and will be taken out of your regular paycheck. While your benefits received under this plan are tax-free, you are responsible for paying taxes on the premiums that pays for your basic LTD coverage. You pay these taxes up front (called imputed income), and the amount is based on your tax bracket. 186 LTD Plus 65% of monthly covered earnings (tax-free)

187 Short-Term (STD) LTD and LTD Plus Plan Provisions A successive period of disability will be considered continuous: STD Plan Benefit Calculation During any month in which you have no disability earnings, the monthly LTD benefit payable is the gross disability benefit minus any other income that reduces your gross disability benefit. If it results from the same or related causes as a previous disability for which LTD benefits were payable, and During any month when you have disability earnings, benefits are calculated as follows: If you earn less than the percentage of ed earnings that would still qualify you to meet the definition of disability/ disabled during at least one month. STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments During the first 24 months that disability benefits are payable to you: - If the sum of your gross disability benefits and disability earnings exceeds 100% of your covered earnings, then your gross disability benefit will be reduced by that difference (as well as by other income benefits) - If the sum of your gross disability benefits and disability earnings does not exceed 100% of your covered earnings, then your gross disability benefit will be reduced by your other income benefits. If, after receiving disability benefits, you return to work in your regular occupation for less than six consecutive months, and Any later period of disability, regardless of the cause, that begins when you are eligible for coverage under another group disability plan provided by any employer, will not be considered a continuous period of disability. For any period of disability that is not considered continuous, you must satisfy a new waiting period. After the first 24 months that disability benefits are payable to you, the monthly benefit payable is the gross disability benefit reduced by other income benefits and 50% of disability earnings. No disability benefits will be paid, and insurance will end, if you are able to work under a modified work arrangement and you refuse to do so without good cause. Successive Periods of If you are ill or injured and unable to work during more than one period, your successive period of disability will either be considered continuous or separate. 187

188 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) Maximum Length of Benefit Payments The maximum length of benefit payments is the later of your Social Security Normal Retirement Age (in effect under the Social Security Normal Retirement Act on the policy effective date) or the maximum benefit period listed in the table below. Age When Occurs Maximum Benefit Period LTD Plan LTD Plus Plan Age 62 & under To the employee s 65th birthday or the date the 42nd monthly benefit is payable Age 63 The date the 36th monthly benefit is payable Age 64 The date the 30th monthly benefit is payable Age 65 The date the 24th monthly benefit is payable Age 66 The date the 21st monthly benefit is payable Age 67 The date the 18th monthly benefit is payable Age 68 The date the 15th monthly benefit is payable Age 69 & over The date the 12th monthly benefit is payable LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Benefits will end on the earliest of the following: The date you earn more than the percentage of ed earnings, from any occupation, set forth in the definition of disability applicable to you at that time A determination by the claims administrator that your disability no longer exists The date you refuse, without good cause, to fully cooperate in all required phases of the rehabilitation plan and assessments The end of the maximum benefit period The date you are no longer receiving appropriate care for your disability The date you fail to cooperate with the claims administrator such cooperation includes, but is not limited to, providing 188 any information or documents needed to determine whether benefits are payable or the actual benefit amount due, or Your death. Benefits may be resumed if you begin to cooperate fully in the rehabilitation plan within 30 days of the date benefits terminated. Reduction of Benefits Under the LTD and LTD Plus plans, your benefit will be reduced by amounts that you (or your dependents) may receive or are assumed to receive under other disability or retirement plans, such as: Employer programs like STD and retirement plans funded by Amounts distributed through GapShare, SERP, and the Executive Deferred Compensation Plan will not reduce your disability benefits. Governmental programs (e.g., Social Security, workers compensation, local, state/provincial or federal government disability or retirement plan or law) provided as a result of employment with This includes damages, compromises or settlements paid in place of such benefits. Other group insurance plans such as group life or group health (to the extent they are paid for by ), if they provide benefits for loss of time from work due to disability (except in California) The Canada and Québec Pension Plans. There may be other sources of income that would reduce your monthly LTD or LTD Plus benefits. The claims administrator will coordinate your LTD and LTD Plus benefits with any of these sources. For a list of offsets, please refer to the Plan Certificate on Gapweb ( benefits.

189 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments Rehabilitation During a Period of If the plan administrator determines that you are a suitable candidate for rehabilitation, you may be required to participate in a rehabilitation plan and assessment at the plan s expense. The rehabilitation plan may, at the plan administrator s discretion, allow for payment of your medical expense, education expense, accommodation expense or family care expense while you participate in the program. If you fail to fully cooperate in all required phases of the rehabilitation plan and assessment without good cause, no disability benefits will be paid and your insurance will end. Survivor Benefit If you die after receiving three monthly payments from the LTD or LTD Plus plans, your spouse, partner or children will receive a one-time amount equal to three times the amount of your gross monthly benefit. If you have no surviving spouse, partner or eligible children (any unmarried child who is less than 21 years old and is chiefly dependent on you for support and maintenance), the benefit will be paid to your estate. Limited Benefit Periods The plan will pay disability benefits on a limited basis during your lifetime for a disability caused by, or contributed to by, any one or more of the following conditions. Once 24 monthly disability benefits have been paid, no further benefits will be payable for any of the following conditions: Alcoholism Mental illness Somatoform disorders (psychosomatic illness). If, before reaching your lifetime maximum benefit, you are confined in a hospital for more than 14 consecutive days, that period of confinement will not count against your lifetime limit. The confinement must be for appropriate care of any of the conditions listed above. Pre-Existing Condition Limitation The LTD Plus plan will not pay for benefits for any period of disability (including pregnancy) caused or contributed to by, or resulting from, a pre-existing condition. A pre-existing condition means any injury or sickness for which you incurred expenses, received medical treatment, care or services, including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a physician within three months before your most recent effective date of insurance. The pre-existing condition limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of disability that begins after you are covered for at least 12 months or after your most recent effective date of insurance, or the effective date of any added or increased benefits. By the Plan The plan will not pay any disability benefits for a disability that results, directly or indirectly, from: Anxiety disorders Suicide, attempted suicide or self-inflicted injury while sane or insane Delusional (paranoid) disorders War or any act of war, whether or not declared Depressive disorders Active participation in a riot Drug addiction or abuse Commission of a felony 189 Eating disorders

190 Short-Term (STD) STD Plan STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan The revocation, restriction or non-renewal of your license, permit or certification necessary to perform the duties of your occupation, unless due solely to injury or sickness otherwise covered by the plan. In addition, the plan will not pay disability benefits for any period of disability during which you are incarcerated or in a penal or corrections institution. Note: Prudential Benefits On July 1, 2008, switched from Prudential to a new administrator, Sedgwick CMS, for leave and disability claims. If you are still receiving disability benefits from Prudential and have a question about your claim, you can contact Prudential directly at Prudential will continue to manage your disability claim until you return to work. LTD And LTD Plus Comparison Additional Plan Information LTD And LTD Plus Plan Provisions State-Mandated Benefits Taxability of Benefit Payments Additional Plan Information Employees who work in California, New Jersey, Rhode Island, Hawaii, New York and Puerto Rico may be eligible to file for state disability benefits. The Short-Term and LongTerm plans will be coordinated with any pay you receive from a state disability plan. You will be taxed on the portion of benefits attributable to company-paid premiums. Additional federal income tax and Social Security taxes may also apply. If you work in California or Rhode Island, it s your responsibility to file with the state for state disability benefits. In California, the disability claim form will be included in your leave of absence (LOA) packet. Or, you can obtain the form from the state disability office or download it at pdf_pub_ctr/de2501.pdf. In Rhode Island, you can complete an application online at or by calling Your application for disability benefits must be made within 31 days following the onset of your disability. Proof of disability must be given to the claims administrator, Sedgwick CMS for STD and STD Plus plans and CIGNA for LTD and LTD Plus plans, within 22 days after the application for benefits. Or, if your application for disability benefits is submitted before the onset of your disability, proof of disability must be provided within 22 days of the onset of the disability. If you work in New York, New Jersey, Hawaii or Puerto Rico, s Short-Term administrator will provide you with the appropriate forms to complete when you file for your disability benefit and leave of absence. To report a disability claim, first gather your leave and disability information, including: State-Mandated Taxability of Benefit Payments Your HR manager s name, phone number and Your annual or hourly pay rate Start date of your disability Your anticipated return-to-work date 190

191 Short-Term (STD) If pregnancy-related, your estimated due date STD Plan Your treating doctor s name, telephone number and fax number STD Plus Plan STD And STD Plus Comparison STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Taxability of Benefit Payments The hospital name and telephone number Your supervisor s name, telephone number and address Your work schedule. Then, call s Leave and Administrator at 800. GAP After reporting your disability and/or disability claim, your claims administrator will mail a leave of absence packet to you within two business days containing the information and forms you may need to complete and submit. Examinations If you are applying for disability benefits or appealing an adverse benefit determination, the claims administrator may request that you submit to an examination by one or more physicians or vocational experts to determine whether you meet the eligibility requirements under the plan for benefits, and whether the disability has existed for the required waiting period. From time to time, the claims administrator may direct you to be re-examined for the purpose of determining whether you continue to be eligible for disability benefits under the Gap Inc. plans. In those cases, the fees charged by the physicians or vocational experts, and the expenses associated with those examinations, will be paid by the plan. Benefit Determinations and Appealing Denied Claims For information on the types of claims that may be filed as well as the process for appealing denied claims please see Claims and Appeals Procedures on page

192 Short-Term (STD) STD Plan STD Plus Plan Term Definition STD And STD Plus Comparison Accident A sudden unforeseeable external event that causes bodily injury to you while you are covered by the plan. Active service You are in active service on a day which is one of s scheduled workdays if any of the following conditions are met: STD And STD Plus Plan Provisions Long-Term (LTD) You are performing your regular occupation for on a full-time basis. You must be working at one of s usual places of business or at some location to which s business requires you to travel. The day is a scheduled holiday or vacation day, or a day which is not one of s scheduled workdays, and you were performing your regular occupation on the preceding scheduled workday. LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated Appropriate care A physician s diagnosis of your disability supported by objective medical evidence, and the plan established by a physician of ongoing medical treatment and care of the disability that conforms to generally accepted medical standards. Claims administrator For the STD and STD Plus plans, Sedgwick Claims Management Services, Inc. (Sedgwick CMS). For the LTD and LTD Plus plans, CIGNA Group Insurance. Taxability of Benefit Payments Covered earnings The amount of your salary or wages calculated on a weekly basis. It does not include amounts received as bonus, commissions, s contributions to a 401(k) plan, or other extra compensation. To calculate your covered earnings: Add all hours paid as a full-time employee within the last 52 weeks, not including hours in excess of 40 hours per week. Note that this does not include hours in the week your disability begins. Determine the number of eligible weeks within the last 52 weeks eligible weeks are weeks with actual hours worked. Divide the sum of hours paid by the number of eligible weeks, and then multiply that total with your current hourly rate (for LTD or LTD Plus plans, multiply this total again by 4.33). Any increase in your covered earnings will not be effective during a period of continuous disability. As a result of sickness or injury, you are unable to perform the material duties of your regular occupation or a qualified alternative because of an illness (including pregnancy) or injury in a non-occupational accident, and you are pregnant or you are unable to earn 80% or more of your covered earnings. After disability benefits have been payable for 24 months, you are considered disabled if, solely due to injury or sickness, you are unable to perform the material duties of any occupation for which you are, or may reasonably become, qualified based on education, training, or experience; and unable to earn 60% or more of your covered earnings. In addition, you must be under the regular and continuous care and treatment of a physician, unless such regular and continuous care and treatment are not medically necessary given the condition, and the disability must be supported by objective medical evidence provided by a physician. The determination of disability will be made by the claims administrator on the basis of objective medical evidence. 192

193 Short-Term (STD) Term Definition STD Plus Plan Injury Any bodily harm resulting directly from an accident, independent of all other causes. STD And STD Plus Comparison ly necessary The treatment or surgical procedure is prescribed by a physician as required treatment of the injury or sickness and appropriate for the injury or sickness, according to conventional medical practice. Objective medical evidence demonstration of anatomical, physiological, or psychological abnormalities manifested by signs or laboratory findings, apart from your perception of any mental or physical impairments. These signs are observed through medically acceptable clinical techniques such as medical history and physical examination. Pre-existing condition Any injury or sickness for which you have incurred expenses, received medical treatment, care or services, including diagnostic measures, prescribed drugs or medicines taken, or for which you would have consulted a physician within three months before your most recent effective date of insurance. Qualified alternative An occupation that meets all of the following conditions: STD Plan STD And STD Plus Plan Provisions Long-Term (LTD) LTD Plan LTD Plus Plan LTD And LTD Plus Comparison LTD And LTD Plus Plan Provisions Additional Plan Information State-Mandated You can perform the material duties of the occupation based on your training, experience, or education It is within the same geographic area as the regular occupation you hold with on the date your disability begins A job in that occupation is offered to you by, and The wages for that occupation, including commissions and bonus, are 80% or more of your ed covered earnings. Taxability of Benefit Payments Regular occupation The occupation you routinely perform at the time your disability begins. In evaluating the disability, the claims administrator will consider duties of the occupation as it is normally performed in the general labor market in the national economy. The term regular occupation does not mean work tasks that are performed for a specific employer or at a specific location. Retirement plan Any defined benefit or defined contribution plan sponsored or funded by It does not include an individual deferred compensation agreement, a profit sharing or any other retirement or savings plan maintained in addition to a defined benefit or other defined contribution pension plan, or any employee savings plan including a thrift, stock option or stock bonus plan, individual retirement account or 401(k) plan. Sickness A physical or mental illness. 193

194 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Plan Coverage While Traveling Your medical, dental and vision plans may provide coverage while you travel. In addition, has several benefits to help keep you safe while traveling: Business Travel Accident (BTA) Insurance Provides life insurance coverage that protects you and your family, should something happen while you are traveling on authorized business for Benefits Abroad (MBA) Provides reimbursement for medical expenses due to illness or injury while traveling on Gap Inc. business, limited to $100,000 per plan year. International SOS Foreign business travel program that provides emergency medical and evacuation assistance, and security assistance while you are traveling internationally. Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance UnitedHealthcare Plans If you are covered by one of the UnitedHealthcare medical plans (HRA, HRA Plus, Hawaii PPO, or Out-of-Area plan), the following rules apply when you are traveling: Traveling in the United States: If you have an emergency and you are within another UnitedHealthcare network area, you can use the network in that area. Call the UnitedHealthcare Customer Service Center at for more information about using another network. If you use an out-of-network provider (even in an emergency), your expenses will be paid at the out-of-network benefit level and the charges will be subject to the applicable plan deductibles and co-insurance. Traveling outside the United States: Emergency treatment received outside the United States will be covered at the in-network level. Eligible non-emergency treatment received outside the United States is covered at the out-of-network level. When submitting your claims, provide the exchange rate of currency for the date of service to ensure you are reimbursed accurately. If you have questions about your prescription drugs, contact Express Scripts Member Services at They can assist you with the following: International SOS Plan About the ISOS Plan Requesting a vacation refill if you are planning to take an extended trip out of the country. You will need a prescription for the additional quantity from your doctor. Plan Services Receiving Care Lost prescription medication while on personal or business travel. 194

195 Plan Coverage Kaiser Plans UnitedHealthcare Plans Kaiser Permanente covers emergency care from plan providers and non-plan providers anywhere in the world. Emergency care includes medically necessary ambulance services and an evaluation by appropriate medical personnel to determine if an emergency medical condition exists. If one exists, emergency care is also the medically necessary care, treatment, and surgery required to stabilize your emergency condition that is, to make you clinically stable within the capabilities of the facility. Clinically stable means that your treating physician believes, within a reasonable medical probability and in accordance with recognized medical standards, that you are safe for discharge or transfer and that your medical condition is not expected to materially worsen during, or as a result of, the discharge or transfer. For more information on emergency care coverage, please refer to the Evidence of Coverage on Gapweb ( benefits > select U.S. Full-Time Benefits. Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan About the ISOS Plan Plan Services Receiving Care MVP Plan When traveling outside the MVP service area, MVP will provide benefits for emergency care services provided at any hospital emergency room and urgent care services provided at a participating urgent care facility. MCS Plan Emergency services are covered through multiplan facilities; for services outside the United States, only emergency services are covered. 195

196 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan Vision Dental If you are enrolled in the Vision or Vision Plus plan and receive services from a non-vsp provider, you will need to pay for the services up front and submit a request for reimbursement. For services received outside the United States, you will be reimbursed according to the out-of-network schedule. You will be reimbursed in U.S. dollars based on the currency exchange rate at the time of service. You are not required to convert foreign currency into U.S. dollars but you may need to translate any description of services, if necessary. If you are enrolled in the Dental or Dental Plus plan and receive treatment from a non-delta Dental dentist, you will need to pay the dentist in full at the time of service. Be sure to get a detailed receipt so you can submit a claim directly to Delta Dental for reimbursement of the covered portion. Once Delta Dental receives your claim, the plan will reimburse you according to the out-ofnetwork level of benefit provided through your plan. As with any dental plan, this reimbursement may not cover your entire cost. If you need to submit a claim, you can print a claim form from the Dental Plan section on Gapweb ( benefits. Submit this claim form with your detailed receipt, which must include the dentist s name, address (including city/ country), services performed, and a list of the teeth treated. The receipt also should indicate the currency in which the dentist billed (whether in U.S. dollars or another currency if traveling outside of the United States). If you need to submit a claim, you can print a claim form from the Vision Plan section on Gapweb ( benefits. Note: When submitting non-english receipts or dental records, please try to translate as much information as possible into English, or provide a patient statement in English detailing the treatment received. About the ISOS Plan Plan Services Receiving Care 196

197 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan About the ISOS Plan Plan Services Receiving Care Business Travel Accident (BTA) Insurance About BTA Insurance The insurance company for the BTA plan is Life Insurance Company of North America. The cost of BTA Insurance is 100% paid by If you are a regular, active, full-time employee of, the BTA plan will cover you and your eligible spouse or partner and children for any accident that occurs while you are traveling on authorized business away from your worksite and in the course of your business. This coverage does not include commuting between your home and place of work or during personal deviations made by you. Personal deviation means an activity that is not reasonably related to your business, and not incidental to the business trip. Travel accident benefits will only be paid if death or loss occurs within 365 days of the accidental injury. BTA coverage begins upon the actual start of a trip whether at your home, place of work or elsewhere. This coverage will end when you arrive at your home or place of work, whichever happens first, or when you make a personal deviation. If you travel to another city and are expected to remain there for more than 60 days, it will be deemed a change in your city of permanent assignment. Expatriate employees are covered 24 hours a day, regardless of whether their travel is for business or for pleasure. BTA Benefit Amounts If you are an active, full-time employee of including international and expatriate employees you are eligible for a BTA benefit amount equal to three times your base pay, up to a maximum of $1 million. The benefit amount for covered dependents of eligible employees is $2, If multiple employees and/or dependents are involved in a single accident or covered event, the plan will pay up to a $35 million aggregate policy maximum for all covered losses resulting from the accident or event. The benefit amounts depend upon the type of loss that is incurred, examples of which are shown in the table below: Type of Loss Insurance Percentage Paid Loss of life 100% of benefit amount Loss of two or more hands or feet 100% of benefit amount Loss of sight in both eyes 100% of benefit amount Loss of speech and hearing (both ears) 100% of benefit amount Total paralysis of both upper and lower limbs 100% of benefit amount Total paralysis of both lower limbs 75% of benefit amount Loss of one hand, one foot or one eye 50% of benefit amount Loss of sight in one eye 50% of benefit amount Loss of speech 50% of benefit amount Loss of hearing (both ears) 50% of benefit amount Total paralysis of upper and lower limbs on one side of the body 50% of benefit amount Loss of thumb and finger of the same hand 25% of benefit amount Paralysis of one upper or one lower limb 25% of benefit amount Severance and reattachment of one hand or foot 25% of benefit amount Loss of all four fingers of the same hand 25% of benefit amount Loss of all the toes of the same foot 20% of benefit amount If the same accident causes more than one of these losses, the plan will pay only one amount, but it will be the largest amount that applies.

198 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan About the ISOS Plan Plan Services Receiving Care For more detailed information, please click here to see the Group Travel Accident Policy. The document is also available on Gapweb ( benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext Injury while the employee is on full-time, active duty in the armed forces. Covered accidents that occur while engaged in Reserve or National Guard training are not excluded until training extends beyond 31 days. War Risk and Terrorism Coverage War risk and terrorism coverage is provided worldwide, except within the United States or any nation of which you are a citizen. The benefit amount for all active, full-time employees is equal to three times base pay up to a maximum of $1 million, with a $5 million aggregate benefit maximum, which applies to all acts of war within a 72-hour period. Third country national contractors have a benefit of $30,000. The benefit amount for dependents is $2,000, subject to the same aggregate benefit maximum. There are several countries that have restricted travel and must be pre-approved. Restricted countries are subject to change without notice. Taking part in a felony If multiple employees and/or dependents are involved in a covered act of war, the plan will pay up to a $5 million aggregate maximum for all covered losses resulting from all acts of war within a 72-hour period. by the BTA Plan BTA plan benefits are not payable if a loss results from: Suicide, attempted suicide or whenever the employee injures himself on purpose, while sane or insane (in Missouri only, this does not apply if employee was insane) War or act(s) of war, whether or not declared, except to the extent that is provided in the war risk and terrorism amendment 198 Travel or flight in any spacecraft; or flight in any aircraft, except to the extent that this is covered under Traveling in the Corporate Jet on the following page Any bacterial infection that was not caused by an accidental cut, wound or food poisoning, or accidental ingestion of contaminated food Commission of or active participation in a riot or insurrection Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a physician and taken in accordance with the prescribed dosage Operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant, including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it. Under the influence of alcohol for purposes of this exclusion means intoxicated as defined by the law of the state in which the covered accident occurred. For a full list of exclusions, please click here to see the Group Travel Accident Policy. The document is also available on Gapweb ( benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext

199 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance Traveling in the Corporate Jet This benefit applies to all full-time employees of and their guests, vendors, legal spouses or partners, non-employee directors, and children who are traveling with employees of Gap Inc. If, while traveling on s corporate jet, an accidental bodily injury results in the loss of life or in the loss of both hands, both feet, the sight in both eyes, or any multiple combinations of these losses, you will receive a benefit amount of five times your annual base pay. The minimum benefit for an employee is $1 million and the maximum benefit is $5 million. The benefit for an insured non-employee and Class 2, part-time employees is $200,000. Pilots and crewmembers are limited to $200,000. Non-employee directors are limited to $200,000. Third-country national contractors are limited to $30,000. There is a war and terrorism aggregate limit of $5 million per accident. Total policy aggregate is $35 million. Completed forms must be returned to Life Insurance Company of North America for processing within 90 days of the death or dismemberment (or as soon as reasonably possible). Any benefits received may be considered taxable income. For more detailed information, please click here to see the corporate jet Travel Accident Policy. The document is also available on Gapweb ( > benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext If there are none, in equal shares to the living parents International SOS Plan You or your designated beneficiary must complete the proper forms to claim benefits under the BTA plan. These forms are available through: About the ISOS Plan Plan Services Receiving Care How and When Claims Are Paid All payments will be made to you or your beneficiary as soon as the claims administrator (Life Insurance Company of North America) receives satisfactory proof of loss. These payments will satisfy the claims administrator s obligation to the extent of the payment. If a covered person has not chosen a beneficiary, or if there is no beneficiary alive when he or she dies, will pay this benefit: 1. To the spouse, if living 2. If not, in equal shares to the living children 4. If there are none, in equal shares to the living brothers and sisters, or 5. If there are none, to the estate. Benefit Determinations and Appealing Denied Claims For information on the types of claims that may be filed as well as the process for appealing denied claims please see Claims and Appeals Procedures on page 228. Benefits Department 2 Folsom Street San Francisco, CA You can also obtain these forms by calling Employee Services at , ext

200 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Benefits Abroad (MBA) Plan About MBA If you are a regular, active, full-time employee, the MBA plan will cover you, your eligible spouse/partner, and children for any accident or illness that occurs while you are traveling on authorized business away from your worksite and in the course of your business. Persons for whom coverage is prohibited under applicable law will not be considered eligible for this plan. provides employees with the Benefits Abroad (MBA) program in partnership with Cigna Global Health Benefits Plan for Expatriates. The cost of MBA coverage is 100% paid by MBA Benefit Amounts The MBA plan generally covers the reasonable and customary (R&C) charges associated with your accident or illness, according to the norms in the country where you received care. See the table below for details on what the MBA plan covers: Concierge and Travel Assistance Plan Feature Benefit Amount maximum benefit (per calendar year) $100,000 Deductible (per calendar year) $50 Co-insurance maximum None U.S. room and board Hospital s average semi-private charge per day of confinement Non-U.S. room and board $700 per day Pregnancy expenses related to pregnancy International SOS Plan About the ISOS Plan Plan Services Receiving Care 200 For more detailed information, please click here to see the policy document. The document is also available on Gapweb ( benefits > select U.S. Full-Time Benefits, or from Employee Services at , ext Cigna will make payments directly to hospitals around the world on your behalf. Cigna also provides the following services to help you manage your medical expenses abroad: Multilingual Customer Service Center Cigna Global Health Benefits multilingual service center is available 24 hours a day. Service center representatives are able to converse in all major languages ( or you can call collect at ). Submit Claims via: - Online Access Through Cigna Envoy ( you can file a claim by following these steps: Select I m on a short term international business assignment from the I am a customer section Enter Username, 00308BMBA, and Password, Cigna1 Select Online Claims on the navigational toolbar at the top of the page. - Toll-Free Fax You can send claims via toll-free fax outside the U.S. and Canada to the claim analyst to expedite reimbursement by eliminating mail time. Cigna will accept your calls from overseas collect and offers a toll-free number in the United States ( , or you can call collect at ). Language Translation Cigna will translate your claims in any language; there is no need to translate claim information before you submit one.

201 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan Direct Deposit/Electronic Fund Transfer Cigna can automatically deposit your reimbursement into your U.S. or Canadian bank account. Global HealthCare Management Services As an MBA member, you have access to a world of specialized services known as Global HealthCare Management Services. These services are designed to give you answers and access wherever you are in the world. When you call Cigna Global Health Benefits Service Center, the following Global HealthCare Management Services are available to you: Physician-to-physician care management Dedicated, 24/7/365 multilingual helpline for superior customer service About MBA Direct access to medical advice/consultations, second opinions, provider referrals and assistance with local admissions MBA Benefit Amounts monitoring Global HealthCare Management Communication of patient condition and treatment plans to family members Concierge and Travel Assistance International SOS Plan Coordination of medically supervised evacuations/repatriations (if evacuation is a covered benefit under your plan) About the ISOS Plan Coordination of treatment plans, if available. Receiving Care As an MBA international business traveler, there may be occasions where you will require travel assistance. For example, you may need to send an emergency message to your family at home, or vice versa. Through Cigna s alliance with International SOS, the world s leading assistance management company, you have at your fingertips a host of specialized services designed to make travel easier for you and give your family members peace of mind. These services are available to you whenever you are on an approved international business trip for Here s just a summary of concierge and travel assistance services available: Lost Document Advice and Assistance Instructions and advice for recovering or replacing lost passport and/or credit cards Companion Ticket Coordination of emergency travel arrangements for family who need to join a hospitalized member, and Translations and Interpreters Emergency 24-hour telephone translation services, as well as referrals to interpreter services in an emergency. Your MBA plan requires that you file a claim form for every accident- or illness-related eligible expense in order to receive reimbursement. The claim form provides Cigna with important reimbursement instructions, such as where to send reimbursements, type of currency, and method of reimbursement (e.g., check, direct deposit, etc.). Plan Services 201 Concierge and Travel Assistance Services

202 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Once you have received treatment, you or your provider must submit a fully completed, signed and dated claim form, along with your itemized bill, to Cigna. You may submit your claim forms to the following addresses. Vision Mail Delivery: Cigna Global Health Benefits P.O. Box Wilmington, DE USA Business Travel Accident (BTA) Insurance Direct Fax: Dental And Vision Benefits Dental About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan About the ISOS Plan Plan Services Receiving Care You can also submit your claims online through Cigna Envoy ( You and must complete and sign an eligibility verification statement to show that you were on an approved business trip. Reimbursement Options Cigna is able to make the following types of reimbursements: Direct reimbursement to the hospital, with your authorization signature on the claim form Reimbursement to you at your address on the claim form in U.S. dollars or local currency Direct check reimbursement, mailed to your bank account in the United States or Canada with the currency type (U.S. or Canadian dollars) and account information completed on the claim form, and Wire transfer to your bank account. 202

203 Plan Coverage UnitedHealthcare Plans Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management Concierge and Travel Assistance International SOS Plan Plan Services About the ISOS Plan Some of the services provided by ISOS are: International SOS (ISOS) is a worldwide travelers medical assistance and security company. It provides pre-travel health advice and medical assistance, as well as travel security information. employees are eligible for ISOS assistance while on business-related travel or expatriate assignments. Gap Inc. has pre-paid International SOS for most services. Payment for actual medical care received, including care at the ISOS clinics, should be handled through your health care benefit programs. Pre-Travel Services: Immunization recommendations You can access information on ISOS by visiting the Foreign Travel Gapweb page. Or, you may access the web page from outside the Company at and enter the membership number: 11BCPA Information on medical services at destination A mobile app is also available for smart phone users. Download the app at and enter the membership number, 11BCPA000181, to receive medical, safety and security alerts for the country you plan to visit. The app also allows for one-touch dialing to the nearest ISOS assistance center. Referrals to travel medicine clinics Health hazard updates Visa requirements Consular information Health-related information/special precautions about destination Travel security-related information. Destination Services: Telephone medical advice Worldwide medical and dental referrals Mental health counseling referrals Assistance with arranging appointments: physician, ambulance, hospitalization You can also call ISOS 24 hours a day at one of the numbers below. Medication replacement/prescription transfer About the ISOS Plan North & South America evacuation Plan Services Europe/Africa/Middle East (44) Support services Receiving Care Asia/Australia/Pacific (65) clinics available in some areas. International SOS Plan Note that ISOS is not just for emergencies contact ISOS for minor medical questions, travel-related information, or travel security-related information, as well as when you have a medical emergency. 203

204 Plan Coverage Receiving Care UnitedHealthcare Plans ISOS operates outpatient medical clinics that provide an international standard of care. If you are not near one of ISOS s clinics, they can refer you to a recommended provider or facility. ISOS has access to a worldwide database that enables them to find appropriate sources of care anywhere in the world. If there is no local facility to offer the care you need, ISOS will transport you to an alternate facility as appropriate. ISOS will refer you to a medical provider who speaks your language. If necessary, ISOS can also assist with translation. Kaiser Plans MVP Plan MCS Plan Dental And Vision Benefits Dental Vision Business Travel Accident (BTA) Insurance About BTA Insurance BTA Benefit Amounts Benefits Abroad (MBA) Plan About MBA MBA Benefit Amounts Global HealthCare Management If you are in a remote location without any medical services nearby, ISOS offers first-aid training at an additional fee and other preventive services in an attempt to reduce the probability of an adverse medical event. These services are available on-site. If medical treatment is needed and is not available nearby, ISOS will transport you to a medical facility as appropriate. You do not need to call to receive authorization for treatment ISOS will do that for you. You only need to call ISOS to start the process. Concierge and Travel Assistance International SOS Plan About the ISOS Plan Plan Services Receiving Care 204

205 Reporting Your Life Event You Get Married or Establish A Partnership You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies Directory (What Happens If ) This section describes what would happen to each of your Gap Inc. benefits if certain events were to occur during the plan year (July 1 through June 30) for example, if you become disabled, if you retire or if you no longer work for Below is a list of life events covered in this section. Additional events and the very important consistency rule are addressed in Making Changes on page 10. In general, your life event must impact your eligibility for benefits in order to change your election. Your Dependent Gains Other Coverage You get married or establish a partnership Your Dependent Loses Coverage You become a parent or gain an eligible child You Take a Leave of Absence Your child is no longer eligible due to age You Change From Full-Time to Part-Time Your eligible spouse/partner/child dies Your spouse becomes eligible for other coverage Your spouse loses other coverage You take a medical, FMLA, military or personal leave of absence You transfer from full-time to part-time status You transfer from part-time to full-time status You retire Your employment with ends You die. You divorce or end a partnership Important! Changes to your Short-Term and Long-Term coverage can only be made during Open Enrollment or within 30 days, ending at midnight Central Time, from the date you are classified as full-time. You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death 205

206 Reporting Your Life Event Reporting Your Life Event You Get Married or Establish a Partnership If you experience a life event during the plan year (July 1 through June 30), you may have the opportunity to make mid-year changes to certain benefit elections. In addition, you may wish to update information such as beneficiary designations for your dependents. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage You must report your life event within 30 calendar days, ending at midnight Central Time, of the date of the life event on Gapweb ( benefits. If you experience a life event within the initial 30-day benefits enrollment period (after first becoming eligible for benefits) and you have not yet enrolled, you will need to contact Employee Services at , ext , to enroll for benefits coverage. Your Dependent Loses Coverage When reporting a life event, please keep in mind the following: You Take a Leave of Absence You can only request a benefits election change on or after the date of the life event. The enrollment system will not allow you to make any changes before the actual date of the life event. You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death If you have problems requesting the election change online, be sure to contact Employee Services at , ext The 30-day deadline (ending at midnight Central Time) still applies, so be sure to notify Employee Services before your deadline. You may be required to provide evidence of your life event. If adding coverage, your changes are effective the first of the month following the life event or the first of the month if your life event occurs on that date, except in the case of birth or adoption. For birth or adoption, coverage will be effective the day of the event. If cancelling coverage, it will typically end the last day of the month in which the event occurs, except in the case of the death of a dependent. If your dependent dies, coverage will end effective the date of death. 206 The 30-day deadline (ending at midnight Central Time) for requesting an election change is firm. Any requests submitted after 30 days (ending at midnight Central Time) will not be accepted, and your next opportunity to request a change is during the next Open Enrollment period that generally takes place each May for coverage effective the following plan year (July 1). It is your responsibility to report any changes to your dependent information and to ensure that your covered dependents are eligible under the plans.

207 Reporting Your Life Event You Get Married or Establish a Partnership You Get Married or Establish a Partnership The table below describes what happens to your benefits when you get married or establish a domestic partnership. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Benefit What You Can Do You may enroll yourself, your new spouse or partner, and any other eligible dependents for medical coverage. (includes ) You may change your current medical plan option when you enroll yourself and/or your dependents. You may change or drop your current medical coverage for you and/or your dependents if you and/or your Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies dependents enroll in your new spouse/partner s medical plan. Dental You may enroll yourself, your new spouse or partner, and any other eligible dependents for dental coverage. You may not change your current dental plan option. Your Dependent Gains Other Coverage You may drop your current dental coverage for you and/or your dependents if you and/or your dependents enroll in your new spouse/partner s dental plan. Your Dependent Loses Coverage You Take a Leave of Absence Vision You may enroll yourself, your new spouse or partner, and any other eligible dependents for Vision Plus coverage. (You are automatically covered by the basic Vision plan, which only covers employees, not dependents.) You Change From Full-Time to Part-Time You may change or drop Vision Plus coverage for you and/or your dependents if you and/or your dependents enroll in your new spouse/partner s vision plan. You Change From Part-Time to Full-Time (EAP) Your new spouse or partner and any eligible dependents are automatically eligible to participate in the EAP. All full- You Retire Health Care FSA You may enroll in or increase your contributions to a Health Care FSA for expenses incurred on behalf of your new time employees, their household members and unmarried children are eligible to participate in the EAP. spouse or partner (if he or she is a qualified tax dependent as defined by the IRS), as well as any other eligible Your Employment With Ends dependents. You may decrease or end contributions to a Health Care FSA if your and/or your dependents expenses become Your Death reimbursable under your new spouse or partner s plan. Dependent (Day) Care FSA You may enroll in or increase your contributions to a Dependent (Day) Care FSA for expenses incurred on behalf of your newly eligible dependent(s). You may decrease or end contributions to a Dependent (Day) Care FSA if your and/or your dependents expenses become eligible under your new spouse or partner s plan. Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. 207

208 Benefit What You Can Do Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply Reporting Your Life Event You Get Married or Establish a Partnership see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You may decrease or drop your Supplemental Life coverage. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child You may update your beneficiary information at any time on Gapweb ( benefits. Dependent Life Insurance Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment Your Child Is No Longer Eligible (AD&D) Insurance on page 168 for more information. Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage Your Dependent Loses Coverage You may elect or increase Dependent Life coverage for your new spouse or partner and any eligible dependents. You may decrease or drop your Dependent Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. Accidental Death & Dismemberment (AD&D) Insurance You Take a Leave of Absence You may enroll yourself, your new spouse or partner, and any eligible dependents for AD&D coverage. You may increase, decrease or drop your AD&D coverage. You may update your beneficiary information at any time on Gapweb ( benefits. You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death 208

209 Reporting Your Life Event You Divorce or End a Partnership You Get Married or Establish a Partnership The table below describes what happens to your benefits if you get divorced or end a partnership. You Divorce or End a Partnership Benefit What You Can Do Drop coverage for your former spouse because he/she will no longer be eligible for coverage. Your former spouse s You Become a Parent or Gain an Eligible Child (including ) Your Child Is No Longer Eligible Vision Your Spouse/Partner/Child Dies (EAP) Your Dependent Gains Other Coverage Dental coverage will end the last day of the month in which the event occurs. Drop coverage for your former partner and his/her children because they will no longer be eligible for coverage. Your former partner and his/her children s coverage will end the last day of the month in which the event occurs. Drop coverage for your children. Coverage for your children will end the last day of the month in which the event occurs. You may enroll yourself and/or your eligible children in health care coverage if you and/or they lose coverage under your former spouse or partner s health care plan. Your Dependent Loses Coverage You may change your current health coverage if your eligible children lose coverage under your former spouse or You Take a Leave of Absence partner s plan and you enroll them in coverage. You Change From Full-Time to Part-Time - You may change your current medical plan option. You Change From Part-Time to Full-Time - You may not change your current dental plan option. - You may change your current vision plan option. Health Care FSA under your former spouse s or partner s Health Care FSA. You Retire Your Employment With Ends You may enroll in or increase contributions to a Health Care FSA if you lose eligibility for expense reimbursement You may decrease or end your contributions to a Health Care FSA to reflect your spouse s or partner s loss of eligibility for expense reimbursement under your Health Care FSA. Dependent (Day) Care FSA You may enroll in or increase contributions to a Dependent (Day) Care FSA if your dependents lose eligibility for expense reimbursement under your former spouse s or partner s Dependent (Day) Care FSA. Your Death You may decrease or end your Dependent (Day) Care FSA contribution if you lose dependents for whom you were incurring eligible expenses (e.g., dependents now living with former spouse or partner). Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. 209

210 Reporting Your Life Event You Get Married or Establish a Partnership Benefit What You Can Do Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You may decrease or drop your Supplemental Life coverage. You Divorce or End a Partnership You may update your beneficiary information at any time on Gapweb ( benefits. You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Dependent Life Insurance the event occurs. However, since Dependent Life is portable, he or she may be able to continue his or her coverage under an individual policy through the insurance company. Note that the premium rate on an individual policy Your Spouse/Partner/Child Dies may be higher than the rate paid for coverage related to your benefits. Your Dependent Gains Other Coverage Dependent Life coverage for your children will not automatically end upon your divorce or ending of a partnership. You may decrease or drop Dependent Life coverage for your children. Your Dependent Loses Coverage You may elect Dependent Life coverage for any eligible children, with no requirement for EOI. You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time Dependent Life coverage for your former spouse or partner automatically ends at the end of the month in which You may update your beneficiary information at any time on Gapweb ( benefits. Accidental Death & Dismemberment (AD&D) Insurance You may enroll yourself and any eligible children in AD&D coverage. You may decrease or drop your AD&D coverage. You may update your beneficiary information at any time on Gapweb ( benefits. You Retire Your Employment With Ends Your Death 210

211 Reporting Your Life Event You Become a Parent or Gain an Eligible Child You Get Married or Establish a Partnership The table below describes what happens to your benefits when you become a parent or gain a new eligible child. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Benefit What You Can Do You may enroll yourself and any other eligible dependents for medical coverage. (includes ) You may change your current medical plan option when you enroll yourself and your dependents. You may change or drop your current medical coverage for you and/or your dependents. You may enroll yourself and any other eligible dependents for dental coverage. Dental Your Spouse/Partner/Child Dies You may not change your current dental plan option. Your Dependent Gains Other Coverage You may drop your current dental coverage for yourself and/or your dependents. Vision You may enroll yourself and any eligible dependents for Vision Plus coverage. (You are automatically covered by the basic Vision plan, which only covers employees, not dependents.) Your Dependent Loses Coverage You may change or drop Vision Plus coverage for you and/or your dependents. You Take a Leave of Absence You Change From Full-Time to Part-Time (EAP) Your new child and any other dependents are automatically eligible to participate in the EAP. All full-time Health Care FSA You may enroll in or increase contributions to a Health Care FSA for expenses incurred on behalf of your newly You Change From Part-Time to Full-Time eligible dependent. You may decrease or end your contributions to a Health Care FSA if your and/or your dependents expenses become You Retire Your Employment With Ends employees, their household members and unmarried children are eligible to participate in the EAP. reimbursable under your spouse or partner s plan. Dependent (Day) Care FSA You may enroll in or increase your contributions to a Dependent (Day) Care FSA for expenses incurred on behalf of your newly eligible dependent. You may decrease or end your contributions to a Dependent (Day) Care FSA if your and/or your dependents Your Death expenses become eligible under your spouse or partner s plan. If you are on a leave of absence, you cannot make any changes to your contributions until you return from leave. Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. 211

212 Benefit What You Can Do Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see Reporting Your Life Event You Get Married or Establish a Partnership Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You may decrease or drop your Supplemental Life coverage. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child You may update your beneficiary information at any time on Gapweb ( benefits. Dependent Life Insurance (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on Your Child Is No Longer Eligible page 168 for more information. Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage Your Dependent Loses Coverage You may elect or increase Dependent Life coverage for any eligible dependents at any time. Evidence of insurability You may decrease or drop your Dependent Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. Accidental Death & Dismemberment (AD&D) Insurance You Take a Leave of Absence You may enroll yourself and any eligible dependents for AD&D coverage. You may increase, decrease or drop your AD&D coverage. You may update your beneficiary information at any time on Gapweb ( benefits. You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death 212

213 Reporting Your Life Event Your Child Is No Longer Eligible Due to Age You Get Married or Establish a Partnership The table below describes what happens to your benefits if your child is no longer eligible due to age. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Benefit What You Can Do, dental and vision coverage for your eligible child will automatically end the last day of the month he/she (including ) Dental You may change or drop your current health plan coverage. - You may change your current medical plan option. Vision - You may not change your current dental plan option. Your Spouse/Partner/Child Dies - You may change your current vision plan option. Your Dependent Gains Other Coverage Your Dependent Loses Coverage You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire turns age 26, unless he/she is disabled and you provide with verification of his/her disability. Note: Your child may be eligible to continue group health care coverage under COBRA. See Continuation of Coverage Under COBRA on page 241 for more information. (EAP) If your child is no longer eligible for other benefits but still lives in your household, he or she may continue to Health Care FSA You may decrease or end your contributions to a Health Care FSA to reflect your child s loss of eligibility for participate in the EAP. expense reimbursement under the Health Care FSA. Dependent (Day) Care FSA You may decrease or end your contributions to a Dependent (Day) Care FSA if your child s expenses are not eligible for reimbursement under the Dependent (Day) Care FSA. Expenses for children age 13 and over are not eligible. Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more Your Employment With Ends information. You may decrease or drop your Supplemental Life coverage. Your Death You may update your beneficiary information at any time on Gapweb ( benefits. Dependent Life Insurance Accidental Death & Dismemberment (AD&D) Insurance Dependent Life coverage for your child automatically ends on the day he or she turns age 23, unless your child is disabled and you provide with verification of his or her disability. Since Dependent Life Insurance can be converted, your child can continue his or her coverage under an individual policy through the insurance company. Note that the premium rate on an individual policy may be higher than the rate paid for coverage related to your benefits. You may update your beneficiary information at any time on Gapweb ( benefits. 213

214 Reporting Your Life Event Your Spouse/Partner/Child Dies You Get Married or Establish a Partnership The table below describes what happens to your benefits if your spouse, partner or child dies. When reporting the death, you must remove your deceased dependent from your list of covered dependents on Gapweb ( benefits. You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child Report the change to drop your deceased dependent s coverage. Coverage for any of your other enrolled Your Child Is No Longer Eligible Dental Your Spouse/Partner/Child Dies Vision (including ) If your dependent dies, you may enroll yourself and/or any eligible dependents in medical, dental or Vision Plus plan coverage. You may also change your current health plan coverage. - You may change your current medical plan option. Your Dependent Gains Other Coverage - You may not change your current dental plan option. - You may change your current vision plan option. (You are automatically covered by the basic Vision plan, which Your Dependent Loses Coverage only covers employees, not dependents.) You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death dependents remains in effect. Coverage for your deceased dependent will end on the date of his or her death. You may drop your current medical, dental, or Vision Plus coverage. Your coverage will end on the day your spouse/ partner/child died. (EAP) Coverage continues for remaining dependents who reside in the same household. Health Care FSA You may enroll in or increase contributions to a Health Care FSA if you and/or your dependents lose eligibility for expense reimbursement under your deceased spouse s or partner s Health Care FSA. Dependent (Day) Care FSA You may decrease your contributions or end contributions for your deceased dependent. You will be able to submit claims for charges incurred on behalf of your dependent before the date of his or her death. Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You may decrease or drop your Supplemental Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. 214

215 Reporting Your Life Event You Get Married or Establish a Partnership You Divorce or End a Partnership Benefit What You Can Do Dependent Life Insurance If your dependent is covered by Dependent Life or AD&D Insurance at the time of his/her death, contact Employee Accidental Death & Dismemberment (AD&D) Insurance Services at , ext , to obtain the applicable claim forms. You are automatically the beneficiary of You Become a Parent or Gain an Eligible Child his or her benefits. You may elect or increase Dependent Life or AD&D coverage for any other eligible dependents. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. Your Child Is No Longer Eligible You may decrease or drop Dependent Life or AD&D coverage. Your Spouse/Partner/Child Dies You may update your beneficiary information at any time on Gapweb ( benefits. Your Dependent Gains Other Coverage Your Dependent Loses Coverage You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death 215

216 Reporting Your Life Event Your Spouse/Partner/Child Gains Other Coverage Due to Change in Employment Status You Get Married or Establish a Partnership The table below describes what changes you can make to your benefits if your dependents gain other coverage due to a change in employment status. You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child You may add, drop or change medical coverage for yourself, your spouse/partner, and/or your eligible children. Your Child Is No Longer Eligible Dental Your Spouse/Partner/Child Dies (includes ) You may add or drop dental coverage for yourself, your spouse/partner, and/or your eligible children. You may not change your current dental plan option. Vision You may add, drop, or change vision coverage for yourself, your spouse/partner, and/or your eligible children. (EAP) You and your dependents continue to be eligible to participate in the EAP as long as they are members of your Your Dependent Loses Coverage Health Care FSA You may enroll in the plan, drop coverage or change contributions. You Take a Leave of Absence Dependent (Day) Care FSA You may enroll in the plan, drop coverage or change contributions. Basic Life Insurance You may update your beneficiary information at any time on Gapweb ( benefits. Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see Your Dependent Gains Other Coverage You Change From Full-Time to Part-Time Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You Change From Part-Time to Full-Time You Retire household. You may decrease or drop your Supplemental Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. Dependent Life Insurance Your Employment With Ends You may elect or increase Dependent Life coverage for any eligible dependents at any time. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. Your Death You may decrease or drop Dependent Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. Accidental Death & Dismemberment (AD&D) Insurance You may enroll yourself and any eligible dependents for AD&D coverage. You may increase, decrease or drop AD&D coverage. You may update your beneficiary information at any time on Gapweb ( benefits. 216

217 Reporting Your Life Event Your Spouse/Partner/Child Loses Coverage Due to Change in Employment Status You Get Married or Establish a Partnership The table below describes what changes you can make to your benefits if your dependent loses other coverage due to a change in employment status and loss of eligibility. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Benefit What You Can Do You may add, drop or change medical coverage for yourself, your spouse/partner, and/or your eligible children. (includes ) Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage Dental You may add or drop dental coverage for yourself, your spouse/partner, and/or your eligible children. You may not change your current dental plan option. Vision You may add or change vision coverage for yourself, your spouse/partner, and/or your eligible children. (EAP) You and your dependents continue to be eligible to participate in the EAP. Your Dependent Loses Coverage You Take a Leave of Absence Health Care FSA You may enroll in the plan, drop coverage or change contributions. Dependent (Day) Care FSA You may enroll in the plan, drop coverage or change contributions. Basic Life Insurance You may update your beneficiary information on Gapweb ( benefits. Supplemental Life Insurance You may elect or increase Supplemental Life coverage. Evidence of insurability (EOI) requirements may apply see You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. You may decrease or drop your Supplemental Life coverage. You Retire Your Employment With Ends You may update your beneficiary information at any time on Gapweb ( benefits. Dependent Life Insurance You may elect or increase Dependent Life coverage for any eligible dependents at any time. Evidence of insurability (EOI) requirements may apply see Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance on page 168 for more information. Your Death You may decrease or drop Dependent Life coverage. You may update your beneficiary information at any time on Gapweb ( benefits. Accidental Death & Dismemberment (AD&D) Insurance You may enroll yourself and any eligible dependents for AD&D coverage. You may increase, decrease or drop your AD&D coverage. You may update your beneficiary information at any time on Gapweb ( benefits. 217

218 Reporting Your Life Event You Take a Leave of Absence, Family, Military, or Personal You Get Married or Establish a Partnership The table below describes what happens to your benefits if you take a leave of absence. When you take a leave of absence whether for a family or medical issue, to serve military duty (military leave), or for personal reasons do not forget to contact Employee Services at , ext , about your leave. You Divorce or End a Partnership You Become a Parent or Gain an Eligible Child Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage Your Dependent Loses Coverage For additional information about Leaves of Absence, such as how to request a leave, your rights and obligations, and more detail about the impact on your benefits, please refer to the Employee Leave of Absence Guide on Gapweb ( benefits, or contact Employee Services. Benefit What You Can Do You will continue health care coverage (medical, dental and vision) for yourself and your eligible dependents for (including ) the duration of your leave and you are responsible for paying your portion of the cost of coverage during the leave. Dental This does not apply for military leaves. If you are receiving disability benefits from the disability carrier, your contributions for benefits coverage may be Vision deducted from your disability checks. Otherwise, your benefits deductions will go into arrears and will be collected You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time upon your return to work. (EAP) You and your dependents may continue to participate in the EAP while you are on a leave of absence. Health Care FSA Your contributions to a Health Care FSA stop while you are on leave. When you return from your leave, your Health Care FSA contributions will begin automatically and be adjusted to meet your plan year goal amount. If you are on military leave, please see page 159 for information on the Heroes Earnings Assistance and Relief Tax You Retire Your Employment With Ends (HEART) Act of 2008 that may affect your ability to access your Health Care FSA funds. Dependent (Day) Care FSA Your contributions to a Dependent (Day) Care FSA stop while you are on leave. If you d like to participate when you return from leave, you must re-enroll by completing a Dependent (Day) Care FSA election form within 30 days of Your Death your return to work. Basic Life Insurance Your Basic Life Insurance will remain in effect for the duration of your leave. Supplemental Life Insurance Your Supplemental Life, Dependent Insurance will remain in effect while you are on leave. Dependent Life Insurance Accidental Death & Dismemberment (AD&D) Insurance Your premiums for coverage will go into arrears while you are on leave and will be double deducted from your paychecks upon your return to work. If you elect to not continue coverage while on leave, your coverage will be automatically reinstated when you return to work. You may update your beneficiary information on Gapweb ( benefits. 218

219 Reporting Your Life Event You Change from Full-Time to Part-Time Status You Get Married or Establish a Partnership The table below describes what happens to your benefits if you transition from full-time to part-time status and are no longer eligible for benefits. You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child Health care coverage (medical, dental and vision) ends on the last day of the month in which you become part- Your Child Is No Longer Eligible Vision time. Dental You may be eligible to continue group coverage under COBRA for yourself and your qualifying dependents. See Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext , Your Spouse/Partner/Child Dies for more information. Your Dependent Gains Other Coverage (EAP) Coverage ends on the last day of the month in which you become part-time. Your Dependent Loses Coverage Health Care FSA Your coverage ends at the end of the month in which you become part-time. You may be eligible to continue coverage under COBRA for the remainder of the plan year. See Continuation You Take a Leave of Absence You Change From Full-Time to Part-Time of Coverage Under COBRA on page 241 or contact Employee Services at , ext , for more information. Your coverage ends at the end of the month in which you become part-time. Dependent (Day) Care FSA You Change From Part-Time to Full-Time You Retire You can continue to submit claims for the remaining balance in your account until September 30 for claims incurred from July 1 through June 30. Basic Life Insurance Coverage ends at the end of the month in which you become part-time. You may convert your coverage to a private policy within 31 days of your full-time status change by calling Minnesota Life at Your Employment With Ends Supplemental Life Insurance Your Death Dependent Life Insurance Coverage ends at the end of the month in which you become part-time. You may convert your Supplemental Life, Dependent Life and Accidental Death & Dismemberment (AD&D) policy to a private policy within 31 days of your full-time status change by calling Minnesota Life at Accidental Death & Dismemberment (AD&D) Insurance Short-Term (STD) Coverage ends on the day you become part-time. Long-Term (LTD) 219

220 Reporting Your Life Event You Change from Part-Time to Full-Time Status You Get Married or Establish a Partnership The table below describes what happens to your benefits if you transition from part-time to full-time status and become eligible for benefits. You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child You may enroll yourself, your spouse/partner, and your eligible children for medical or dental coverage. Your Child Is No Longer Eligible Dental Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage (including ) Vision You will be automatically enrolled the basic Vision plan, which only covers employees, not dependents. You may enroll yourself, your spouse or partner, and your eligible children for Vision Plus coverage. (EAP) You will automatically become eligible to participate in the EAP when you change from part-time to full-time Your Dependent Loses Coverage Health Care FSA You may enroll in the Health Care FSA. You Take a Leave of Absence Dependent (Day) Care FSA You may enroll in the Dependent (Day) Care FSA. Basic Life Insurance You are automatically enrolled in this coverage. Make sure to enter your beneficiary information on Gapweb You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time ( benefits. Supplemental Life Insurance your initial eligibility period. Make sure to enter your beneficiary information on Gapweb ( benefits. Dependent Life Insurance You may elect Dependent Life coverage for your spouse or partner, and any eligible dependents. Evidence of insurability (EOI) requirements may apply. Your Death 220 You may elect Supplemental Life coverage of up to three times your annual base pay without evidence of insurability (EOI). EOI will be required if you elect four times your annual base pay or if you elect coverage after You Retire Your Employment With Ends status as will your household members and unmarried children. You are automatically the beneficiary. Accidental Death & Dismemberment (AD&D) Insurance You may enroll yourself, your spouse/partner, and your eligible children in AD&D coverage. Make sure to enter your beneficiary information on Gapweb ( benefits.

221 Reporting Your Life Event You Get Married or Establish a Partnership Benefit What You Can Do Short-Term (STD) You are automatically enrolled in the basic STD and LTD plans. You may enroll in the STD Plus and LTD Plus plans only Long-Term (LTD) during your initial benefits eligibility period (within 30 days, ending at midnight Central Time, of the date you are You Divorce or End a Partnership classified as full-time), or the Open Enrollment period. Note: If you do not enroll for either of the Plus disability plans during your period of initial benefits eligibility, You Become a Parent or Gain an Eligible Child there is a 12-month waiting period for coverage for pre-existing conditions if you enroll during a later Open Enrollment period. Your Child Is No Longer Eligible Your Spouse/Partner/Child Dies Your Dependent Gains Other Coverage Your Dependent Loses Coverage You Take a Leave of Absence You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends Your Death 221

222 Reporting Your Life Event You Retire You Get Married or Establish a Partnership The table below describes what happens to your benefits if you retire. When you are getting ready to retire, contact Employee Services at , ext You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child Coverage for you and your enrolled dependents ends on the last day of the month in which you retire. Dental You may be able to continue coverage under COBRA for yourself and your eligible dependents. See Your Child Is No Longer Eligible Vision Your Spouse/Partner/Child Dies Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext , for more information. (EAP) Coverage ends on the last day of the month in which you retire. Your Dependent Gains Other Coverage You may be able to continue coverage under COBRA for yourself and your eligible dependents. See Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext. Your Dependent Loses Coverage You Take a Leave of Absence 20600, for more information. Health Care FSA Coverage ends on the last day of the month in which you retire. Contributions stop on your last paycheck. You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends You may be able to continue coverage under COBRA for the remainder of the plan year. See Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext , for more information. Dependent (Day) Care FSA Coverage ends on the last day of the month in which you retire. Your deductions will stop with your last paycheck. You can continue to submit claims for the remaining balance in your account until September 30 for claims incurred from July 1 through June 30. Basic Life Insurance Coverage ends on the last day of the month in which you retire. You can convert your Basic Life coverage by applying for an individual policy and paying the first premium within 31 days after your Life Insurance Your Death terminates. Supplemental Life Insurance Your Supplemental Life, Dependent Life and Supplemental AD&D Insurance plans are portable meaning you can elect to keep your coverage. Dependent Life Insurance Accidental Death & Dismemberment (AD&D) Insurance You must request portable life insurance within 31 days of your retirement date. Note that the premium rate Short-Term (STD) Coverage ends on your last day of work. on your portable policy may be higher than the rate you paid for coverage as an active employee. Long-Term (LTD) 222

223 Reporting Your Life Event Your Employment with Ends You Get Married or Establish a Partnership The table below describes what happens to your benefits if your employment with ends. When you terminate your employment, contact Employee Services at , ext You Divorce or End a Partnership Benefit What You Can Do You Become a Parent or Gain an Eligible Child Coverage for you and your enrolled dependents will end on the last day of the month in which you terminate. Dental You may be able to continue coverage under COBRA for yourself and your eligible dependents. See Your Child Is No Longer Eligible Vision Your Spouse/Partner/Child Dies Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext , for more information. (EAP) Coverage for you and your dependents ends on the last day of the month in which you terminate. Your Dependent Gains Other Coverage You may be able to continue coverage under COBRA for yourself and your eligible dependents. See Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext. Your Dependent Loses Coverage You Take a Leave of Absence 20600, for more information. Health Care FSA Coverage ends on the last day of the month in which you terminate. Contributions stop on your last paycheck. You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire Your Employment With Ends You may be able to continue coverage under COBRA for the remainder of the plan year. See Continuation of Coverage Under COBRA on page 241 or contact Employee Services at , ext , for more information. Dependent (Day) Care FSA Coverage ends on the last day of the month in which you terminate. Your deductions will stop with your last paycheck. You can continue to submit claims for the remaining balance in your account until September 30 for claims incurred from July 1 through June 30. Basic Life Insurance Coverage ends on your last day of work. You can convert your Basic Life coverage by applying for an individual policy and paying the first premium within 31 days after your Life Insurance terminates. Your Death Supplemental Life Insurance Your Supplemental Life, Dependent Life and Supplemental AD&D Insurance plans are portable meaning you can elect to keep your coverage. Dependent Life Insurance Accidental Death & Dismemberment (AD&D) Insurance You must request portable life insurance within 31 days of your termination date. Note that the premium rate Short-Term (STD) Coverage ends on your last day of work. on your portable policy may be higher than the rate you paid for coverage as an active employee. Long-Term (LTD) 223

224 Reporting Your Life Event Your Death You Get Married or Establish a Partnership In the event of your death, your dependents or a family representative should contact Employee Services at , ext , as soon as possible You Divorce or End a Partnership Benefit What Your Surviving Dependents Can Do You Become a Parent or Gain an Eligible Child Coverage for your enrolled dependents ends on the last day of the month in which your death occurs. Dental Your dependents may be eligible to continue coverage under COBRA. See Continuation of Coverage Under Your Child Is No Longer Eligible Vision Your Spouse/Partner/Child Dies (EAP) Coverage for your dependents ends on the last day of the month in which your death occurs. COBRA on page 241 or contact Employee Services at , ext , for more information. Your dependents may be eligible to continue coverage under COBRA. See Continuation of Coverage Under Your Dependent Gains Other Coverage Your Dependent Loses Coverage You Take a Leave of Absence COBRA on page 241 or contact Employee Services at , ext , for more information. Coverage ends on the last day of the month in which your death occurs. Health Care FSA Contributions stop on your last paycheck. Dependent (Day) Care FSA Your deductions will stop with your last paycheck. Claims may be submitted for the remaining balance in your account until September 30 for claims incurred from July 1 through June 30, as long as the services were You Change From Full-Time to Part-Time You Change From Part-Time to Full-Time You Retire received while you were participating in the plan and actively working full-time. Basic Life Insurance Benefits are paid to your beneficiary(ies) upon approval from the insurance carrier. Supplemental Life Insurance Dependent Life Insurance Dependent Life Insurance ends on the date of your death. Dependent Life Insurance is portable meaning your covered dependents can elect to keep their coverage. Your Employment With Ends Your Death Your covered dependents must request portable life insurance within 31 days of your death. Note that the premium rate on portable policies may be higher than the rate paid for coverage related to benefits. Accidental Death & Dismemberment (AD&D) Insurance For any AD&D coverage that you carry, benefits are paid to your beneficiary(ies) upon approval from the insurance carrier. AD&D Insurance is portable meaning your covered dependents can elect to keep their coverage. Your covered dependents must request portable AD&D Insurance within 31 days of your death. Note that the premium rate on portable policies may be higher than the rate paid for coverage related to benefits. 224

225 Coordination of Benefits Coordination of Benefits Rules Legal and Claims Information Claims And Appeals Procedures Coordination of Benefits Health Benefit Claims and Appeals Coordination of benefits (COB) applies to you if you are covered by more than one health benefits plan, including any one of the following: Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Another employer-sponsored health benefits plan A medical component of a group long-term care plan, such as skilled nursing care No-fault or traditional fault type medical payment benefits or personal injury protection benefits under an auto insurance policy payment benefits under any premises liability or other types of liability coverage, or Medicare or other governmental health benefit (see If You Are Entitled to Medicare on page 227 for special rules). If coverage is provided under two or more plans, COB determines which plan is primary and which plan is secondary. The plan considered primary pays its benefits first. Any remaining expenses may be paid under the other plan, which is considered secondary. The secondary plan may determine its benefits based on the benefits paid by the primary plan. For employees whose employment was involuntarily terminated or who have retired, any plan that covers them or their dependents in a classification other than involuntarily terminated or retired will pay first. If the other plan does not also have this kind of provision, this provision will not apply. 225 has the right to obtain or provide any information needed to administer the coordination of benefits provision. You and your covered dependents also must give the plan any information needed to pay benefit claims. If the plan pays more than it should have paid under the coordination of benefits rule, the plan is entitled to collect the excess amount from you, your covered dependent, or another source, such as the provider. Coordination of Benefits Rules for Health Plans The procedures and timeframes described in this section are the general coordination of benefits rules applicable to the health plans. If you have trouble understanding your coordination of benefits rules, contact Employee Services at , ext Under coordination of benefits, the benefits you receive from all sources for the same eligible expense cannot be greater than the actual amount of the eligible expense. One plan pays benefits first, up to its benefit maximums. Then the other plan determines the benefits it will provide based on the remaining eligible expenses and its terms. If you and your dependents are enrolled in a health plan, as well as another employer-sponsored plan (such as your spouse s plan at work), the health plan coordinates its coverage with the other plan. The coordination of benefits rules determine which plan pays benefits first.

226 Coordination of Benefits Here s how it works, in general: Coordination of Benefits Rules When the health plan pays first, in other words, if the health plan is the primary plan, it pays benefits as though no other plan exists. The other plan may or may not pay benefits. You may submit charges not covered by the health plan for possible reimbursement to the other plan, if any. Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers When the health plan pays second, in other words, if the health plan is the secondary plan, it may or may not pay a benefit, depending on what the other plan (the primary plan) has paid. The most an enrolled person can receive is a combined total of 100% of eligible expenses from both plans. Please Note: If you are enrolled in the HRA, HRA Plus, Hawaii PPO, or Out-of-Area Plan and it pays second, the nonduplication of benefits provision applies. This means that the plan will not pay twice for the same covered services and same level of benefits already paid from the primary plan. If you have dependents covered through another health plan, adding them as a dependent under your UnitedHealthcare medical plan may not provide them with any added benefits. Plan Administration Information Example Let s say you cover your spouse under the HRA Plan and he s also covered under his employer s plan: His plan will pay first, and then the HRA Plan will pay second. If his plan pays 80% for a service and that same service is also covered at 80% through the HRA Plan, no additional benefits will be paid from the HRA Plan. 226 The health plan will pay for a covered health service by following the steps below: The health plan determines the amount it would have paid based on the primary plan s allowable expense If the health plan would have paid less than the primary plan paid, the health plan pays no benefits If health plan would have paid more than the primary plan paid, the health plan will pay the difference. The maximum combined payment you can receive from all plans may be less than 100% of the total allowable expense. Which Plan Pays First? If you or your covered dependents are also covered under another health plan, the first of the following rules which applies determines which plan is primary: 1. A plan without a coordination of benefits provision is considered primary. The health plan will always be secondary to medical payment coverage or personal injury protection (PIP) coverage under any auto liability or no-fault insurance policy. 2. A plan in which you are covered as other than a dependent (for example, as an active employee) rather than as a dependent is primary. If you also are a Medicare beneficiary and, as a result of federal law, a plan covering you as an active employee is primary, Medicare is secondary, and a plan covering you as a retiree determines benefits and pays last. If you are covered as a dependent of an active employee and you are a Medicare beneficiary, the plan covering you as a dependent is primary. Medicare is secondary, and the plan covering you as a retiree (or as other than a dependent) determines benefits and pays last.

227 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information 3. For a child whose parents are married or are living together, whether or not they have ever been married, or if a court decree establishes joint custody of your child without specifying which parent is responsible to provide health coverage, uses the birthday rule to determine which plan pays benefits first when your child is covered under both parents plans. Under the birthday rule, the plan covering the parent whose birthday falls first in the calendar year is primary. The plan of the parent whose birthday falls later in the year is the secondary plan. 5. A plan in which you are enrolled as an active employee (or as that employee s dependent) rather than as a laid-off or retired employee is primary. If both parents share the same birthday, the primary plan will be the plan that has covered one parent the longest. The secondary plan will be the plan that has covered the other parent for a shorter period of time. 8. If none of the above rules determines which plan is primary, the allowable expenses shall be shared equally between the plans. 4. For a child whose parents are divorced or separated or are not living together, whether or not they were ever married, and your children are covered under both parents plans, the birthday rule does not apply. Instead, uses the following rules to determine which plan pays benefits first: First, the plan of the parent to whom the court specifically assigned financial responsibility for health care expenses (for instance, through a Qualified Child Support Order) Then, the plan of the parent who has custody Then, the plan of the spouse married to the parent who has custody Then, the plan of the parent who does not have custody, and 6. In most cases, a plan in which you are enrolled as an active employee or subscriber rather than as a COBRA participant is primary. 7. The plan covering the individual for the longest period of time is considered primary. has the right to obtain or provide any information needed to administer the coordination of benefits rules. You and your covered dependents also must give the health plan any information needed to pay benefit claims. If the health plan pays more than it should have paid under the coordination of benefits rules, the health plan is entitled to collect the excess amount from you, your covered dependent, or another source, such as the provider. If You Are Entitled to Medicare The provisions of this section apply to the maximum extent permitted by federal law. will not reduce the benefits due any member because of Medicare eligibility where federal law requires the medical plan to determine its benefits without regard to Medicare benefits. Finally, the plan of the spouse married to the parent who does not have custody. 227

228 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information When Does the Plan Pay First? In general, the medical plan would be primary and pay benefits first for: Eligible employees age 65 and over with current employment status and spouses age 65 and over who participate in the medical plan on the basis of the employee s current employment status Social Security disabled individuals who are covered by the Gap Inc. medical plan on the basis of current employment status (their own or a family member s current employment status) and who are entitled to Medicare benefits (e.g., disabled spouses or dependents of an active employee, or Social Security disabled participants who have returned to work) For the first 30 months of Medicare entitlement, for certain individuals who become eligible for Medicare on the basis of having end-stage renal disease (ESRD), regardless of the reason for the employer coverage. If any of these situations apply to you or your dependents enrolled in Medicare and also covered by a medical plan, the Gap Inc. medical plan will be primary. This means that you must file your medical claims with the medical plan first. Any claims not paid by the medical plan may then be filed with Medicare. If you wish to have Medicare as your primary coverage, you cannot elect a medical plan. In all other situations, Medicare will pay benefits before the Gap Inc. medical plan. 228 Claims and Appeals Procedures The procedures outlined below are representative of the actual claims and appeals procedures followed by the claims administrators of benefit plans that are subject to ERISA and offered under the plan. Please refer to the relevant sections of this SPD or the benefits summaries, which are available on Gapweb ( benefits, for the claims procedure that a specific plan s claims administrator will follow. Any claim or appeal for a specific benefit plan shall be made, in accordance with the applicable insurance policy or administrative agreement, directly to the claims administrator for that specific benefit. See Claims Administrators and Plan Numbers on page 255 for a list of claims administrators. A claim for benefits must be filed within 12 months from the date the claim was incurred or as provided in the applicable insurance policy or administrative agreement. You may not file a lawsuit or take legal action to recover benefits under the plan until you have exhausted the entire applicable ERISA claim and appeal procedures. In addition, you may not begin legal action more than 90 days after the date the claims administrator renders its final decision upon appeal or as provided in the applicable insurance policy or administrative agreement. If you have trouble receiving plan material, contact Employee Services at , ext

229 Coordination of Benefits Health Benefit Claims and Appeals Procedures Coordination of Benefits Rules You must follow the claims rules established by the individual health plans (medical, prescription drug, dental, vision, and Health Care FSA) and their claims administrators. The following information pertains to the HRA, HRA Plus, Hawaii PPO and Out-of-Area medical plans, prescription drug, dental, vision and Health Care FSA plans. If you are covered by a different medical plan, please refer to your medical plan s evidence of coverage or guidelines, which can be found on Gapweb ( com)> benefits. Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Filing an Initial Claim If you are required to file an initial claim for benefits, you must do so within the time specified by the benefit plan and in accordance with the plan s established claim procedures. See the medical, prescription drug, dental, vision, and Health Care FSA sections of this SPD, or the applicable benefit summary for details on filing claims, or contact the claims administrator listed in Claims Administrators and Plan Numbers on page 255. Benefit summaries are available on Gapweb ( benefits. If you have trouble receiving plan material, contact Employee Services at , ext Overview of Procedures In general, health care claims are divided into four categories: urgent care claims, pre-service claims, post-service claims, and concurrent care decisions. (Health Care FSA claims are always considered post-service claims.) These claim types are outlined on the following pages. After a claim is submitted, it is reviewed by the plan s claims administrator to determine whether the service or benefit can be covered by the plan. This is known as a benefit determination. 229 Definitions Claim. Any request for plan benefits made to the proper person in accordance with the plan s claims filing procedures, including any request for a service that must be pre-approved. Claims must be submitted in writing to the appropriate claims administrator listed in Claims Administrators and Plan Numbers on page 255. Adverse Decision or Adverse Appeal Decision. A denial, reduction, termination of or failure to provide or make payment (in whole or in part) for a benefit. An adverse decision includes a decision to deny benefits based on: (i) an individual s ineligibility to participate in the plan; (ii) utilization review; (iii) a service being characterized as experimental or investigational or not medically necessary or appropriate or not meeting the definition of a covered health service; or (iv) a concurrent care decision. Authorized Representative. An individual authorized to act on your behalf in pursuing a claim or appeal in accordance with procedures established by the plan. For urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative. (A health care professional is a physician or other health care professional who is licensed, accredited, or certified to perform specified health services consistent with state law.) For information about appointing an authorized representative, contact the claims administrator listed in Claims Administrators and Plan Numbers on page 255.

230 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Notice of Benefit Determination After your claim is reviewed, you may receive a notice of benefit determination depending on the type of claim submitted. For urgent care and pre-service claims, you will receive a notice of benefit determination regardless of whether the claim is approved or an adverse decision is made. For post-service and concurrent care decisions, you will receive a notice of benefit determination only if your claim is denied. The timeframe to provide notice of a benefit determination generally starts when a written claim for benefits is received by the claims administrator. A notice of benefit determination may be provided in writing by hand delivery, mail, or electronic delivery. However, in some urgent cases, the claims administrator may first provide notice orally, followed by written or electronic notice within three calendar days. The procedures and timeframes for reviewing each claim and providing notice of benefit determination vary and are described below. Urgent Care Claims An urgent care claim is any claim for medical care or treatment that has to be decided more quickly because the normal timeframes for decision-making could seriously jeopardize your life, health or your ability to regain maximum function, or, in the opinion of a physician with knowledge of your condition, subject you to severe pain that cannot be adequately managed without the care or treatment addressed in the claim. A medical plan must defer to an attending provider to determine if a claim is urgent. After the claims administrator receives your urgent care claim, a notice of benefit determination will be provided as soon as possible considering the medical urgency, and no later than 72 hours after receipt of your claim. 230 Incomplete Urgent Care Claims If a properly filed urgent care claim is missing information needed for a coverage decision, the claims administrator will notify you or your authorized representative as soon as possible, but no later than 24 hours after receiving the claim. You will be notified of the specific information necessary to complete the claim and will have a reasonable amount of time considering the circumstances (but not less than 48 hours) to provide the specific information. The claims administrator will then provide notice of the claim decision as soon as possible, but no later than 48 hours after the earlier of: The date the claims administrator receives the specified information, or The end of the additional time period given for providing the information. Pre-service Claims A pre-service claim is any claim for medical care or treatment other than an urgent care claim that must be approved in advance of receiving medical care (for example, requests to precertify a hospital stay or pre-approval for certain services under a utilization review plan). Pre-service claims do not apply to dental or vision claims. After the claims administrator receives your pre-service claim, a notice of benefit determination will be provided within a reasonable period of time appropriate to the medical circumstances, and no later than 15 days after receipt of your claim. This timeframe may be extended for up to an additional 15 days for matters beyond the claims administrator s control, in this case you will be notified of the extension, reason for delay and when the claims administrator expects to make a decision before the initial 15-day deadline.

231 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information If an extension is necessary because certain information was not submitted with the claim, the notice will describe the required information that is missing, and you will be given an additional period of at least 45 days after you receive the notice to furnish the information. The claims administrator s extension period will begin when you respond to the request for additional information. The claims administrator will then provide a notice of benefit determination within 15 days after your response is received. Improperly Filed Pre-Service Claim If a pre-service claim is not filed in accordance with the plan s claim procedures, the claims administrator will notify you no later than five days after receiving the claim. If the claim is an urgent care case, you will be notified within 24 hours. Notice of an improperly filed pre-service claim may be provided orally or in writing, if you request. The notice will identify the proper procedures to be followed in filing the claim. In order to receive notice of an improperly filed pre-service claim, you or your authorized representative must have communicated your request regarding the claim to the applicable claims administrator listed in Claims Administrators and Plan Numbers on page 255. The request must include: The identity of the claimant A specific medical condition or symptom, and A request for approval for a specific treatment, service or product. Post-service Claims A post-service claim is any other type of claim, including a claim for reimbursement through the dental, vision or Health Care FSA plans. In the case of a denial or adverse decision of your post-service claim, the claims administrator will provide a notice of benefit determination no later than 30 days after receipt of your claim. This timeframe may be extended for up to an additional 15 days for matters beyond the claims administrator s control. In this case, you will be notified of the extension, reason for delay and when the claims administrator expects to make a decision before the initial 30-day deadline. If an extension is necessary because certain information was not submitted with the claim, the notice will describe the required information that is missing, and you will be given an additional period of at least 45 days after you receive the notice to furnish the information. The claims administrator s extension period will begin when you respond to the request for additional information. The claims administrator will then provide a notice of benefit determination within 15 days after your response is received. Concurrent Care Decisions A concurrent care decision is any decision in which the claims administrator after having previously approved an ongoing course of medical treatment provided over a period of time or a specific number of treatments subsequently reduces or terminates coverage for the treatments (other than by plan amendment or termination). In the event your ongoing course of medical treatment will be reduced or terminated, you will be notified sufficiently in advance to provide an opportunity to appeal and obtain a decision on appeal before your benefit is reduced or terminated. 231

232 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information If you request an extension of ongoing treatment in an urgent circumstance, you will be notified as soon as possible given the medical urgency, and no later than 24 hours after the claims administrator receives your claim provided the claim is submitted to the claims administrator at least 24 hours before the expiration of the prescribed time period or number of treatments. If you request an extension of ongoing treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to post-service or pre-service timeframes, whichever applies. Appealing an Adverse Decision If you have a question or concern regarding the process, service, policies or procedures used to review your claim, contact the claims administrator listed in Claims Administrators and Plan Numbers on page 255. In many cases the issue can be resolved by contacting the claims administrator directly. If you disagree with the decision made on your claim, you (or your authorized representative) may file a written appeal with the applicable claims administrator within 180 days after your receipt of the notice of adverse decision. For a list of claims administrators, see Claims Administrators and Plan Numbers on page 255. If you do not appeal on time, you may lose your right to file suit in a state or federal court, as you will not have exhausted your internal administrative appeal rights (which is generally a requirement before you can sue in federal court). Your appeal should include the reasons you believe the claim was improperly denied, and all additional facts and documentation you consider relevant in support of your appeal. The decision on your appeal will consider all comments, documentation, records, and other information you submit, even if they were not submitted or considered during the initial claim decision. 232 Your appeal will not be reviewed by the individual who denied the initial claim or that person s subordinate. The reviewer will give the claim a fresh look and make an independent decision regarding the claim. If your claim was denied based on medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the field of medicine involved in your claim. The health care professional will not be the same person (or a subordinate of the person) who was consulted on the initial decision. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, or a covered health service.) If requested by the claimant, the claims administrator will also identify any medical or other experts whose advice was obtained in considering the original decision on your claim, whether or not the claims administrator relied on their advice. For appeals involving urgent care claims, the claims administrator will accept either oral or written requests for appeals for an expedited review. All necessary information may be transmitted between the claims administrator and you or health plan providers by telephone, fax or other available expeditious methods. Notice of Appeal Decision After your appeal is reviewed by the claims administrator, you will receive a notice of the appeal decision. The timeframes for providing a notice of the appeal decision generally start when a written appeal is received by the claims administrator and may be provided in writing through in-hand, mail or electronic delivery. Urgent care decisions may be delivered by telephone, fax, or other expeditious methods. The timeframes for providing notice are:

233 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Urgent Care Appeals. As soon as possible considering the medical urgency and no later than 72 hours after receipt of your appeal. Similar to the earlier appeals process, a new decision-maker will review your second-level appeal and will not give deference to the original decision made on your claim. Pre-Service Appeals. Within a reasonable period of time appropriate to the medical circumstances and no later than 15 calendar days after receipt of your appeal. If your claim and subsequent appeal were denied based on medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the field of medicine involved in your claim. It will not be the same person (or a subordinate of the person) who was consulted on the earlier decisions. If requested by the claimant, the claims administrator will also identify any medical or other experts whose advice was obtained in considering the original decision on your claim, whether or not the claims administrator relied on their advice. Post-Service Appeals. Within a reasonable period of time appropriate to the medical circumstances and no later than 60 calendar days after receipt of your appeal (30 calendar days for the HRA, HRA Plus, Hawaii PPO, Out-of-Area and Prescription Drug plans). Final Appeal of Adverse Decision HRA, HRA Plus, Hawaii PPO, and Out-of-Area Plans, and Health Care FSA If you disagree with the decision made regarding your appeal, the HRA, HRA Plus, Hawaii PPO, and Out-of-Area medical plans, prescription drug and Health Care FSA plans provide a second and final level of appeal. You (or your authorized representative) may file a written appeal with the claims administrator within 60 days (90 days for prescription drug claims) after your receipt of the notice of adverse appeal decision. If you do not appeal on time, you may lose your right to file suit in a state or federal court, as you will not have exhausted your internal administrative appeal rights (which is generally a requirement before you can sue in federal court). You should include the reasons you believe the claim was improperly denied, and all additional facts and documentation you consider relevant in support of your appeal. The decision on your appeal will consider all comments, documentation, records, and other information you submit, even if they were not submitted or considered during the prior review. 233 For appeals involving urgent care claims, the claims administrator will accept either oral or written requests for appeals for an expedited review. All necessary information may be transmitted between the claims administrator and you or health plan providers by telephone, fax, or other available expeditious methods. Notice of Final Appeal Decision After your final appeal is reviewed by the claims administrator, you will receive a notice of final appeal decision. The timeframes for providing a notice of final appeal decision generally start when a written appeal is received by the claims administrator and may be provided in writing through in-hand, mail, or electronic delivery. Urgent care decisions may be delivered by telephone, fax, or other expeditious methods. The timeframes for providing notice are: Urgent Care Appeals. As soon as possible considering the medical urgency and no later than 72 hours after receipt of your appeal.

234 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Pre-Service Appeals. Within a reasonable period of time appropriate to the medical circumstances and no later than 15 calendar days after receipt of your appeal. Post-Service Appeals. Within a reasonable period of time appropriate to the medical circumstances and no later than 30 calendar days after receipt of your appeal. The claims administrator has the discretion to construe and interpret the terms of the plan and the authority and responsibility to make factual determinations. Benefits will only be paid if the claims administrator determines, in its discretion, that you are entitled to them. The claims administrator s decisions are conclusive and binding. External review is not available if the reason for denial is based on eligibility or benefit coverage limits. You or your representative may request a standard external review by sending a written request to the address set out in the claims administrator s decision letter. You or your representative may request an expedited external review, in urgent situations as detailed on page 236, by calling the toll-free number on your ID card or by sending a written request to the address set out in the decision letter. A request must be made within four months after the date you received the claims administrator s decision. An external review request should include all of the following: A specific request for an external review External Review Program If, after exhausting your internal appeals, you are not satisfied with the determination made by the claims administrator, or if the claims administrator fails to respond to your appeal in accordance with the required timing, you may be entitled to request an external review of the determination. This process is available at no charge to you. The covered person s name, address, and insurance ID number If one of the above conditions is met, you may request an external review of adverse benefit determinations based upon any of the following: An external review will be performed by an Independent Review Organization (IRO). The IRO is composed of persons who are not employed by the claims administrator or any of its affiliates. There are two types of external reviews available: Clinical reasons The exclusions for experimental or investigational services or unproven services Rescission of coverage (coverage that was cancelled or discontinued retroactively), or Your designated representative s name and address, when applicable The service that was denied, and Any new, relevant information that was not provided during the internal appeal. A standard external review, and An expedited external review. As otherwise required by applicable law. 234

235 Coordination of Benefits Rules Standard External Review A standard external review is comprised of all of the following: Claims And Appeals Procedures A preliminary review by the claims administrator of the request Health Benefit Claims and Appeals A referral of the request by the claims administrator to the IRO, and Coordination of Benefits Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information A decision by the IRO. Within the applicable timeframe after receipt of the request, the claims administrator will complete a preliminary review to determine whether the individual for whom the request was submitted meets all of the following: Is or was covered under the plan at the time the health care service or procedure that is at issue in the request was provided Has exhausted the applicable internal appeals process, and Has provided all the information and forms required so that the claims administrator may process the request. After the preliminary review is completed, the claims administrator will issue a notification in writing to you. If the request is eligible for external review, it will be forwarded to an IRO to conduct the review. The claims administrator will assign requests by either rotating claims assignments among the IROs or by using a random selection process. The IRO will notify you in writing of your eligibility and acceptance for external review. You may submit in writing to the IRO, within 10 business days following the date of receipt of this notice, additional information that the IRO will consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted by you after 10 business days. 235 The claims administrator will provide to the assigned IRO the documents and information considered in making the claim determination. The documents include: All relevant medical records All other documents relied upon, and All other information or evidence that you or your physician submitted. If there is any information or evidence you or your physician wish to submit that was not previously provided, you may include this information with your external review request and the claims administrator will include it with the documents forwarded to the IRO. In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by the claims administrator. The IRO will provide written notice of its decision within 45 days after it receives the request for the external review (unless they request additional time and you agree). The IRO will deliver the notice of its decision to you and the claims administrator and it will include the clinical basis for the determination. Upon receipt of a decision reversing the claims administrator s determination, the plan will immediately provide coverage or payment for the benefit claim at issue in accordance with the terms and conditions of the plan, and any applicable law regarding plan remedies. If the decision is that payment or referral will not be made, the plan will not be obligated to provide benefits for the health care service or procedure.

236 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Expedited External Review An expedited external review is similar to a standard external review. The most significant difference between the two is that the time periods for completing certain portions of the review process are much shorter, and in some instances you may file an expedited external review before completing the internal appeals process. You may make a written or verbal request for an expedited external review if you receive either of the following: An adverse benefit determination of a claim or appeal if the adverse benefit determination involves a medical condition for which the time frame for completion of an expedited internal appeal would seriously jeopardize the life or health of the individual or would jeopardize the individual s ability to regain maximum function and you have filed a request for an expedited internal appeal, or A final appeal decision, if the determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the individual or would jeopardize the individual s ability to regain maximum function, or if the final appeal decision concerns an admission, availability of care, continued stay, or health care service, procedure or product for which the individual received emergency services, but has not been discharged from a facility. Immediately upon receipt of the request, the claims administrator will determine whether the individual meets both of the following: Is or was covered under the plan at the time the health care service or procedure that is at issue in the request was provided, and 236 Has provided all the information and forms required so that the claims administrator may process the request. After the review is complete, the claims administrator will immediately send a notice in writing to you. If the request is eligible for expedited external review, the claims administrator will assign an IRO in the same manner used to assign standard external reviews. The claims administrator will provide all necessary documents and information considered in making the adverse benefit determination or final adverse benefit determination to the assigned IRO electronically or by telephone or fax or any other available expeditious method. The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the same type of information and documents considered in a standard external review. In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by the claims administrator. The IRO will provide notice of the decision as expeditiously as the claimant s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request. If the initial notice is not in writing, within 48 hours after the date of providing the initial notice, the assigned IRO will provide written confirmation of the decision to you and the claims administrator. Your Right to Information Upon request to the applicable claims administrator listed in Claims Administrators and Plan Numbers on page 255, and free of charge, you have a right to reasonable access to and copies of all documentation, records, and other information relevant to the claims administrator s denial of a claim or appeal. Information is relevant if it:

237 Coordination of Benefits Was relied upon in making the decision on your claim or appeal Coordination of Benefits Rules Was submitted to, considered, or generated by the claims administrator in considering your claim or appeal, or Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Demonstrates compliance with the claims administrator s administrative processes for making claim decisions. You are also entitled access to, and a copy of, any internal rule, guideline, protocol, or other similar criteria used as a basis for a decision on your denied claim upon request, free of charge. Similarly, if your claim is denied based on a determination involving a medical judgment, you are entitled to an explanation of the scientific or clinical reasons for that determination free of charge upon request. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, or a covered health service.) In addition, if voluntary appeals or alternative dispute resolution options are available under the plan, you are entitled to receive information about the procedures for using these alternatives. See Your Rights and Privileges Under ERISA on page 248 for additional information on legal action you can take if you feel your right to a benefit has been improperly denied. Non-Health Benefit Claims and Appeals Procedures The claims procedures outlined on the following pages are representative of the actual claims procedures followed by the claims administrators of non-health benefit plans that are subject to ERISA and offered under the plan. See the applicable benefit summaries for the plans in which you are enrolled for details on filing claims. Benefit summaries are available on Gapweb ( benefits. 237 If you have trouble receiving plan material, contact Employee Services at , ext Filing an Initial Claim You (or your beneficiaries) must follow the claims procedures established by the various non-health benefit plans. If you are required to file an initial claim for benefits, you must do so within the time specified by the benefit plan and in accordance with the plan s established claim procedures. See the applicable benefit information in this SPD or the benefit summaries available on Gapweb ( benefits for details on filing claims. See Claims Administrators and Plan Numbers on page 255 for a list of claims administrators and their contact information. Definitions Claim. A request for plan benefits made in accordance with the claims administrator s claims filing procedures. Claims must be submitted in writing to the appropriate claims administrator listed in Claims Administrators and Plan Numbers on page 255. Adverse Decision or Adverse Appeal Decision. A denial, reduction, termination of or a failure to provide or make payment (in whole or in part) for a benefit. Authorized Representative. An individual authorized to act on your behalf in pursuing a claim or appeal, based on reasonable procedures established by the claims administrator. For information about appointing an authorized representative, contact the claims administrator listed in Claims Administrators and Plan Numbers on page 255.

238 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Notice of Adverse Decision If your claim is denied or reduced, you will be provided with a notice of adverse decision. For the disability (STD and LTD) plans, the notice of adverse decision will be provided within 45 days after the date your claim is first properly filed with the claims administrator. If more time is needed by the claims administrator to make a decision, you will be notified of the reasons for the delay before the end of the 45-day period. The claims administrator may extend the decision-making period for up to 30 days. If additional time is needed, the claims administrator may extend the decision-making period for an additional 30 days. You will be notified of the second extension before the end of the first extension period. The notice of extension may include a request for additional information from you. You must provide the requested information to the claims administrator within 45 days. The claims administrator s 30-day extension period will begin when you respond to the request for additional information. For the Life, AD&D and Business Travel Accident plans, the notice of adverse decision will be provided within 90 days after the date your claim is first properly filed with the claims administrator. If more time is needed by the claims administrator to make a decision, you will be notified of the reasons for the delay before the end of the initial 90-day period. The claims administrator may extend the decision-making period for up to 90 days if the claims administrator determines that special circumstances require an extension. Appealing an Adverse Decision If you disagree with the decision on your claim, you (or your authorized representative) may file a written appeal with the 238 applicable claims administrator. For a list of claims administrators, see Claims Administrators and Plan Numbers on page 255. For the disability (STD and LTD) plans, the appeal must be filed within 180 days after you receive the notice of adverse decision. For the Life, AD&D and Business Travel Accident plans, the appeal must be filed within 60 days after you receive the notice of adverse decision. You should include the reasons you believe the claim was improperly denied and all additional facts and documentation you consider relevant in support of your appeal. If you do not appeal on time, you may lose your right to file suit in a state or federal court, as you will not have exhausted your internal administrative appeal rights (which is generally a requirement before you can sue in state or federal court). For the disability plans, your appeal will not be reviewed by the individual who denied the initial claim or that person s subordinate. The reviewer will give the claim a fresh look and make an independent decision regarding the claim. If your claim was denied based on medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the field of medicine involved in your claim. The health care professional will not be the same person (or a subordinate of the person) who was consulted on the initial decision. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate.) If requested by the claimant, the claims administrator will also identify any medical or other experts whose advice was obtained in considering the original decision on your claim, whether or not the claims administrator relied on their advice.

239 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information For all non-health plan claims, the decision will consider all comments, documentation, records and other information you submit, even if they were not submitted or considered during the initial claim decision. Was submitted to, considered, or generated by the claims administrator in considering your claim, or Notice of Appeal Decision Your appeal will be decided within a reasonable amount of time after it is filed. If a voluntary appeals process or alternative dispute resolution is available under the plan, you will receive information about such procedures. For the disability (STD and LTD) plans, the claims administrator will provide notice of its decision within 45 days after the date you file the appeal. The claims administrator may extend the decision-making period for up to 45 days if special circumstances require extra time. You will be notified of the extension before the end of the first 45-day period. If your claim or appeal is denied based on a determination involving a medical judgment, you are entitled to an explanation of the scientific or clinical reasons for that determination free of charge upon request. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate.) For the Life, AD&D and Business Travel Accident plans, the claims administrator will provide notice of its decision within 60 days after the date you file the appeal. The claims administrator may extend the decision-making period for up to 60 days if special circumstances require extra time. You will be notified of the extension before the end of the first 60-day period. The notice of extension will indicate the special circumstances requiring an extension and the date by which the claims administrator expects to render the determination on review. Your Right to Information Upon request to the applicable claims administrator listed in Claims Administrators and Plan Numbers on page 255, and free of charge, you have a right to reasonable access to and copies of all documentation, records, and other information relevant to the claims administrator s denial of a claim. Information is relevant if it: Was relied upon in making the decision on your claim 239 Demonstrates compliance with the claims administrator s administrative processes for making claim decisions. See Your Rights and Privileges Under ERISA on page 248 for additional information on legal action you can take if you feel your right to a benefit has been improperly denied. Continuation of Health Care Coverage This section describes what happens to your benefits if you take an approved leave of absence or if you lose health coverage because of certain eligibility or employment-related events. Continuation Coverage During Leaves of Absence Family and Leaves of Absence Generally, if you take a leave of absence that qualifies as a family or medical leave under the Family and Leave Act of 1993 or applicable state law (collectively, FMLA leave ), health coverage (medical, dental, vision, and ) and Health Care Flexible Spending Account (Health Care FSA) for you and your eligible dependents may continue as long as you continue paying your portion of the cost of coverage during the leave.

240 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Your contributions, if any, will continue to be deducted from any short- or long-term disability payments and any requested paid time off payouts. During an unpaid FMLA leave, you may pay as you go on the same schedule that applied before your leave began. Payments will be made on an after-tax basis, if you are on unpaid FMLA leave. If you take a military leave, but your medical coverage is terminated, for instance, because you do not elect the extended coverage, upon reemployment you will be treated as if you had not taken a military leave when determining whether an exclusion or waiting period applies upon your reinstatement into the applicable plan. If you are participating in the Dependent (Day) Care Flexible Spending Account (FSA), your contributions will stop while you are on an FMLA leave. If you would like to participate in the Dependent (Day) Care FSA when you return from a leave, you must re-enroll within 30 days from your return-to-work date. Generally, no exclusions or waiting periods may be imposed upon reinstatement, except exclusions or waiting periods that would normally apply if you had not lost coverage due to your military leave. For additional information on FMLA leave, such as how to request a leave, your rights and obligations, and the impact on plan benefits, please refer to the Employee Leave of Absence Guide on Gapweb ( benefits or contact Employee Services. Military Leaves of Absence If you take a military leave of absence that qualifies as a leave under the Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA ), you may continue medical coverage for up to 24 months as long as you give advance notice (with certain exceptions) of the leave. If the entire length of the leave is 30 days or less, you will not be required to pay any more than the portion you paid before the leave. If the entire length of the leave is 31 days or longer, you may be required to pay up to 102% of the entire cost of the coverage. You can continue medical coverage for the lesser of 24 months, beginning on the date the absence begins, or the length of the leave. 240 Under circumstances in which COBRA continuation coverage rights also apply, an election for continuation coverage will be an election to take concurrent COBRA/USERRA medical coverage. For more information, see Continuation of Coverage Under COBRA on the following page. For additional information on military leave, such as how to request a leave, your rights and obligations, and the impact on plan benefits, see the Employee Leave of Absence Guide on Gapweb ( benefits or call the Leave and Administrator at 800.GAP Other Leaves of Absence Health benefits will continue for yourself and your eligible dependents during other leaves of absence such as pregnancy disability leave (PDL), parental bonding leave, or non-fmla medical leaves as long as you pay the required contributions during your leave. Refer to the Employee Leave of Absence Guide on Gapweb ( benefits or contact Employee Services. This guide will explain your options for benefits coverage while you are on leave.

241 Coordination of Benefits Continuation of Coverage Under COBRA Coordination of Benefits Rules Under a federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, employees and/or their dependents may be eligible to continue health plan coverage (called COBRA coverage ) at group rates. Health plan coverage available under COBRA includes the medical, dental, vision,, and Health Care Flexible Spending Account (Health Care FSA) plans. Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information COBRA coverage is available in certain instances, called qualifying events, where coverage under the plan would otherwise end. You may elect to continue coverage at your own expense on an after-tax basis when the coverage that you have through the plan ends. The coverage described below may change as permitted or required by changes in any applicable law. The following information is intended to inform you of your rights and obligations under the continuation coverage provisions of COBRA. In some states, state law provisions may also apply to the insurers and HMOs offering benefits under the plan. For more information, contact the COBRA administrator listed under Claims Administrators and Plan Numbers on page 255. You do not have to show that you are insurable to choose COBRA coverage. However, COBRA coverage is provided subject to your eligibility for coverage as described on the following page. Gap Inc. reserves the right to terminate your coverage retroactively if it s determined that you are ineligible under the terms of the plan. 241 Cost of COBRA Coverage You will be required to pay up to 102% of the cost of COBRA coverage. If your coverage is extended from 18 months to 29 months for disability, you will be required to pay up to 150% of the cost of COBRA coverage beginning with the 19th month of coverage. The cost of group health coverage periodically changes. If you elect COBRA coverage, the COBRA administrator will notify you of any changes in the cost. Premiums are established in a 12-month determination period and will increase during that period if the plan has been charging less than the maximum permissible amount, if the qualified beneficiary changes coverage level, or in the case of a disability extension. The initial payment for COBRA coverage is due 45 days from the date of your election. Thereafter, you must pay for coverage on a monthly basis. You have a grace period of 30 days. Contacting the COBRA Administrator If you have any questions about COBRA coverage or the application of the law, contact the COBRA administrator listed under Claims Administrators and Plan Numbers on page 255. You may also contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of regional and district EBSA offices are available through EBSA s website at

242 Coordination of Benefits Rules Obligation to Notify the COBRA Administrator You must notify the COBRA administrator in writing immediately if: Claims And Appeals Procedures Your marital status has changed Health Benefit Claims and Appeals You, your spouse or a dependent has changed addresses, or Coordination of Benefits Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information A dependent loses eligibility for dependent coverage under the terms of the plan. All notices and other communications regarding COBRA coverage and your health plans should be directed to the COBRA administrator. Who Is Eligible for COBRA If you are covered by the plan on the day before a qualifying event, you have the right to choose COBRA coverage if you lose coverage under the terms of the plan because of a reduction in your hours of employment or the termination of your employment (unless you are terminated because of your gross misconduct). If you are enrolled in the plan and do not return to work following a leave of absence qualifying under the Family and Leave Act (FMLA), the event that will trigger COBRA coverage is the date that you indicate you won t be returning to work following the leave or the last day of the FMLA leave period, whichever is earlier. If you are the spouse of an employee and you are covered by the plan on the day before the qualifying event, you are considered a qualified beneficiary. That means you have the right to choose COBRA coverage for yourself if you lose group health coverage under the terms of the plan for any of the following reasons: Your spouse dies Your spouse s employment is terminated (for reasons other than gross misconduct) or your spouse s hours of employment are reduced 242 You divorce or legally separate from your spouse (this includes a divorce or legal separation that occurs after the employee drops you from coverage, if the employee acted in anticipation of the divorce or legal separation), or Your spouse becomes entitled to Medicare (Part A, Part B, or both). If you are a child of an employee and you are covered under the plan on the day before the qualifying event, you are also considered a qualified beneficiary. This means you have the right to COBRA coverage if you lose coverage under the terms of the plan for any of the following reasons: The employee dies The employee s employment is terminated (for reasons other than the employee s gross misconduct) or the employee s hours of employment are reduced The employee becomes entitled to Medicare (Part A, Part B, or both), or You cease to be an eligible child under the plan. If the covered employee elects continuation coverage and then has a child (either by birth, adoption or placement for adoption) during that period of COBRA coverage, the new child is a qualified beneficiary. In accordance with the terms of the plan and the requirements of federal law, these qualified beneficiaries can be added to COBRA coverage by providing a written notice to the COBRA administrator of the new child s birth, adoption or placement for adoption at the address listed in Claims Administrators and Plan Numbers on page 255. This written notice should include information about the new child who will be receiving COBRA coverage. The COBRA administrator may ask for documentation supporting the birth, adoption, or placement for adoption of the new child.

243 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information If a qualified beneficiary fails to notify the COBRA administrator about a new child within 30 days of the birth, adoption or placement for adoption, COBRA coverage cannot be elected for the new child. Newly acquired eligible dependents (such as a spouse) won t be considered qualified beneficiaries, but may be added as dependents. Notify the COBRA administrator within 30 days if you acquire a new spouse and want to enroll them in COBRA coverage. COBRA-like Continuation of Coverage for Partners Although domestic partners and civil union partners are not qualified beneficiaries under COBRA, currently provides COBRA-like continuation coverage to partners and their children who were covered under the health plans when group coverage would otherwise have been lost. In the description of federal COBRA above, whenever the term: Spouse is used and wherever qualified beneficiary when referring to a spouse is used, the term partner as defined by the plan also generally applies Wherever the terms child or children are used, or wherever qualified beneficiary(ies) when referring to a child or children is used, the child/children of a partner also generally applies Wherever the term divorce is used, termination of partnership also generally applies, and Your Duties You must, in writing, inform the COBRA administrator of a divorce, legal separation or child s loss of dependent status under the plan, if you wish to preserve your right to elect COBRA coverage. You must provide notice within 30 days from the latest of (1) the date of the divorce, legal separation, or loss of dependent status; or (2) the date coverage is lost because of the event. Notice must be provided to the COBRA administrator on a form which can be obtained from the COBRA administrator. The notice should be completed and provided to the COBRA administrator at the address listed in Claims Administrators and Plan Numbers on page 255. The notice must identify the employee or qualified beneficiary requesting COBRA coverage and the qualifying event that gave rise to the individual s right to COBRA coverage. In addition, the employee or qualified beneficiary may be required to provide the COBRA administrator with documentation supporting the occurrence of the qualifying event. If you fail to notify the COBRA administrator within this 30-day period, the right to elect COBRA coverage will be lost. When the COBRA administrator is notified that one of these events has happened, the COBRA administrator will in turn notify you about your right to choose COBRA coverage. Wherever the term COBRA continuation coverage is used, COBRA-like continuation coverage also generally applies. However, be aware that certain HMOs may not allow continuation coverage for partners or the children of partners. Contact the HMO directly for specific information. 243

244 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information The COBRA Administrator s Duties Qualified beneficiaries will be notified of the right to elect COBRA coverage if they lose coverage under the terms of the plan because of any of the following events: The employee dies The employee s employment is terminated (for reasons other than the employee s gross misconduct) or the employee s hours of employment are reduced, or The employee becomes covered by Medicare (Part A, Part B, or both). Electing COBRA To elect or inquire about COBRA coverage, contact the COBRA administrator at the number listed in Claims Administrators and Plan Numbers on page 255. Under the law, you have 60 days to elect COBRA coverage measured from the date you would lose your active coverage because of one of the events described earlier, or, if later, 60 days after you receive notice of your right to elect COBRA coverage. An employee or family member who doesn t choose COBRA coverage within the time period described above loses the right to elect COBRA coverage. The employee and family members will be required to reimburse the plan for any claims mistakenly paid after the date coverage would normally have ended. If you choose COBRA coverage, your coverage will be the same coverage you had immediately before the event and the same coverage that is being provided to similarly situated beneficiaries. Similarly situated generally refers to a current employee or dependent who hasn t had a qualifying event. You will have the same opportunity to change coverage as similarly situated active employees have (e.g., at Open Enrollment 244 or if you gain a new dependent). This also means that if the coverage for similarly situated employees or family members is modified, your coverage will be modified. Plan Changes During COBRA While you or your dependents have COBRA coverage, there may be changes to the health plans, such as new deductibles, covered expenses or changes to your premiums. All changes will also apply to your COBRA coverage. Separate Elections Each qualified beneficiary has the right to elect COBRA coverage. This means that a spouse or eligible child can elect COBRA coverage even if the covered employee chooses not to. However, a covered employee or spouse may elect COBRA coverage on behalf of other qualified beneficiaries, and a parent or legal guardian may elect COBRA coverage on behalf of a minor child. Length of COBRA Coverage If elected, COBRA coverage begins on the date your active employee coverage ends. For dependents that no longer satisfy the requirements for dependent coverage, COBRA coverage begins on the first day of the month following the date of the qualifying event. However, coverage won t take effect unless COBRA coverage is elected as described previously and the required premium is received. The maximum duration of COBRA coverage depends on the reason you or your covered dependents are eligible for COBRA coverage. If group health coverage ends because of your termination of employment or reduction in hours, COBRA coverage may continue for you and your covered spouse and dependents for up to 18 months.

245 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves However, if termination of employment or reduction of hours follows Medicare enrollment, the COBRA coverage period for your spouse and eligible children is 36 months from the Medicare enrollment date or 18 months from the subsequent termination or reduction of hours, whichever is longer. COBRA coverage for your covered spouse and dependents may continue for up to 36 months if coverage would otherwise end because: You die You divorce or legally separate, or Coverage Under COBRA Your child loses eligibility for coverage. ERISA Rights and General Plan Provisions Note that COBRA coverage for the Health Care FSA ends at the end of the plan year in which the qualifying event occurs. Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Extension The 18 months of COBRA coverage may be extended to 29 months if an employee or covered family member is determined by the Social Security Administration to be disabled at any time during the first 60 days of an 18-month COBRA coverage period. This 11-month extension is available to all family members who have elected COBRA coverage due to the termination of employment or reduction in hours. It also applies to family members who aren t disabled. To benefit from the extension, the qualified beneficiary must provide the COBRA administrator with the disability determination within 60 days after the later of (1) the Social Security Administration s determination of disability; (2) the date on which a qualifying event occurs; or (3) the date coverage is lost because of the qualifying event. The notice of Social Security disability must also be furnished to the COBRA administrator before the end of the original 18-month COBRA coverage period. 245 During COBRA coverage, if the Social Security Administration determines that the qualified beneficiary is no longer disabled, the COBRA administrator must be informed within 30 days. The notice can be made by providing to the COBRA administrator a copy of the notice from the Social Security Administration, or by other written means. The notice must properly identify the qualified beneficiary who is no longer disabled and the date the notice of redetermination was received. The 11-month COBRA extension will end at the end of the month in which the redetermination notice from the Social Security Administration is received by the qualified beneficiary. Second Qualifying Event Extensions Your spouse and dependents may have additional qualifying events while they are covered by COBRA. These events can extend their 18- or 29-month continuation period to 36 months, but in no event will they have more than 36 months of COBRA measured from the first day of the month following the first qualifying event that originally allowed them to elect coverage. This extension may be available to the spouse and any eligible children receiving continuation coverage if the employee or former employee dies, gets divorced or legally separated or if the child stops being eligible under the plan. This only occurs if the additional event would have caused the spouse or child to lose coverage under the plan had the first qualifying event not occurred. The law requires a qualified beneficiary to notify the COBRA administrator if any of these additional qualifying events occur. This notice must be provided within 60 days from the latest of (1) the date of the second qualifying event; or (2) the date coverage would have been lost because of the event. Notice of the additional qualifying event must be provided to the COBRA administrator on the appropriate form, which may

246 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information be obtained from the COBRA administrator. The form should be returned to the COBRA administrator at the address listed in Claims Administrators and Plan Numbers on page 255. The notice must include information about the qualified beneficiary requesting additional COBRA coverage and the qualifying event that gave rise to the individual s right to additional COBRA coverage. In addition, the qualified beneficiary may be required to provide the COBRA administrator with documentation supporting the occurrence of the qualifying event. If a qualified beneficiary (or his/her representative) fails to provide the appropriate notice and supporting documentation, if required, to the COBRA administrator during the 60-day notice period, the qualified beneficiary won t be entitled to extended COBRA coverage. Early Termination of COBRA Coverage COBRA coverage will terminate before the expiration of the 18-, 29-, or 36-month period for any of the following reasons: no longer provides group health coverage to any of its employees, or The premium for COBRA coverage isn t paid on time (within the applicable grace period). You will be sent a termination notice to notify you of early termination of COBRA coverage due to the above events. COBRA coverage will also terminate early if: The qualified beneficiary becomes covered after the date COBRA coverage is elected under another group health plan that doesn t contain any applicable exclusion or limitation for any pre-existing condition of the individual 246 The qualified beneficiary first becomes entitled to Medicare after the date COBRA coverage is elected, or Coverage has been extended for up to 29 months due to disability, and the Social Security Administration has made a final determination that the individual is no longer disabled. You are required to inform the COBRA administrator if you experience the above events. Trade Act of 2002 Second COBRA Election The Trade Act of 2002 created a second COBRA election for workers displaced by the impact of foreign trade and who are determined to be trade adjustment assistance (TAA)-eligible individuals. TAA-eligible individuals who declined COBRA when they were first eligible can elect COBRA within 60 days of the first day of the month in which they become TAA-eligible individuals. Nonetheless, this election may not be made more than six months after the date the TAA individual s group health plan coverage ended. If you have questions about your extended ability to elect COBRA coverage, you may call the United States Department of Labor, Employment and Training Administration, Office of Trade Adjustment Assistance toll free at More information about the Trade Act of 2002 is also available at tradeact/directives/107pl210.cfm. COBRA and FMLA Taking an approved FMLA leave isn t considered a qualifying event that would make you eligible for COBRA coverage. However, a COBRA qualifying event occurs if: You, your spouse, or your dependent is covered by the plan on the day before the leave begins (or you or your dependent becomes covered during the FMLA leave), and

247 Coordination of Benefits Rules You do not return to employment at the end of the FMLA leave or you terminate employment during your leave. Claims And Appeals Procedures COBRA coverage begins on the earlier of the following: Coordination of Benefits Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves When you inform the COBRA administrator that you are definitely not returning to work, or The end of the leave, if you do not return to work. HIPAA Certificate of Coverage When your COBRA coverage ends, you will automatically receive a certificate of coverage that: Coverage Under COBRA Confirms that you had whatever medical coverage you continued through COBRA, and ERISA Rights and General Plan Provisions States how long you were covered. Your Rights and Privileges Under ERISA If you become eligible for other medical coverage that excludes or delays coverage for certain pre-existing conditions, you can use this certificate to receive credit against the new plan s pre-existing condition limit for the time you were covered by the plan. General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information In addition to the certificate you receive automatically, you also may request an additional certificate from your medical plan by contacting them at the number listed in Claims Administrators and Plan Numbers on page 255. State Continuation of Coverage Rights Many states require insured medical plans and HMOs to provide extended health coverage to participants after their group coverage ends. These rights generally supplement federal COBRA, or provide continuation coverage to those who are ineligible for federal COBRA coverage. Because the laws vary from state to state, you should review the benefit plan summaries on Gapweb ( benefits and/or contact your medical plan directly to learn about any rights you may 247 have under state law. That way, you can meet any election and premium requirements necessary to take advantage of these state continuation coverage rights. Even if you are not enrolled in an insured medical plan or HMO, please review the section below as it may impact your enrollment decisions when you initially enroll, or at Open Enrollment. For example, you may want to switch from a self-funded medical plan to an insured medical plan or HMO during Open Enrollment in order to take advantage of these rights. Participants in California HMOs or Insured Plans Cal-COBRA Extended Continuation Coverage. Insured medical plans and HMOs regulated in California are required to offer COBRA-qualified beneficiaries who are enrolled in their plans and exhaust their 18 or 29 months of federal COBRA coverage an additional period of continuation coverage. Qualified beneficiaries must be offered up to a total of 36 months of combined federal and Cal-COBRA, starting from the date federal COBRA began. Note that Cal-COBRA does not apply to s vision, dental or. Contact your California insured medical plan or HMO directly for further information on Cal-COBRA. The plan will be able to supply you with further information regarding how to enroll, deadlines for enrollment, premium amounts, deadlines for submitting premiums and how Cal-COBRA might be beneficial to you. Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or denial of coverage.

248 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Conversion Privileges When medical coverage ends for you or any dependent covered by an insured medical plan, you may be able to apply for an individual medical policy from that plan. You are not eligible for another group health plan, Medicare or Medicaid, and do not have any other health insurance coverage. The coverage and benefits may not be the same as those provided by the medical plans, and the rates will vary depending on your age, where you live, and other factors. For additional information on your conversion rights, you should check with your HMO or insurance carrier, or refer to the appropriate benefit summary. Your Rights and Privileges Under ERISA Note: You may also be able to purchase an individual policy from a different HMO or insurance carrier, other than the carrier for a medical plan that provides the group coverage that you are losing. Conversion coverage may be available for other benefits. Refer to your benefit summary for more information. Right to Individual Health Coverage Under HIPAA, if you are an eligible individual, you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without a pre-existing condition exclusion. To be an eligible individual, you must meet the following requirements: You have had coverage for at least 18 months without a break in coverage of 63 days or more Your most recent coverage was under a group health plan Your most recent coverage was not terminated because of fraud or non-payment of premiums ERISA Rights and General Plan Provisions As a participant in the plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). The benefit plans maintained by that are governed by ERISA include those described in this SPD, except for the Dependent (Day) Care Flexible Spending Account Plan (a non-erisa plan). ERISA provides that all plan participants have the right to: Receive Information About Your Plan and Benefits You can examine, without charge, at the plan administrator s office and at other specified locations (such as worksites) all documents governing the plan. This includes insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration (EBSA). By submitting a written request to the plan administrator, you can obtain copies of documents governing the operation of the plan, including insurance contracts, copies of the latest annual report (Form 5500 Series), and an updated summary plan description. (The administrator can charge you a reasonable fee for the copies.) You should receive a summary of the plan s annual financial report. The plan administrator is required by law to provide a copy of this summary annual report to each plan participant. You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision), and 248

249 Coordination of Benefits To request the above information, send a written request to: Coordination of Benefits Rules Benefits Department Plan Administrator 2 Folsom Street San Francisco, CA Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Continue Group Health Plan Coverage You can continue health care coverage (medical, vision, dental,, and Health Care FSA) for yourself, spouse and/or your dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. For more details, review the COBRA information in this SPD, the relevant benefit summary, and the COBRA notice that was mailed to your home. If you need another copy of these documents, call Employee Services at , ext Reduce or Eliminate Exclusionary Periods If you have creditable coverage from another medical plan, you are entitled to a reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group medical plan. Your group medical plan or health insurance issuer should provide a certificate of creditable coverage, free of charge, in the following instances: When you lose coverage under the plan When you become entitled to elect COBRA continuation coverage When your COBRA continuation coverage ends If you request it before losing coverage, or If you request it up to 24 months after losing coverage. 249 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. These people, called fiduciaries of the plan, have a duty to operate your plan prudently and in the interest of you and other plan participants and beneficiaries. No one, including, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right (within certain time schedules) to: Know why this was done Obtain copies of documents relating to the decision without charge, and Appeal any denial. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive your copies 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. After exhausting your appeal rights, you may file suit in a state or federal court if you have a claim for benefits which is denied or ignored, in whole or in part. After exhausting your appeal rights, you may file suit in a federal court if you disagree with the plan s decision or lack thereof concerning the qualified status of a medical child support order.

250 Coordination of Benefits Rules You may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court if: Claims And Appeals Procedures Plan fiduciaries misuse the plan s money, or Health Benefit Claims and Appeals You are discriminated against for asserting your rights. Coordination of Benefits Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information 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 your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA or need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C or You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at EBSA (3272) or on the internet at General Plan Provisions Acts of Third Parties When you or your covered dependent ( you ) are injured or become ill because of the alleged to have caused or who caused actions or alleged to have caused or who caused inactions of a third party, the plan may cover your eligible health care (medical and dental) expenses. However, to receive coverage, 250 you must notify the plan, and you must follow special plan rules. This section describes the plan s procedures with respect to subrogation and right of recovery. Subrogation means that if an injury or illness is someone else s alleged or who caused fault, the plan has the right to seek expenses it pays for that illness or injury directly from the alleged or at-fault party or any of the sources of payment listed later in this section. A right of recovery means the plan has the right to recover such expenses indirectly out of any payment made to you by the alleged or at-fault party or any other party related to the illness or injury. By accepting plan benefits to pay for treatments, devices, or other products or services related to such illness or injury, you agree that the plan: Has a first priority right to receive payment on any claim against a third party before you receive payment from that third party. Further, the plan s first priority right to payment is superior to any and all claims, debts or liens asserted by any medical providers, including but not limited to hospitals or emergency treatment facilities, that assert a right to payment from funds you recover from a third party. Has an equitable lien on any and all monies paid (or payable) to you or for your benefit by any responsible party or other recovery to the extent the plan paid benefits for such sickness or injury May appoint you as constructive trustee for any and all monies paid (or payable to) you or for your benefit by any responsible party or other recovery to the extent the plan paid benefits for such sickness or injury, and

251 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information May bring an action on its own behalf or on the covered person s behalf against any responsible party or third party involved in the sickness or injury. The plan may file suit in your name and take appropriate action to assert its rights under this section. The plan is not required to pay you part of any recovery it may obtain from a third party, even if it files suit in your name. If you (or your attorney or other representative) receive any payment from the sources listed later in this section through a judgment, settlement or otherwise when an illness or injury is a result of a third party, you agree to place the funds in a separate, identifiable account and that the plan has an equitable lien on the funds, and/or you agree to serve as a constructive trustee over the funds to the extent that the plan has paid expenses related to that illness or injury. This means that you will be deemed to be in control of the funds. You must pay the plan back first, in full, out of such funds for any health care expenses the plan has paid related to such illness or injury. You must pay the plan back up to the full amount of the compensation you receive from the responsible party, regardless of whether your settlement or judgment says that the money you receive (all or part of it) is for health care expenses. Furthermore, you must pay the plan back regardless of whether the third party admits liability and regardless of whether you have been made whole or fully compensated for your injury. No socalled Fund Doctrine or Common Fund Doctrine or Attorney s Fund Doctrine shall defeat this right. If any money is left over, you may keep it. Additionally, the plan is not required to participate in or contribute to any expenses or fees (including attorney s fees and costs) you incur in obtaining the funds. 251 The plan s sources of payment through subrogation or recovery include (but are not limited to) the following: Money from a third party that you, your guardian, or other representatives receive or are entitled to receive Any constructive or other trust that is imposed on the proceeds of any settlement, verdict, or other amount that you, your guardian or other representatives receive Any equitable lien on the portion of the total recovery which is due the plan for benefits it paid, and Any liability or other insurance (for example, uninsured motorist, underinsured motorist, medical payments, workers compensation, no-fault, school, homeowners, or excess or umbrella coverage) that is paid or payable to you, your guardian or other representatives. As a plan participant, you are required to: Cooperate with the plan s efforts to ensure a successful subrogation or recovery claim, including setting funds aside in a particular account. This also includes doing nothing to prejudice the plan s subrogation or recovery rights outlined in this SPD. The plan s rights will not be reduced due to your own negligence. Notify the plan within 30 days of the date any notice is given by any party, including an attorney, of your intent to pursue or investigate a claim to recover damages or obtain compensation due to sustained injuries or illness Provide all information requested by the plan, the claims administrator or their representatives, or the plan administrator or its representatives Appear at medical examinations and legal proceedings, such as depositions or hearings, as requested, and

252 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Execute and deliver such documents as may be required and do whatever else is needed to secure the plan rights. Made in error Your failure to cooperate with the plan or its agents is considered a breach of contract. As such, the plan may terminate your plan participation, take legal action against you, and/or offset your future benefits for the value of benefits advanced in the event that the plan does not recover, if you do not provide the information, authorizations, or otherwise cooperate in a manner that the plan considers necessary to exercise its rights or privileges under the plan. Advanced during the time period of meeting the deductible, or If the subrogation provisions in these Acts of Third Party provisions conflict with subrogation provisions in an insurance contract governing benefits at issue, the subrogation provisions in the insurance contract will govern. If the right of recovery provisions in these Acts of Third Party provisions conflict with right of recovery provisions in an insurance contract governing benefits at issue, the right of recovery provisions in the insurance contract will govern. Require that the overpayment be returned when requested, or All plan rights under this section remain enforceable against the heirs and estate of any covered person. The provisions of this section apply to the parents, guardian, or other representative of a covered child who incurs a sickness or injury caused by a third party. If a third party causes you to suffer a sickness or injury while you are covered under this plan, the provisions of this section continue to apply, even after you are no longer a covered person. The plan has the authority and discretion to resolve all disputes regarding the interpretation of the language stated herein. Right of Recovery The plan has the right to recover benefits it has paid on you or your dependent s behalf that were: 252 Due to a mistake in fact Advanced during the time period of meeting the out-of-pocket maximum. Benefits paid because you or your dependent misrepresented facts are also subject to recovery. If the plan provides a benefit for you or your dependent that exceeds the amount that should have been paid, the plan will: Reduce a future benefit payment for you or your dependent by the amount of the overpayment. The plan has the right to recover benefits it has advanced by: Submitting a reminder letter to you or a covered dependent that details any outstanding balance owed to the plan, and Conducting courtesy calls to you or a covered dependent to discuss any outstanding balance owed to the plan. No Estoppel of Plan No person is entitled to any benefit under the plan or any benefit plan except and to the extent expressly provided under the plan or the benefit plan. The fact that payments have been made from the plan or benefit plan in connection with any claim for benefits under the plan or benefit plan does not (a) establish the validity of the claim; (b) provide any right to have such benefits continue for any period of time; or (c) prevent the plan or benefit plan from recovering the benefits paid to the extent that the plan administrator ultimately determines that there in fact was no right to payment of the benefits under the plan or benefit plan.

253 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers Plan Administration Information Thus, if a benefit is paid to a person under the plan or benefit plan and it is thereafter determined by the plan administrator that such benefit should not have been paid (whether or not attributable to an error by such person, the plan administrator or any other person), then the plan administrator may take such action as it deems necessary or appropriate to remedy such situation, including without limitation, by deducting the amount of any such overpayment from any succeeding payments to or on behalf of such person under the plan or benefit plan or from any amounts due or owing to such person by a participating employer or under any other plan or arrangement benefiting the employees or former employees of, or otherwise recovering such overpayment from whoever has benefited from it. No Guarantee of Employment By adopting and maintaining the plan and these benefit plans, Gap Inc. has not entered into an employment contract with any person. Nothing in the plan documents gives any employee the right to be employed by or to interfere with s right to discharge any plan participant at any time. Similarly, these plans do not give the right to require any plan participant to remain employed by, or to interfere with an employee s right to terminate employment with Gap Inc. at any time. Assignment of Benefits Except as otherwise may be required under a qualified medical child support order (QMCSO) which assigns benefits to a child who has been designated as an alternate recipient in accordance with the plan s QMCSO procedures; by applicable law; or as otherwise specifically provided in the plan or plan material; neither you nor your dependents nor your beneficiaries may assign, sell, transfer, pledge, charge, encumber, or allow the attachment or alienation of any amount payable to you, your spouse, dependents, or any beneficiaries at any time under the 253 plan. Any attempt to so assign, sell, transfer, pledge, charge, encumber, or allow the attachment or alienation of any such amount, whether presently or thereafter payable, will be void. If you, your spouse, dependent, or beneficiary attempt to alienate, sell, transfer, assign, pledge, attach, charge, or otherwise encumber any amount payable under the plan, or any part thereof, or if a person s bankruptcy or other event would cause amounts payable under the plan to be subject to the person s debts or liabilities, then the plan administrator may direct that such amount be withheld and that the same or any part thereof be paid or applied to or for the benefit of you, your spouse (as defined under federal law) or your dependents, or any of them in such manner and proportion as the plan administrator may deem proper. Such payment shall constitute a complete discharge of the liability of the benefit plan,, and the plan. However, you may request and authorize the plan administrator or the appropriate insurance company or service provider to pay benefits directly to the hospital, physician, dentist or other person furnishing services or supplies covered under the applicable benefit plan and any such payment, if made, shall constitute a complete discharge of the liability of the benefit plan,, and the plan. If the plan administrator determines that an underpayment of benefits has been made, the plan administrator shall take such action as it deems necessary or appropriate to remedy such situation. However, in no event shall interest be paid on the amount of any underpayment. Amendment and Termination of the Plan reserves the right, in its sole discretion, to modify, change, revise, amend, or terminate the plan and any health benefit program sponsored under the plan at any time, for any reason,

254 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Claims Administrators and Plan Numbers and without prior notice as it relates to the provision of benefits for any active or former employee, including any beneficiary or dependent of such active or former employee, in whole or in part. s right to amend or terminate the plan includes, but is not limited to, changes in the eligibility requirements, premiums, or other employee payments charged, benefits provided, and termination of all or a portion of the coverage provided under the plan. Administration of Plan, as plan administrator, has absolute discretionary authority to control and manage the operation and administration of the plan, to correct errors, and to construe and interpret the provisions under the plan, including but not limited to determinations regarding eligibility and benefits. The plan administrator may delegate duties and responsibilities as it deems appropriate to facilitate the day-to-day administration of the plan and, unless the plan administrator expressly provides to the contrary, any such delegation will carry with it the plan administrator s full discretionary authority to accomplish the delegation. The Company s Contributions may fund benefits provided under the plan in whole or in part. Contributions made by will be made at the times and in the manner determined by and are subject to change. No assets will be set aside for the purpose of providing benefits under the plan. will pay benefits (including any insurance premiums necessary for the purchase of benefits) required under the plan out of its general assets. In no event shall have any obligation to fund self-funded benefits provided under the plan in advance of the date that such benefits are payable or pre-pay the premiums or other fees required in order to provide insured benefits under the plan. s contributions, if any, may be paid directly to the insurance company or other provider under the plan. Such payment shall constitute a complete discharge of the liability of the plan. No participant, dependent, or beneficiary shall have any right to, interests in or claim for any particular assets of, the plan, any benefit program or any underlying contract, trust or other funding vehicle. Plan Administration Information 254

255 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Plan Information Claims Administrators and Plan Numbers Please direct all claims and claim appeals to the claims administrator for the benefit plan in which you are enrolled. Benefit Plan Overview of Procedures Non-Health Benefit Claims and Appeals HRA, HRA Plus, Hawaii PPO, Out-of-Area Group No Continuation Of Health Care Coverage ERISA Rights and General Plan Provisions UnitedHealthcare Services, Inc. P.O. Box Salt Lake City, UT Self-insured Kaiser HMO Northern California Policy No Your Rights and Privileges Under ERISA General Plan Provisions Type of Funding Coverage During Leaves Coverage Under COBRA Claims Administrator (Claims and Referrals) Claims Administrators and Plan Numbers Kaiser Permanente Claims Administration Department P.O. Box 7004 Downey, CA Plan Administration Information (Claims and Referrals) Plan Information Insured Kaiser Permanente Claims Administration Department P.O. Box Oakland, CA Kaiser HMO Southern California Policy No Insured Kaiser HMO Hawaii Policy No /11 Insured Kaiser Permanente 711 Kapiolani Blvd. Honolulu, HI (Oahu) (Neighbor Islands) 255

256 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Benefit Plan Claims Administrator Type of Funding MVP HMO Policy No MVP Health Care P.O. Box 2207 Schenectady, NY Insured Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals MCS Puerto Rico Policy No Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Cigna Global Health Benefits Policy No A Benefits Abroad (MBA) Policy No B Plan Information Claims Administrators and Plan Numbers Plan Administration Information Insured Cigna Global Health Benefits P.O. Box Wilmington, DE Your Rights and Privileges Under ERISA General Plan Provisions Insured Card Systems of Puerto Rico P.O. Box San Juan, PR Insured Cigna Global Health Benefits P.O. Box 1511 Wilmington, DE USA Prescription Drug Benefits (HRA, HRA Plus, Hawaii PPO, Out-of-Area plan participants only) Express Scripts Group GAPINCRX Self-insured Express Scripts P.O. Box Lexington, KY Dental Self-insured Delta Dental P.O. Box Sacramento, CA Delta Dental Group No. 600 Delta Dental Plus Group No deltadentalins.com/gap 256

257 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Benefit Plan Claims Administrator Type of Funding VSP P.O. Box Sacramento, CA Insured Vision Vision Vision Plus (EAP) Life Resources Insured Magellan Health Services Health Care FSA Health Care FSA Group No Self-funded UnitedHealthcare Services, Inc. FSA Unit P.O. Box El Paso, TX Your Rights and Privileges Under ERISA General Plan Provisions Plan Information Dependent (Day) Care FSA Claims Administrators and Plan Numbers Dependent (Day) Care FSA Group No Self-funded UnitedHealthcare Services, Inc. FSA Unit P.O. Box El Paso, TX Plan Administration Information Life Insurance Insured Minnesota Life 400 Robert Street North St. Paul, Minnesota, Basic Life Supplemental Life Policy No G

258 Coordination of Benefits Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Benefit Plan Accidental Death & Dismemberment (AD&D) Policy No G Continuation Of Health Care Coverage Coverage During Leaves Coverage Under COBRA ERISA Rights and General Plan Provisions Your Rights and Privileges Under ERISA Insured Short-Term (STD) Policy No. FLK STD Plus Policy No. FLK Sedgwick Claims Management Services Long-Term (LTD), LTD Plus Policy No. FLK CIGNA Group Insurance Self-funded Insured Business Travel Accident Business Travel Accident (BTA) ABL Life Insurance Company Of North America 400 North Brand Blvd Glendale CA Insured Intake Phone: (English) (Spanish) Plan Information Plan Administration Information Minnesota Life 400 Robert Street North St. Paul, Minnesota, General Plan Provisions Claims Administrators and Plan Numbers Type of Funding Overview of Procedures Non-Health Benefit Claims and Appeals Claims Administrator Accidental Death & Dismemberment COBRA Administrator ADP COBRA Services 500 Windward Parkway Alpharetta, GA

259 Coordination of Benefits Plan Administration Information Coordination of Benefits Rules Claims And Appeals Procedures Health Benefit Claims and Appeals Overview of Procedures Non-Health Benefit Claims and Appeals Continuation Of Health Care Coverage Coverage During Leaves Official Plan Names/ Health and Life Plan: Plan 502 Numbers Plan: Plan 504 Employer/Plan Sponsor 2 Folsom Street San Francisco, CA Employer I.D Number Type of Plan The benefit programs are welfare benefit plans which include medical, dental, vision, health care flexible spending account, employee assistance plan, short term disability, long term disability, life, business travel accident, and accidental death and Coverage Under COBRA dismemberment benefits. ERISA Rights and General Plan Provisions Type of The benefit programs are provided under both self-funded and insured arrangements. The insured plans (which include Administration/ HMOs) are provided under group contracts between and the carriers (including HMOs). is responsible for Your Rights and Privileges Under ERISA Insurance Issuers determining eligibility for benefits, the amount of any benefits payable and for prescribing the claims procedures for the plan. Plan Funding The insured arrangements are paid by insurance policies. The benefits and other plan costs (such as administrative costs) for General Plan Provisions Plan Information Claims Administrators and Plan Numbers the self-funded programs are paid from the general assets of the Company. Plan Administrator Benefits Department 2 Folsom Street Plan Administration Information San Francisco, CA Employee Services: , ext Claims Administrator See previous pages Agent for Service of Legal Process Corporate Counsel 2 Folsom Street San Francisco, CA Plan Year Begins July 1 and ends June 30 Contribution Sources Employer and employee contributions 259

260 Contact Information For details about your benefits, please refer to the specific sections in this SPD or to the benefits summaries on Gapweb ( benefits > select U.S. Full-Time Benefits. Or, call the appropriate number listed below: For Questions about Contact At and Prescription Drug Coverage HRA and HRA Plus Out-of-Area Hawaii PPO UnitedHealthcare Services, Inc Kaiser HMO (California) Kaiser California Kaiser HMO (Hawaii) Kaiser Hawaii (Oahu) (Neighbor Islands) MCS Plan (Puerto Rico) Card Systems MVP HMO (Fishkill, NY) MVP Health Care Express Scripts Delta Dental VSP Cigna Global Health Benefits (CGHB) (if dialing internationally, use that country s AT&T access code), or (reverse charges accepted) Dental Dental and Dental Plus Vision Vision and Vision Plus Cigna Global Health Benefits 260

261 For Questions about Contact At Magellan Health Services Health Care FSA and Dependent (Day) Care FSA UnitedHealthcare Services, Inc Health Care Spending MasterCard UnitedHealthcare Services, Inc (EAP) EAP (FSAs) Life and Accidental Death & Dismemberment (AD&D) Life Insurance and AD&D Minnesota Life Short-Term (STD) and LOA Sedgwick Claims Management Services (Sedgwick CMS) Long-Term (LTD) CIGNA Cancer Care Support Program (for UnitedHealthcare participants) Alere COBRA ADP Benefit Services Workers Compensation Risk Management , ext Health Care Claims and Clinical Support Your HealthCare Advocate 866.GAP.3211 and Leave of Absence (LOA) Other For general questions, please contact Employee Services at , ext

262 Index A B C D E F G H I J K L M N O P Q R S T U V W X Y Index A abortion (family planning), 23, 36, 45, 66 accelerated benefit (life insurance), 171 accidental death & dismemberment insurance (AD&D), 174 airbag benefit, 175 beneficiary designation, 179 benefit amounts, 174 brain damage benefit, 176 child care benefit, 177 child dismemberment double benefit, 177 claim appeal, 237 coma benefit, 176 common accident benefit, 177 description of coverage, 174 disappearance benefit, 176 education benefit, 177 exclusions, 178 exposure benefit, 177 extended dependents insurance benefit, 178 file a claim, 180 options, 174 portability, 179 rehabilitative physical therapy benefit, 177 seatbelt benefit, 177 spouse or domestic partner training benefit, 178 what s not covered, 178 Accredo (specialty pharmacy), 123 actively-at-work (active service) provision accidental death & dismemberment insurance (AD&D), 9, 179 disability insurance, 9 life insurance, 9, 171 acupuncture, 23, 36, 44, 60 adoption assistance (EAP), 149 ADP Benefit Services (COBRA), 258, 261 adult/elder services (EAP), 150 airbag benefit (AD&D), 175 alcoholism/substance use disorder treatment, 25, 37, 46, 58, 80, 86, 96, 99, 101, 149, 156, 189 Alere (Cancer Care Support Program), 61, 261 alternative treatments, 84 ambulance services, 23, 36, 44, 60, 61, 95, 98, 101, 103 appeals health benefit claims, 229 non-health benefit claims, 237 assignment of benefits, 253 authorized representative, 229, 237 autism (neurobiological disorders), 58, 72, 106 B beneficiaries accidental death & dismemberment insurance (AD&D), 174, 179 Business Travel Accident (BTA) insurance,

263 A B C D E F G H I J K L M N O P Q R S T U V W X Y designation, 7 life insurance, 171 benefits claims appeal denial, 232, 238 filing (see claims, filing) benefits coordination, 225 benefits eligibility changing positions, 8, 11 coverage effective date, 8 eligible dependents, 2 eligible employees, 2 Hawaii employees, 9 losing eligibility, 15 while on a leave of absence, 218 benefits enrollment, default coverage, 5 designating beneficiaries, 7 enrollment deadline, 7 HIPAA special enrollment, 6, 12 how to enroll, 5 late enrollment (life insurance), 7 life events, 205 making changes, 10 Open Enrollment, 5, 10 when coverage ends, 15 benefits while you travel, 194 Business Travel Accident (BTA) insurance, 197 dental and vision, 196 medical, 194 International SOS plan, 203 Benefits Abroad (MBA), 200 birth control (family planning), (see contraception) brand-name drugs, 96, 99, 102, 103, 119, 129 breast pump coverage (preventive care), 23, 35, 43, 76, 156 C Cancer Care Support Program, 61, 261 Cancer Resource Services, 61, 62 cardiac rehabilitation (rehabilitation services), 78, 156 certificate of prior health care coverage, 247, 249 child care accidental death & dismemberment insurance (AD&D), 177 Dependent (Day) Care FSA, 161 child life insurance, 170 chiropractic care (spinal treatment), 23, 36, 44, 80, 101 Cigna Global Health Benefits, 147, 200, 256, 260 Cigna (Long-Term ), 182, 186, 190, 258, 261 claims, appealing adverse decisions health benefit claims, 229 concurrent care decisions, 231 external review, 234 post-service claims, 231 pre-service claims, 230 urgent care claims, 230 non-health benefit claims,

264 A B C D E F G H I J K L M N O P Q R S T U V W X Y claims, filing accidental death & dismemberment insurance (AD&D), 180 Business Travel Accident (BTA) insurance, 199 dental plans, 137, 229 Dependent (Day) Care FSA, 166 disability plans, 190 Health Care FSA, 158, 229 life insurance, 237 Benefits Abroad (MBA), 201 prescription drug plan, 128, 229 UnitedHealthcare medical plans HRA and HRA Plus, 31, 229 Hawaii PPO, 50, 229 Out-of-Area, 40, 229 vision plans, 145, 229 clinical trial, 57, 62, 106, 135 co-insurance, definition of, 107 colonoscopy preventive care, 76 scopic procedures (diagnostic), 79 coma benefit (AD&D), 176 confirmation statement, 6 Congenital Heart Disease (CHD) services, 62 Consolidated Omnibus Budget Reconciliation Act (COBRA), 241 changes, 244 coverage, 241 cost, 241 disability extension, 245 duration, 244 electing COBRA, 244 eligibility, 242 HIPPA certificate of coverage, 247 notification, 241, 243 second qualifying events, 245 termination, 246 contact lenses, 142, 153 continuation of health care coverage (while on a) family and medical leave, 239 military leave, 240 other leave of absence, 240 contraception (family planning), 18, 23, 35, 43, 66, 75, 99, 126 conversion (life insurance and AD&D), 173 coordination of benefits, 225 co-pay, definition of, 49, 129 cosmetic surgery, 88, 102, 156, 185 counseling EAP, 149 nutritional, 73 coverage continuation (COBRA), 241 coverage effective date, 8 custodial care, 90, 108 D death benefits (AD&D), 174 deductible, definition of, 108 Delta Dental, 131, 256,

265 A B C D E F G H I J K L M N O P Q R S T U V W X Y denial of claims (appeals), 228 dental accident, 63, 134 dental plans, 131 basic services, 133 benefits while you travel, 196 claims appeal, 232 coverage, 131 deductible, 132 diagnostic services, 132 exclusions, 135 filing a claim, 137 major services, 133 maximum benefit per plan year, 132 myofascial pain dysfuntion (MPD), 134 orthodontia, 134, 137 pre-determination of benefits, 132 pregnancy benefit, 132 prescription drugs, 134 preventive services, 132 providers, 131 Reasonable & Customary (R&C) limits, 140 second opinions, 136 temporomandibular joint disorder (TMJ), 134 Dependent (Day) Care Flexible Spending Account (FSA), 161 contribution limits, 163 eligible expenses, 164 enrollment, 162 filing a claim, 166 Health Care Spending MasterCard, 165 ineligible expenses, 165 qualifying individuals, 161 reimbursement, 166 special rules for highly compensated employees, 163 tax savings, 161, 166 dependent eligibility, 2 diabetes management program, 55 diabetes services, 64 disability Long-Term, 186 Short-Term, 182 disability earnings, 187 disappearance (AD&D), 176 disease and condition management services, 54 divorce (COBRA continuation), 242 doctor office visits, 23, 35, 44, 73, 95, 98, 100, 103 domestic partner coverage, 2 imputed income, 3 drug abuse treatment (substance abuse), 25, 37, 46, 58, 80, 86, 96, 99, 101, 149, 156, 189 drugs, prescription, 96, 99, 102, 103, 117 durable medical equipment, 23, 36, 44, 58, 64, 95,

266 A B C D E F G H I J K L M N O P Q R S T U V W X Y E EAP, 149 eligibility (benefits), 2 changing positions, 8 COBRA, 242 coverage effective date, 8 dependents, 2 full-time employees, 8 Hawaii employees, 9 losing eligibility, 15 while on leave of absence, 239 eligible dependents children, 3 partner, 2 spouse, 2 emergency health services, 65 emergency/urgent care, 65, 83 (EAP), 149 enrollment (benefits) default coverage, 5 designating beneficiaries, 7 enrollment deadline, 5 HIPAA special enrollment, 6, 12 how to enroll, 5 late enrollment (life insurance), 7 life events, 205 making changes, 10 Open Enrollment, 5, 10 when coverage ends, 15 enteral feedings, 66 equipment, medical, 23, 36, 44, 58, 64, 95, 98, 101 ERISA rights, 248 evidence of insurability (EOI) (life insurance), 7, 168, 169, 170, 171 exclusions (what s not covered) accidental death & dismemberment insurance (AD&D), 178 alternative treatments, 84 Business Travel Accident (BTA) insurance, 198 comfort and convenience, 84 cosmetic procedures (physical appearance), 88 dental, 135 Dependent (Day) Care FSA, 165 (EAP), 151 experimental, investigational or unproven services, 85, 135 foot care, 85, 102 gender identity disorder, 85 general medical, 90 Health Care FSA, 156 hearing, 89 infertility, 88 jawbone surgery, 86 Long-Term, 189 medical supplies and appliances, 86 mental health/substance use disorder, 86 nutrition and health education, 87 pregnancy and infertility, 88 prescription drugs,

267 A B C D E F G H I J K L M N O P Q R S T U V W X Y Short-Term, 184 transplants, 89 vision, 89 expatriate health, 147 medical plan notices, 187 experimental, investigational or unproven services dental, 135 UnitedHealthcare medical plans, 85 exposure (AD&D), 177 Express Scripts, 117, 256, 260 external review, 234 eye and vision care, 141 benefits while you travel, 196 coordination of benefits, 144 discounts, 143 exclusions, 143 eye exam, 142 filing a claim, 145 filing a complaint, 145 glasses and contacts, 141, 142 laser vision correction, 144 low vision benefit, 144 F family planning, 23, 36, 45, 66, 95, 98 financial services (EAP), 150 flexible spending accounts (FSAs) Dependent (Day) Care FSA, 161 Health Care FSA, 153 foot orthotics, 24, 36, 45, 66 formulary, 119 G Benefits Department, 259 Employee Services, 259 Leave of Absence and Administrator, 1 Gapweb, 1 gender identity disorder treatment, 24, 36, 45, 66 generic drugs definition of, 129 generic substitution, 119 gynecological exam (see women s preventive health services) H Hawaii PPO plan, 43 claims appeal, 52, 232 co-insurance, 49 co-pays, 49 coverage while traveling abroad, 49 covered services, 43, 60 deductible, 43, 49 exclusions, 84 filing a claim, 50 ID cards, 47 out-of-pocket maximum, 50 paying for care,

268 A B C D E F G H I J K L M N O P Q R S T U V W X Y prescription drug coverage, 117 preventive services, 43, 75 providers, 47 HC-5 requirement (Hawaii), 9 Health Care Flexible Spending Account (FSA), 153 eligibility, 153 eligible expenses, 155 enrollment, 154 filing a claim, 158, 229 Health Care Spending MasterCard, 157 ineligible expenses, 156 leaves of absence, 155 qualified locations and providers, 158 special rules for highly compensated employees, 154 health coverage continuation (COBRA), 241 HealtheNotes, 56 health improvement plan, 53 Health Insurance Portability and Accountability Act (HIPAA) certificate of coverage, 247 privacy of health information, 105, 148 right to individual health coverage, 248 special enrollment for medical plan coverage, 6, 12 health reimbursement account (HRA), 19 eligible expenses, 27 filing a claim, 31 HRA dollar proration, 30 HRA dollars, 20, 28 overview, 28 paying providers, 31 requesting reimbursement, 33 using a Health Care FSA with an HRA, 30 Healthy Pregnancy Program, 54 hearing aids, 68, 156 hearing exam, 68, 95, 156 highly compensated employees (HCE) Dependent (Day) Care FSA, 163 Health Care FSA, 154 home health care, 24, 36, 45, 58, 68, 96, 98, 101, 161 homeopathic care (see alternative treatments) hospice care, 24, 36, 45, 58, 68, 96, 98, 150 hospital inpatient stays, 23, 36, 44, 69, 95, 98, 101, 103 maternity stays, 24, 37, 45, 74, 101, 104 outpatient (surgery), 23, 36, 44, 81, 95, 98, 101, 103 how to file a claim accidental death & dismemberment insurance (AD&D), 180, 237 dental, 137, 229 Dependent (Day) Care FSA, 166 Health Care FSA, 158, 229 life insurance, 237 Long-Term, 190, 237 Benefits Abroad (MBA), 201 prescription drugs, 128, 229 Short-Term, 190, 237 UnitedHealthcare medical plans, 31, 40, 50, 229 vision, 145,

269 A B C D E F G H I J K L M N O P Q R S T U V W X Y HRA and HRA Plus medical plans, 18 claims appeal, 229 co-insurance, 21, 29 coverage while traveling abroad, 28 covered services, 22, 60 deductible, 21, 29 exclusions, 84 filing a claim, 31 health reimbursement account (HRA), 19, 28 HRA dollars, 20, 28 ID cards, 26 out-of-pocket maximum, 29 paying for care, 28 prescription drug coverage, 117 preventive services, 18, 23, 75 providers, 26 I ID cards UnitedHealthcare medical plans, 26, 38, 47 immunizations, 23, 35, 43, 75, 95, 98, 100, 126 imputed income health benefits, 3 Long-Term, 186 Short-Term, 183 infertility services, 24, 36, 45, 58, 69, 79, 96, 101, 125 injections, 70, 95 International SOS Plan, 203 J jaw conditions, 86, 134, 135 K Kaiser medical plans Kaiser California HMO, 94 Kaiser Hawaii HMO, 97 L lab, X-ray and diagnostics (outpatient), 70 laser vision correction, 144 leaves of absence benefits while on, 218 legal services (EAP), 150 life event directory, 205 life insurance accelerated benefit, 171 actively-at-work provision, 171 basic life insurance, 168 beneficiary, 171 benefit reduction, 171 child coverage, 170 claim appeal, 238 continuation or conversion, 172 designating beneficiaries, 171 evidence of insurability, 7, 168, 169, 170, 171 filing a claim, 237 payment of benefits,

270 A B C D E F G H I J K L M N O P Q R S T U V W X Y portability, 172 spouse/domestic partner coverage, 170 supplemental life, 169 taxable life insurance, 168 waiver of premium, 169 lifetime benefit maximum disability, 189 hospice care, 69 infertility, 70, 125 major medical and organ transplant (travel and lodging benefit), 83 MPD and TMJ, 134 orthodontia, 134 Long-Term, 186 calculating benefits, 187 claim appeal, 238 coverage comparison, 186 disability, definition of, 192 disability earnings, 187 exclusions, 189 filing a claim, 190, 237 limited benefit periods, 189 maximum benefit period, 188 pre-existing condition limitation, 189 reduction of benefits, 188 state-mandated disability benefits, 190 successive periods of disability, 187 survivor benefit, 189 taxability of benefit payments, 190 waiting period, 186 M Magellan Health Services (EAP), 149, 257, 261 mail-order prescriptions (Express Scripts), 121, 125 mammography lab and X-ray (diagnostic), 70 preventive care, 75 mastectomy (breast reconstruction procedures), 77, 104, 147 maternity services (pregnancy), 24, 37, 45, 74, 101 maximum benefits per plan year acupuncture, 60 chiropractic care, 80 dental, 132 home health care, 68 Benefits Abroad (MBA), 200 rehabilitation services, 78 maximum lifetime benefit disability, 189 hospice care, 69 infertility, 70, 125 major medical and organ transplant (travel and lodging benefit), 83 MPD and TMJ, 134 orthodontia, 134 MCS medical plan (Puerto Rico), 103 medical benefits while on a leave of absence,

271 A B C D E F G H I J K L M N O P Q R S T U V W X Y medically necessary, definition of, dental, 139 disability, 193 medical plans Kaiser medical plans Kaiser California, 94 Kaiser Hawaii, 97 MCS medical plan (Puerto Rico), 103 MVP HMO (Fishkill, NY), 100 United Healthcare medical plans Hawaii PPO, 43 HRA and HRA Plus, 18 Out-of-Area, 35 Medicare, 13, 59, 104, 111, 227, 242 Medicare Part D Prescription Drug Coverage, 104, 148 mental health and substance use disorders exclusions, 86 inpatient and outpatient, 25, 37, 46, 80, 96, 99, 101 mental health/substance use disorder (MH/SUD) administrator, 81 mental health services description of, 71 exclusions, 86 inpatient and outpatient, 25, 37, 46, 80, 96, 99, 101 mental health/substance use disorder (MH/SUD) administrator, 71 special mental health programs and services, 71 military leave benefits while on, 218, 240 Minnesota Life Insurance Company, 168, 257, 258 MPD treatment, 134, MVP HMO (Fishkill, NY), 100 mynurseline, 54 My Rx Choices, 118 myuhc.com, 53, 260, 261 N Neonatal Resource Services (NRS), 72 neurobiological disorders (autism spectrum disorders), 72, 58 Newborns and Mothers Health Protection Act, 74, 104, 148 non-emergency care, 61, 194 nurse midwives, 74 nutritional counseling, 73 O obesity surgery, 24, 73 occupational therapy (rehabilitation services), 78, 101 office visits (physician office services), 23, 35, 44, 73, 95, 98, 100, 103 Open Enrollment, 5, 10 orthodontia, 134, 137 orthotics, 24, 36, 45, 66, 112 ostomy supplies, 73 Out-of-Area medical plan, 35 claims appeal, 232 co-insurance, 39 coverage, 35 coverage while traveling abroad, 39 deductible, 35,

272 A B C D E F G H I J K L M N O P Q R S T U V W X Y exclusions, 84 filing a claim, 40 ID cards, 38 out-of-pocket maximum, 39 paying for care, 39 prescription drug coverage, 117 preventive services, 43, 75 providers, 38 out-of-pocket maximums, medical, 22, 35, 43, 95, 98, 100, 103 overpayment, recovery, 252 P paid time off use of while on leave, 240 use of while on Long-Term, 186 use of while on Short-Term, 182 payroll deductions Dependent (Day) Care FSA, 162 Health Care FSA, 154 life insurance, 168, 171 Personal Health Support, 56 Personal Health Support notification (benefits requiring notification), 57 pharmacies participating, 120 specialty, 123 physical therapy (rehabilitation services), 78, 101 physician fees (medical services), 73 physician office services, 73 plan administrator, 259 podiatry, 24, 37, 45, 74 portability option, accidental death & dismemberment insurance (AD&D), 179 life insurance, 172 post cochlear implant aural therapy (rehabilitation services), 78 pre-existing condition limitation Long-Term, 189 Short-Term, 185 preferred drug (see formulary) pregnancy (maternity services) dental, 132 Healthy Pregnancy Program, 54 maternity hospital stays, 104, 148 medical, 24, 37, 45, 74, 101 premium, waiver of (life insurance), 169 prescription drugs authorization (drugs requiring), 123 brand-name, 119, 129 claim appeal, 232 coverage overview, 119 definition, 130 exclusions, 127 Express Scripts Home Delivery Pharmacy, 121 filing a claim, 128 formulary, 119 generics, 119,

273 A B C D E F G H I J K L M N O P Q R S T U V W X Y ID card, 117 immunizations, 126 infertility pharmacy benefits, 125 mail order, 121 participating pharmacies, 120 preferred drugs, 119 preventive drugs, 126 specialty pharmacy (Accredo), 123 supply limits, 123 preventive care access to benefits, 76 breast pump coverage, 76 definition of, 113 exams, 75 screenings, 75 privacy rights (HIPAA), 105, 148 private duty nursing, 24, 37, 45, 77 prosthetic devices, 24, 37, 46, 77 providers dental, 131 UnitedHealthcare medical plans, 26, 38, 47 vision, 141 pulmonary rehabilitation (rehabilitation services), 78 Q qualified medical child support order (QMSCO), 4 R reconstructive procedures breast reconstruction procedures, 77, 104 other procedures, 77 recovery of overpayment, 252 rehabilitation services inpatient facility services, 79 outpatient services, 78 reminder programs, 55 Reproductive Resource Services (RSS), 79 residential treatment facility, 58, 71, 72, 80, 113 resource and referral services (EAP), 149 S scopic procedures (outpatient diagnostic and therapeutic), 79 seatbelt benefit (AD&D), 177 Sedgwick Claims Management (STD), 182, 258, 261 Short-Term (STD), 182 claim appeal, 238 coverage comparison, 183 disability, definition of, 192 exclusions, 184 filing a claim, 190, 237 maximum benefit period, 183 pre-existing condition limitation, 185 reduction of benefits, 184 state-mandated disability benefits, 190 successive periods of disability,

274 A B C D E F G H I J K L M N O P Q R S T U V W X Y taxability of benefit payments, 190 waiting period, 183 skilled nursing facility, 25, 37, 46, 79, 96, 98 Social Security Administration, 245 speech therapy (rehabilitation services), 78 spinal treatment (chiropractic and osteopathic manipulative therapy), 80 spouse, 2 same-sex, 2, 3 spouse life insurance, 170 state-mandated disability benefits, 190 sterilization (family planning), 66, 156 stress management (EAP), 149 subrogation, 250 substance abuse services (substance use disorder services) description of, 80 exclusions, 86 inpatient and outpatient, 25, 37, 46, 96, 99, 101 mental health/substance use disorder (MH/SUD) administrator, 81 partial hospitalization, 58 residential treatment, 58 special substance use disorder programs and services, 81 supplemental life insurance, 169 surgery breast reconstruction, 77 gender reassignment, 24, 36, 45, 67 inpatient, 69, 73 laser vision correction, 144 obesity, 73 oral, 133 outpatient, 81 transplant, 81 T terminally ill accelerated benefit (AD&D), 171 hospice care, 24, 36, 45, 58, 68, 96, 98, 150 therapeutic treatments (outpatient), 81 TMJ treatment, 134 total disability life insurance, 169 medical, definition of, 114 transitional care (mental health/substance use disorder services), 71, 81, 115 transplant services donor costs, 82 overview, 81 travel and lodging, 82 treatment decision support, 56 U United Healthcare medical plans, 18 Hawaii PPO, 43 HRA and HRA Plus, 18 Out-of-Area,

275 A B C D E F G H I J K L M N O P Q R S T U V W X Y urgent care center services, 83 USERRA rights, 240 V vision plans, 141 claims appeal, 232 contact lenses, 142, 144 coordination of benefits, 144 coverage, 141, 142 exclusions, 143 eye exam, 142 filing a claim, 145, 229 laser vision correction, 144 lens discounts, 142 low vision benefit, 144 prescription glasses, 142, 143 providers, 141 Vision Service Plan (VSP), 141, 257, 260 W waiver of premium (life insurance), 169 weight management, 54 Women s Health and Cancer Rights Act, 104, 147 women s preventive health services, 18, 75 workers compensation, 185, 261 X x-ray services, 23, 35, 44, 70, 71, 75, 95, 98, 100, 132 Y Your HealthCare Advocate, 1,