ST. VINCENT DE PAUL REHABILITATION SERVICES OF TEXAS DBA PEAK PERFORMERS EMPLOYEE HEALTH BENEFIT PLAN

Transcription

1 ST. VINCENT DE PAUL REHABILITATION SERVICES OF TEXAS DBA PEAK PERFORMERS EMPLOYEE HEALTH BENEFIT PLAN BENEFIT DOCUMENT & SUMMARY PLAN DESCRIPTION OF THE MEDICAL AND PRESCRIPTION BENEFITS EFFECTIVE: JANUARY 1, 2015 ADMINISTERED BY:

2 TABLE OF CONTENTS Page IMPORTANT INFORMATION / NOTICES... 1 UTILIZATION MANAGEMENT PROGRAM... 4 MEDICAL BENEFIT SUMMARY... 6 ELIGIBLE MEDICAL EXPENSES MEDICAL LIMITATIONS AND EXCLUSIONS GENERAL EXCLUSIONS COORDINATION OF BENEFITS (COB) SUBROGATION AND REIMBURSEMENT, THIRD PARTY RECOVERY ELIGIBILITY AND EFFECTIVE DATES TERMINATION OF COVERAGE EXTENSION OF COVERAGE PROVISIONS COBRA CONTINUATION COVERAGE CLAIMS PROCEDURES APPEAL PROCEDURES DEFINITIONS GENERAL PLAN INFORMATION STATEMENT OF RIGHTS PRIVACY RULES / HIPAA SECURITY ADDENDUM FOR PRESCRIPTION DRUGS... 91

3 IMPORTANT INFORMATION / NOTICES WHO TO CONTACT FOR ADDITIONAL INFORMATION A Plan participant can obtain additional information about Plan coverage of a specific drug, treatment, procedure, preventive service, etc. from the office that handles Claims on behalf of the Plan (the Contract Administrator ). See the first page of the General Plan Information section for the name, address and phone number of the Contract Administrator. THE NEWBORNS AND MOTHERS HEALTH PROTECTION ACT Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean delivery. However, Federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). THE WOMEN'S HEALTH AND CANCER RIGHTS ACT Under Federal law, group health plans must include coverage for the following post-mastectomy services and supplies when provided in a manner determined in consultation between the attending physician and the patient: (1) reconstruction of the breast on which a mastectomy has been performed, (2) surgery and reconstruction of the other breast to produce symmetrical appearance, (3) breast prostheses, and (4) physical complications of all stages of mastectomy, including lymphedemas. Plan participants must be notified, upon enrollment and annually thereafter, of the availability of benefits required due to the Women s Health and Cancer Rights Act (WHCRA). DEFINITIONS Some of the terms used in this document begin with a capital letter. These terms have special meanings and are included in the Definitions section. When reading this document, it will be helpful to refer to this section. Becoming familiar with the terms defined therein will give you a better understanding of the benefits and provisions. NOTICE OF RIGHT TO RECEIVE A CERTIFICATE OF CREDITABLE COVERAGE Under the Health Insurance Portability and Accountability Act of 1996 (commonly known as HIPAA), an individual has the right to receive a certificate of prior health coverage, called a certificate of creditable coverage or certificate of group health plan coverage, from the Plan Sponsor or its delegate. If Plan coverage or COBRA continuation coverage terminates (including termination due to exhaustion of all lifetime benefits under the Plan), the Plan Sponsor will automatically provide a certificate of creditable coverage. The certificate is provided at no charge and will be mailed to the person at the most current address on file. A certificate of creditable coverage will also be provided, on request, in accordance with the law (i.e., a request can be made at any time while coverage is in effect and within twenty-four (24) months after termination of coverage). Written procedures for requesting and receiving certificates of creditable coverage are available from the Plan Sponsor. Peak Performers Employee Health Benefit Plan / page 1

4 IMPORTANT INFORMATION / NOTICES, continued COBRA NOTIFICATION PROCEDURES It is a Plan participant s responsibility to provide the following Notices as they relate to COBRA Continuation Coverage: Notice of Divorce or Legal Separation - Notice of the occurrence of a Qualifying Event that is a divorce or legal separation of a covered Employee from his or her spouse. Notice of Child s Loss of Dependent Status - Notice of a Qualifying Event that is a child s loss of Dependent status under the Plan (e.g., a Dependent child reaching the maximum age limit). Notice of a Second Qualifying Event - Notice of the occurrence of a second Qualifying Event after a Qualified Beneficiary has become entitled to COBRA Continuation Coverage with a maximum duration of 18 (or 29) months. Notice Regarding Disability - Notice that: (a) a Qualified Beneficiary entitled to receive COBRA Continuation Coverage with a maximum duration of 18 months has been determined by the Social Security Administration to be disabled at any time during the first 60 days of continuation coverage, or (b) a Qualified Beneficiary as described in (a) has subsequently been determined by the Social Security Administration to no longer be disabled. Notice Regarding Address Changes It is important that the Plan Administrator be kept informed of the current addresses of all Plan participants or beneficiaries who are or may become Qualified Beneficiaries. Notification must be made in accordance with the following procedures. Any individual who is either the covered Employee, a Qualified Beneficiary with respect to the Qualifying Event, or any representative acting on behalf of the covered Employee or Qualified Beneficiary may provide the Notice. Notice by one individual shall satisfy any responsibility to provide Notice on behalf of all related Qualified Beneficiaries with respect to the Qualifying Event. Form or Means of Notification - Notification of the Qualifying Event must be made in writing. Notice may be made on the COBRA administrator s Election Form and Plan Alternatives. This form is available, without cost, from the Employer s Human Resources office. Content - Notification must include an adequate description of the Qualifying Event or disability determination. In the case of a disability determination, a copy of the Social Security Administration determination of disability must be included. The Qualified Beneficiary must also provide any additional information as the Plan deems necessary for making the appropriate determination with regard to the Notice. Delivery of Notification - Notification must be received by the COBRA administrator. Refer to the General Information page for contact information. Time Requirements for Notification - In the case of a divorce, legal separation or a child losing dependent status, Notice must be delivered within 60 days from the later of: (1) the date of the Qualifying Event, (2) the date health plan coverage is lost due to the event, or (3) the date the Qualified Beneficiary is notified of the obligation to provide Notice through the Summary Plan Description or the Plan Sponsor s General COBRA Notice. If Notice is not received within the 60-day period, COBRA Continuation Coverage will not be available, except in the case of a loss of coverage due to foreign competition where a Peak Performers Employee Health Benefit Plan / page 2

5 IMPORTANT INFORMATION / NOTICES, continued second COBRA election period may be available see Effect of the Trade Act in the COBRA Continuation Coverage section of the Plan s Summary Plan Description or Benefit Document. If an Employee or Qualified Beneficiary is determined to be disabled under the Social Security Act, Notice must be delivered within 60 days from the later of: (1) the date of the determination, (2) the date of the Qualifying event, (3) the date coverage is lost as a result of the Qualifying Event, or (4) the date the covered Employee or Qualified Beneficiary is advised of the Notice obligation through the SPD or the Plan Sponsor s General COBRA Notice. Notice must also be provided within the 18-month COBRA coverage period. Any such Qualified Beneficiary must also provide Notice within 30 days of the date he is subsequently determined by the Social Security Administration to no longer be disabled. The Plan will not reject an incomplete Notice as long as the Notice identifies the Plan, the covered Employee and Qualified Beneficiary(ies), the Qualifying Event/disability determination and the date on which it occurred. However, the Plan is not prevented from rejecting an incomplete Notice if the Qualified Beneficiary does not comply with a request by the Plan for more complete information within a reasonable period of time following the request. Peak Performers Employee Health Benefit Plan / page 3

6 UTILIZATION MANAGEMENT PROGRAM The Plan includes a Utilization Management Program as described below. The purpose of the program is to encourage Covered Persons to obtain quality medical care while utilizing the most cost efficient sources. The Plan Sponsor has contracted with an independent Utilization Management Organization to provide preauthorization services. The name and phone number of the organization is shown on the Employee's coverage identification card. The procedures outlined below must be followed to avoid a penalty for non-compliance. PREAUTHORIZATION REQUIREMENTS The Notification Procedure - The Utilization Management Program requires that the Covered Person, his or her attending Physician, or a member of his or her family contact the Utilization Management Organization as follows: for a scheduled hospital admission or any inpatient facility stay, including 23 hour observation stays prior to admission; for an emergency hospital admission by 5:00 p.m. on the first business day following admission; for a maternity hospital admission - within 48 hours following admission if the admission is expected to exceed 48 hours following a vaginal delivery, or 96 hours following a caesarean section. Prior authorization will not be required for a maternity hospital admission which does not exceed 48 hours following a normal vaginal delivery, or 96 hours following a cesarean section delivery. However, if/when the Pregnancy confinement for the mother or newborn is expected to exceed these limits, prior authorization for such extended confinement is required; for home health services. The following information needs to be provided to the Utilization Management Organization: the Employee's name, address and Social Security number; the patient's name, address, telephone number, date of birth and sex; the name, address and telephone number of the attending physician and the hospital; the reason for the hospital confinement the expected (or, if an emergency, the actual) date of admission; and, the name of the Plan ST. VINCENT DE PAUL REHABILITATION SERVICES OF TEXAS DBA PEAK PERFORMERS Employee Benefit Plan If, in the opinion of the patient s Physician, it is necessary for the patient to be confined for a longer time than initially authorized, the Physician may request that additional days be authorized by contacting the Utilization Management Organization no later than the last authorized day. Penalty for Non-Compliance - If the preauthorization requirements are not completed for a Hospital admission or any of the procedures or services listed above, an additional Deductible of $250 will be applied before Plan benefits are determined. In addition, if the Utilization Management Organization determines that any Inpatient days were not Medically Necessary, no benefits will be payable for those days. Any additional share of expenses which becomes the Covered Person's responsibility for failure to comply with these requirements will not be considered eligible medical expenses and thus will not apply to any deductibles, coinsurance or out-of-pocket maximums of the Plan. Peak Performers Employee Health Benefit Plan / page 4

7 UTILIZATION MANAGEMENT PROGRAM, continued See the Claims Procedures section for information about a Claimant s right to appeal a reduced or denied Claim. NOTE: The Plan will not reduce or deny a claim for failure to obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where application of the prior approval process could seriously jeopardize the life or health of the patient (e.g., the patient is unconscious and is in need of immediate care at the time medical treatment is required). MORE INFORMATION ABOUT PREAUTHORIZATION It is the Employee's or Covered Person s responsibility to make certain that the compliance procedures of this program are completed. To minimize the risk of reduced benefits, an Employee should contact the review organization to make certain that the facility or attending Physician has initiated the necessary processes. Prior authorization is not a guarantee of coverage. The Utilization Management Program is designed ONLY to determine whether or not a proposed setting and course of treatment is Medically Necessary and appropriate. Benefits under the Plan will depend upon the person's eligibility for coverage and the Plan's limitations and exclusions. Nothing in the Utilization Management Program will increase benefits to cover any confinement or service which is not Medically Necessary or which is otherwise not covered under the Plan. See "Pre-Service Claims" in the Claims Procedures section for more information, including information on appealing an adverse decision (i.e. a benefit reduction) under this program. CASE MANAGEMENT SERVICES In situations where extensive or ongoing medical care will be needed, the Utilization Management Organization may, with the patient's and Plan Sponsor's consent, provide case management services. Such services may include contacts with the patient, his or her family, the primary treating Physician, other caregivers and care consultants, and the hospital staff as necessary. The Utilization Management Organization will evaluate and summarize the patient's continuing medical needs, assess the quality of current treatments, coordinate alternative care when appropriate and approved by the Physician and Plan Sponsor, review the progress of alternative treatment after implementation, and make appropriate recommendations to the Plan Sponsor. The Plan Sponsor expressly reserves the right to make modifications to Plan benefits on a case-by-case basis to ensure that appropriate and cost-effective care can be obtained in accordance with these services. NOTE: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Also, each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis. Peak Performers Employee Health Benefit Plan / page 5

8 MEDICAL BENEFIT SUMMARY CHOICE OF NETWORK OR NON-NETWORK PROVIDERS The Plan Sponsor has contracted with First Health PPO Network for health care providers. When obtaining health care services, a Covered Person has a choice of using providers who are participating in a Network or any other Covered Providers of his or her choice (Non-Network providers). However, services performed at a Non-Network provider are NOT COVERED by the Plan. Network providers have agreed to provide services to Covered Persons at negotiated rates. When a Covered Person uses a Network provider his or her out-of-pocket costs may be reduced because he will not be billed for expenses in excess of those rates. The Plan may also include other benefit incentives to encourage Covered Persons to use Network providers whenever possible - see the Schedule of Medical Benefits, below. The Plan Sponsor will automatically provide a Plan participant with information about how he can access a directory of Network Providers for his or her service area. This information will be provided without charge. The directory will be available either in hard copy as a separate document, in electronic format or online. Since certain covered services and supplies may not be available through the Network, a Covered Person should refer to the Network list or directory to determine if any particular specialty is includedin the Network. There may be circumstances when a Network provider cannot be used. Non-Network provider services will not be covered except in the following circumstances: Ancillaries - If, while receiving treatment in a covered Network facility, a Covered Person receives ancillary services from a Non-Network provider (i.e., an anesthesiologist or a provider for diagnostic services), such Non-Network services will be covered at the Network benefit levels. Emergency Care - If a Covered Person requires care for a Medical Emergency and must use the services of a Non-Network provider, any such expenses will be paid at Network benefit levels until the patient's condition has been stabilized to the point that his or her Physician releases him to be transferred to Network provider care. Thereafter, the Covered Person must be transferred to Network-provider care or Non- Network benefit levels will apply. Network Care Not Available Within 100 Miles of a Covered Person s Physical Location If a Covered Person requires care and such care is not available from a Network provider within 100 miles of the Covered Person s physical address, benefits for Non-Network care will be payable at the Network benefit level if attempts by the plan to contract directly with said provider is unsuccessful. 6

9 MEDICAL BENEFIT SUMMARY, continued SCHEDULE OF MEDICAL BENEFITS BENEFIT MAXIMUMS Amounts credited towards individual Maximums are also credited towards the Calendar Year Maximum Benefit. Once the Calendar Year Maximum Benefit is met, no additional benefits are available under the Plan. Once a Maximum Benefit for a specified service is met, no additional benefits for that service are available for the remainder of the time period specified. Maximum Benefits include Network and Non-Network benefits, combined. Chiropractic Care Occupational Therapy Physical Therapy Speech Therapy Skilled Nursing Facility 20 Visits per Calendar Year 60 Visits per Calendar Year for occupational, physical, and speech therapy combined 60 Visits per Calendar Year for occupational, physical, and speech therapy combined 60 Visits per Calendar Year for occupational, physical, and speech therapy combined 90 Days per Calendar Year IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. 7

10 MEDICAL BENEFIT SUMMARY, continued CALENDAR YEAR DEDUCTIBLES Individual Deductible - The Individual Deductible is an amount which a Covered Person must pay before any money is paid by the Plan for any Covered Services. Each calendar year, a new Deductible amount is required. Family Maximum Deductible - If eligible medical expenses equal to the Family Maximum Deductible are incurred collectively by family members during a Calendar Year and are applied toward Individual Deductibles, the Family Maximum Deductible is satisfied. A "family" includes a covered Employee and his or her covered Dependents. Deductible Amounts Network Non-Network Individual Deductible Family Maximum Deductible $6,450 $12,900 Not Covered Not Covered IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. 8

11 MEDICAL BENEFIT SUMMARY, continued CALENDAR YEAR OUT-OF-POCKET MAXIMUMS Some Covered Expenses are paid by the Plan at less than one hundred percent. The remaining percentage of the expense, known as "co-insurance", must be paid by the Covered Person. Except as specified below, co-insurances paid by a Covered Person are credited towards that person's Out-of-Pocket Maximum. Copays are also credited towards that person's Out-of-Pocket Maximum. The Individual Out-of-Pocket Maximum is satisfied once a Covered Person has paid the Individual Out-of-Pocket Maximum amount. The Family Out-of-Pocket Maximum is satisfied once two family members have satisfied their Individual Out-of-Pocket Maximums. Once the Family Out-of-Pocket Maximum is satisfied, all Individual Out-of-Pocket Maximums for that family are considered to be satisfied for the remainder of that Calendar Year. Amounts incurred with Network providers are credited toward the Network Out-of-Pocket Maximum only. Amounts incurred with Non-Network providers are credited toward the Non-Network Out-of-Pocket Maximum only. Once an Out-of-Pocket Maximum has been satisfied, all remaining Covered Expenses for that Covered Person incurred during that same Calendar Year will be payable by the Plan at one hundred percent, except as specified below. Out-of-Pocket Maximums Network Non-Network Individual Family $6,450 $12,900 Not Covered Not Covered Expenses Not Credited Toward the Out-of-Pocket Maximum Penalties for failure to comply with the Utilization Management Program, including any portion of a hospital stay that is not certified by the Utilization Management Program as being Medically Necessary Non-Covered Expenses Expenses in excess of any Maximum Benefit Amounts in excess of Reasonable and Customary IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. MEDICAL BENEFIT SUMMARY, continued 9

12 ELIGIBLE MEDICAL EXPENSES The percentages shown in the summary below reflect the amounts the Plan pays of Eligible Expenses after any required Deductible or Co-Pay has been deducted. The percentages apply to "Reasonable and Appropriate" charges. For Network providers, this means that the percentages apply to the negotiated rates and not necessarily to the provider's actual charges or the usual charges of similar providers. See "Reasonable and Appropriate" in the Definitions section for more information. Eligible Medical Expenses Network Non-Network Primary care physician Allergy Care $30 Copay Office Visits Not Covered Specialist $60 Copay Testing, Injections and Serum 100%, Deductible Waived Ambulance 100% after Deductible 100% after Deductible Ambulatory Surgical Center 100% after Deductible Not Covered Attention Deficit Disorders (ADD & ADHD) Office Visits, Testing, and Medication Management Autism Office Visits, Testing Chiropractic Care Limited to 20 visits per Calendar Year Diagnostic Lab & X-Ray In physician s office Primary care physician $30 Copay Specialist $60 Copay Primary care physician $30 Copay Specialist $60 Copay Not Covered Not Covered $30 Copay Not Covered No additional copay after office visit copay Not Covered Independent Free-standing Facility 100% after Deductible Not Covered MRI, CT, PET scans 100% after Deductible Not Covered Dialysis If Non-Network Provider services are covered because network provider is unavailable, the maximum allowable charge is limited to 200% of Medicare's allowable rate 100% after Deductible Not Covered Durable Medical Equipment 100% after Deductible Not Covered Emergency Room Facility Charge (includes lab and xray facility fees done as part of emergency room visit) $300 Copay, then 100% after Deductible Physician Charge 100% after Deductible 100% after Deductible $300 Copay, then 100% after Deductible Hearing Testing 100% after Deductible Not Covered (Except initial newborn hearing screening covered at 100%, deductible waived) Home Health Care 100% after Deductible Not Covered Home Infusion Therapy 100% after Deductible Not Covered IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. MEDICAL BENEFIT SUMMARY, continued 10

13 Eligible Medical Expenses Network Non-Network Hospice Services Inpatient 100% after Deductible Not Covered Outpatient 100% after Deductible Not Covered Family Bereavement Counseling 100% after Deductible Not Covered Hospital Services Inpatient Care Precertification Required 100% after Deductible Not Covered Outpatient Care 100% after Deductible Not Covered Outpatient Surgery 100% after Deductible Not Covered All Other Outpatient Services & Supplies 100% after Deductible Not Covered Eligible Expenses for Inpatient room and board are limited to the Semi-Private Room Charge (see Definitions) or the Reasonable and Appropriate charge for necessary confinement to an Intensive Care Unit. Medical Supplies, Disposable 100% after Deductible Not Covered Mental Health & Substance Abuse Services Inpatient Treatment Precertification Required 100% after Deductible Not Covered Partial Day Treatment 100% after Deductible Not Covered Outpatient Visits 100% after Deductible Not Covered Maternity Services Initial Office Visit to Confirm Pregnancy $30 Copay, then 100% Not Covered Subsequent Physician Services 100% after Deductible Not Covered Facility Charges 100% after Deductible Not Covered Newborn Charges ( if baby added to plan) (Note: some newborn preventive screenings are paid at 100%, with deductible waived if required under PPACA) Physician Services Office Visits - Primary Care physician Office Visits - Specialist Injections, Labs and X-rays 100% after Deductible $30 Copay, then 100% $60 Copay, then 100% Copay waived if billed with office visit Not Covered Not Covered Not Covered Office Surgery 100% after Deductible Not Covered Surgical Injections (injections including a Not Covered surgical code) In-Office Infusion Therapy Hospital Visits 100% after Deductible 100% after Deductible Not Covered 100% after Deductible Surgery 100% after Deductible Not Covered IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. MEDICAL BENEFIT SUMMARY, continued Eligible Medical Expenses Network Network Preventive Care Plan pays 100%, Not Covered 11

14 Preventive Care includes, but is not limited to, - physical exam, including related routine diagnostic tests and immunizations; - routine well child care, including related diagnostic tests, screenings and immunizations; - a routine well-woman exam, including pelvic exam and Pap smear; routine mammograms - charges for contraception services, including sterilization, physician-prescribed devices and medications - routine colonoscopy; - all other federally mandated Preventive Care. Deductible Waived * Some age and frequency restrictions apply. See separate Preventive Care Detail section. Prescription Drugs, Outpatient Retail Program (30 day max supply) Generic Drugs Preferred Brand-Name Drugs Non- Preferred Brand-Name Drugs $10 Copay $50 Copay $70 Copay Mail Order Program (90 day max supply) Generic Drugs Preferred Brand-Name Drugs Non- Preferred Brand-Name Drugs $25 Copay $125 Copay $175 Copay Not Covered Prescription drug coverage involves a program through an independent vendor. To use the retail program, a Covered Person takes his or her drug ID card to a participating pharmacy to fill his or her prescription order. A prescription can be purchased in up to a 30-day supply for the Co-Pays shown. The program also includes a mail-order option for maintenance (longer-term) drugs. Mail-order drugs are available in up to a 90- day supply for the Co-Pays shown. If a Physician authorizes a generic drug but the Covered Person chooses a brand-name, the Covered Person will be required to pay the brand-name Co-Pay plus the difference in price between the brand-name drug and its generic equivalent. A list of covered and excluded drugs is provided elsewhere in this document or is available from the Plan Sponsor. NOTE: The full terms and conditions of the prescription drug program are not described herein but are as determined between the Plan Sponsor and the organization(s) offering the program(s). Eligible Medical Expenses Retail Clinic Office Visit Primary Care clinics located inside pharmacy or other Network $30 Copay, then 100% Non-Network Not Covered 12

15 retail store, staffed with Nurse Practitioners or other licensed professionals providing basic primary care services Sleep Disorders Sleep Testing 100% after Deductible Not Covered Treatment 100% after Deductible Not Covered Therapy Services Occupational Therapy Physical Therapy Speech Therapy Limited to 60 visits per Calendar Year for Occupational, Physical, and Speech Therapy Combined $30 Copay if done in office or free-standing facility 100% after Deductible if billed by Hospital Not Covered Not Covered Not Covered Radiation Therapy 100% after Deductible Not Covered Transplants 100% after Deductible Not Covered Urgent Care Facility, per visit $50 Copay, then 100% $50 Copay, then 100% All Other Eligible Medical Expenses 100% after Deductible Not Covered IMPORTANT: CERTAIN HEALTH CARE SERVICES MAY REQUIRE PRIOR AUTHORIZATION TO AVOID BENEFIT REDUCTION. SEE THE UTILIZATION MANAGEMENT PROGRAM SECTION. 13

16 ELIGIBLE MEDICAL EXPENSES This section is a listing of those medical services, supplies and conditions which are covered by the Plan. This section must be read in conjunction with the Medical Benefit Summary to understand how Plan benefits are determined (application of Deductible requirements and benefit sharing percentages, etc.). All medical care must be received from or ordered by a Covered Provider. Except as otherwise noted below or in the Medical Benefit Summary, eligible medical expenses are the Reasonable and Appropriate charges for the items listed below and which are incurred by a Covered Person subject to the Definitions, Limitations and Exclusions and all other provisions of the Plan. In general, services and supplies must be approved by a Physician or other appropriate Covered Provider and must be Medically Necessary for the care and treatment of a covered Sickness, Accidental Injury, Pregnancy or other covered health care condition. For benefit purposes, medical expenses will be deemed to be incurred on: - the date a purchase is contracted; or - the actual date a service is rendered. Alcoholism - see "Substance Abuse Care" Allergy Testing & Treatment - Allergy testing and treatment, including allergy injections. Ambulance Medically Necessary transport of a Covered Person by professional ambulance to a local Hospital or Skilled Nursing Facility for Inpatient care, or to the nearest Hospital for emergency care. Transportation by ambulance to a non-medical facility only if Medically Necessary and if prior authorization is obtained from the Plan Administrator. Expenses for transportation by air will be covered only if an air ambulance is Medically Necessary. Ambulatory Surgical Center - Services and supplies provided by an Ambulatory Surgical Center (see Definitions) in connection with a covered Outpatient surgery. Anesthesia - Anesthetics and services of a Physician or certified registered nurse anesthetist (CRNA) for the administration of anesthesia. Attention Deficit Disorders (ADD & ADHD) - Testing and treatment (i.e., periodic Physician check-ups for evaluation and medication management) for attention deficit disorder (ADD) or attention deficit hyperactive disorder (ADHD). Biofeedback - Biofeedback, recreational, or educational therapy, or other forms of self-care or self-help training or any related diagnostic testing. Must be approved by Plan Sponsor after providing documented proof of Medical Necessity. Birthing Center - Services and supplies provided by a Birthing Center (see Definitions) in connection with a covered Pregnancy. Only in-network Birthing Centers are covered. Blood - Blood and blood derivatives (if not replaced by or for the Covered Person), including blood processing and administration services. Chemical Dependency - see "Substance Abuse Care" 14

17 ELIGIBLE MEDICAL EXPENSES, continued Chemotherapy - Professional services and supplies related to the administration of chemical agents in the treatment or control of a Sickness. Chiropractic Care - Musculoskeletal manipulation and modalities (hot & cold packs, etc.) provided by a chiropractor (DC) to correct vertebral disorders such as incomplete dislocation, off-centering, misalignment, misplacement, fixation, abnormal spacing, sprain or strain. Contraceptives - Injections, implants, devices or the fitting or removal of devices or any other services or supplies provided for birth control purposes. NOTE: Oral contraceptives and contraceptive patches are available through the independent prescription program. See the Addendum for Prescription Drugs for information. Covered Provider Services - Services or supplies received from Covered Providers (see Covered Provider in the Definitions section), which are not otherwise expressly included in this list of Eligible Medical Expenses and which are not expressly excluded in the list of Medical Limitations and Exclusions. Diabetes Education - Charges of a diabetic day care center or services of a Physician or other professionals who are knowledgeable about the treatment of diabetes (such as a registered nurse, registered pharmacist or registered dietitian) for the purpose of enabling a diabetic and his or her family to understand and practice daily management of diabetes. Diagnostic Lab & X-ray, Outpatient - Laboratory, X-ray and other non-surgical services performed to diagnose medical disorders, including scanning and imaging work (e.g., CT scans, MRIs), electrocardiograms, basal metabolism tests, and similar diagnostic tests generally used by Physicians throughout the United States. Dialysis Services: (Limited to Not More Than 200% of Medicare Allowable Rate on Non-Network Providers) Dialysis services and supplies, including the training of a person to assist the patient with home dialysis, when provided by a Hospital, freestanding dialysis center or other appropriate Covered Provider. Durable Medical Equipment - Rental of durable medical equipment (but not to exceed the fair market purchase price) or purchase of such equipment where only purchase is permitted or where purchase is more cost-effective due to a long-term need for the equipment. Such equipment must be prescribed by a Physician and required for therapeutic use in treatment of an active Sickness or Accidental Injury. Excess charges for deluxe equipment or devices will not be covered. If an item of durable medical equipment is purchased, a replacement will be covered after a 5-year period. Replacement within five (5) years is covered only if approved by the Utilization Management Organization. "Durable medical equipment" includes such items as crutches, wheelchairs, hospital beds, traction apparatus, head halters, cervical collars, oxygen and dialysis equipment, etc., which: (1) can withstand repeated use, (2) are primarily and customarily used to serve a medical purpose, (3) generally are not useful to a person in the absence of Sickness or Accidental Injury, and (4) are appropriate for use in the home. NOTE: Transcutaneous electrical nerve stimulation (TENS) units are not covered through Durable Medical Equipment. Hearing Exams - Routine hearing exams. Hearing aids are not covered. ELIGIBLE MEDICAL EXPENSES, continued 15

18 Home Health Care The following necessary services and supplies which are furnished to a Covered Person by or on behalf of a Home Health Care Agency, in accordance with a home health care plan, and where the patient would otherwise have been hospitalized. Home Health care must begin within seven (7) days after a Hospital confinement, unless that requirement is waived by the Plan Administrator: - part-time or intermittent services by or under the supervision of a registered nurse (RN); - services of physical, occupational and/or speech therapists; - part-time or intermittent services of home health aides that consist primarily of caring for the patient; - medical supplies, drugs and medicines prescribed by a Physician and laboratory services, but only to the extent that such items would have been covered if the patient had been confined in a Hospital. NOTE: Covered home health care expenses will not include food, food supplements, home-delivered meals, transportation, housekeeping services or other services which are custodial in nature and could be rendered by nonprofessionals. Hospice Care - Care of a Covered Person with a terminal prognosis (i.e., a life expectancy of six months or less) who has been admitted to a formal program of Hospice care. Eligible Expenses include Hospice program charges for: - Inpatient Hospice facility services and supplies; - services of a Physician; - at-home care including part-time nursing care, use of medical equipment, rental of wheelchairs and hospitaltype beds; and - emotional support services and physical/chemical therapies. Hospital Services - Hospital services and supplies provided on an Outpatient basis and/or Inpatient care, including daily room and board and ancillary services and supplies. Hypnotherapy Covered when used for treatment of nicotine addiction. Limited to 10 visits per Calendar Year. Covered for In-Network providers only. Non-Network providers are not covered. Infusion Therapy - Administration by an appropriate Covered Provider of prescription drugs by injection into a vein, a muscle, the skin or the spinal canal. It also includes drugs administered by aerosol into the lungs or by a feeding tube. Medical Supplies, Disposable - Disposable medical supplies such as surgical dressings, catheters, colostomy bags, jobst stockings and related supplies. Jobst stockings are limited to 2 pairs per calendar year. Medicines - Medicines which are dispensed and administered to a Covered Person during an Inpatient confinement or during a Physician's office visit. See "Prescription Drugs, Outpatient" in the Medical Benefit Summary for pharmacy drugs. ELIGIBLE MEDICAL EXPENSES, continued Mental Health Care Inpatient, partial day treatment, and Outpatient treatment of mental health conditions. 16

19 Partial day treatment means continuous treatment consisting of not less than 4 hours and not more than 12 hours in any 24-hour period under a program based in a Hospital. For Plan purposes, "mental health conditions" include schizophrenic disorders, paranoid disorders, affective disorders (depression, mania, manic-depressive illness), anxiety disorders, somatoform disorders, personality disorders, and disorders of infancy, childhood and adolescence. NOTE: A mental health condition or covered mental health care will not include: - learning and behavior disorders including attention deficit disorder, hyperkinetic syndrome, autism or mental retardation; - hypnotherapy; - marriage and family counseling; - sex counseling or sex therapy; - vocational testing or training. Midwife - Services of a certified or registered nurse midwife when provided in conjunction with a covered Pregnancy - see "Pregnancy Care" below. Newborn Care Routine Hospital and Physician care for a covered newborn child during the child s birth confinement. Includes Hearing Tests for Newborns and Circumcision. In accordance with the Newborns' and Mothers' Health Protection Act, the Plan will not restrict benefits for a Hospital stay for a newborn (birth confinement) to less than forty-eight (48) hours following a normal vaginal delivery or ninety-six (96) hours following a cesarean delivery. Also, the Utilization Management Program requirements for Inpatient Hospital admissions will not apply for this minimum length of stay and early discharge is only permitted if the decision is made between the attending Physician and the mother. NOTE: A covered newborn who is sick or injured is eligible for benefits to the same extent as any other Covered Person. Nebulizer and Nebulizer Treatments When administered by a facility or physician. Nebulizer and associated supplies for home use are available through the Prescription Drug Program. Nicotine Addiction - Nicotine withdrawal programs, facilities, or supplies. See the Addendum for Prescription Drugs for additional information. Nursing Services, Private Duty Outpatient services of a registered nurse (RN) or licensed practical nurse (LPN) for private duty nursing services when Medically Necessary and prescribed in writing by the attending Physician or surgeon specifically as to duration and type. Occupational Therapy - Professional services of a licensed occupational therapist, when ordered by a Physician for treatment of a Sickness (including a congenital condition) or Accidental Injury. NOTE: Maintenance therapy or therapy for vocational rehabilitation is not covered. Recreational programs or supplies used in occupational therapy are not covered. Orthognathic Surgery - Medically Necessary surgery to correct a receding or protruding jaw. ELIGIBLE MEDICAL EXPENSES, continued Orthotics - Non-dental braces, casts, splints, trusses and other orthotics (including foot orthotics) which are prescribed by a Physician and custom-made. Non-custom foot orthotics/arch supports are not covered. 17

20 Oxygen - see "Durable Medical Equipment" Physical Therapy - Professional services of a licensed physical therapist, when rendered under the direction of a Physician and for treatment of a Sickness (including a congenital condition) or Accidental Injury. Physician Services - Medical and surgical treatment by a Physician (MD or DO), including office, home or Hospital visits, clinic care and consultations. See "Second (& 3rd) Surgical Opinion" below for requirements applicable to surgery opinion consultations. Podiatry Services of a podiatrist for Medically Necessary care. Pregnancy Care - Pregnancy-related expenses of a covered Employee or covered Dependent. Pregnancy-related expenses include the following, but may include other services which are deemed to be Medically Necessary by the patient's attending Physician: - pre-natal visits and routine pre-natal and post-partum care; Note: Doula services are specifically excluded. - expenses associated with a vaginal or cesarean delivery as well as expenses associated with any complications of pregnancy; - genetic testing or amniocentesis when deemed Medically Necessary by a Physician. In accordance with the Newborns' and Mothers' Health Protection Act, the Plan will not restrict benefits for a Pregnancy Hospital stay for a mother and her newborn to less than forty-eight (48) hours following a normal vaginal delivery or ninety-six (96) hours following a cesarean section. Also, the Utilization Management Program requirements for Inpatient Hospital admissions will not apply for this minimum length of stay and early discharge is only permitted if the decision is made between the attending Physician and the mother. NOTE: Pregnancy coverage will not include: (1) Lamaze and other charges for education related to pre-natal care and birthing procedures, (2) adoption expenses or (3) expenses of a surrogate mother. Prescription Drugs - Drugs and medicines which are dispensed and administered to a Covered Person during an Inpatient confinement or during a Physician's office visit. Coverage for other Outpatient drugs (i.e., pharmacy purchases) is provided through a separate program. See the Addendum for Prescription Drugs for additional information. Preventive Care - Certain preventive services which are provided in the absence of sickness or injury. See the Table below for further information. ELIGIBLE PREVENTIVE CARE DETAIL Adult Preventive Care Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked Alcohol Misuse screening and counseling NETWORK PROVIDERS 100% Covered 100% Covered NON-NETWORK PROVIDERS NONE NONE 18

21 Aspirin use to prevent cardiovascular disease for men and women of certain ages (must be physician approved) NETWORK PROVIDERS 100% Covered NON-NETWORK PROVIDERS NONE Blood Pressure screening for all adults 100% Covered NONE Cholesterol screening for adults of certain ages 100% or at higher risk Covered NONE Colorectal Cancer screening for adults over % Covered NONE Depression screening for adults 100% Covered NONE Diabetes (Type 2) screening for adults with 100% high blood pressure Covered NONE Diet counseling for adults at higher risk for 100% chronic disease Covered NONE HIV screening for everyone ages 15 to 65, and 100% other ages at increased risk Covered NONE Immunization vaccines for adults as follows -- doses, recommended ages, and recommended populations vary: Hepatitis A 100% Covered NONE Hepatitis B 100% Covered NONE Herpes Zoster 100% Covered NONE Human Papillomavirus 100% Covered NONE Influenza (Flu Shot) 100% Covered NONE Measles, Mumps, Rubella 100% Covered NONE Meningococcal 100% Covered NONE Pneumococcal 100% Covered NONE Tetanus, Diphtheria, Pertussis 100% Covered NONE Varicella 100% Covered NONE Obesity screening and counseling for all adults 100% Covered NONE Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 100% Covered NONE Syphilis screening for all adults at higher risk 100% Covered NONE Tobacco Use screening for all adults and cessation interventions for tobacco users 100% Covered NONE Preventive Health Services for Women Anemia screening on a routine basis for pregnant women 100% Covered NONE Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast 100% Covered NONE cancer Breast Cancer Mammography screenings every 1 to 2 years for women over % Covered NONE Breast Cancer Chemoprevention counseling for women at higher risk 100% Covered NONE Breastfeeding comprehensive support and 100% Covered NONE 19

22 counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer screening for sexually active women Chlamydia Infection screening for younger women and other women at higher risk Contraception: Food and Drug Administrationapproved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may become pregnant Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea screening for all women at higher risk Hepatitis B screening for pregnant women at their first prenatal visit HIV screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older Osteoporosis screening for women over age 60 depending on risk factors Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk Sexually Transmitted Infections counseling for sexually active women Syphilis screening for all pregnant women or other women at increased risk Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users Urinary tract or other infection screening for pregnant women Well-woman visits to get recommended services for women under 65, including preconception care and certain prenatal care Preventive Health Services for Children NETWORK PROVIDERS NON-NETWORK PROVIDERS 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 100% Covered NONE 20

23 NETWORK PROVIDERS NON-NETWORK PROVIDERS Autism screening for children at 18 and 24 months 100% Covered NONE Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 100% Covered NONE to 10 years, 11 to 14 years, 15 to 17 years. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years, 5 100% Covered NONE to 10 years, 11 to 14 years, 15 to 17 years. Cervical Dysplasia screening for sexually active females 100% Covered NONE Depression screening for adolescents 100% Covered NONE Developmental screening for children under age 3 100% Covered NONE Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 17 years. 100% Covered NONE Fluoride Chemoprevention supplements for children without fluoride in their water source 100% Covered NONE Gonorrhea preventive medication for the eyes of all newborns 100% Covered NONE Hearing screening for all newborns 100% Covered NONE Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 100% Covered NONE Hematocrit or Hemoglobin screening for children 100% Covered NONE Hemoglobinopathies or sickle cell screening for newborns 100% Covered NONE HIV screening for adolescents at higher risk 100% Covered NONE **Hypothyroidism screening for newborns 100% Covered NONE Immunization vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis 100% Covered NONE Haemophilus influenzae type b 100% Covered NONE Hepatitis A 100% Covered NONE Hepatitis B 100% Covered NONE Human Papillomavirus 100% Covered NONE Inactivated Poliovirus 100% Covered NONE Influenza (Flu Shot) 100% Covered NONE Measles, Mumps, Rubella 100% Covered NONE Meningococcal 100% Covered NONE Pneumococcal 100% Covered NONE Rotavirus 100% Covered NONE Varicella 100% Covered NONE Iron supplements for children ages 6 to 12 months at risk for anemia 100% Covered NONE 21

24 NETWORK PROVIDERS Lead screening for children at risk of exposure 100% Covered NONE Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. NON-NETWORK PROVIDERS 100% Covered NONE Obesity screening and counseling 100% Covered NONE Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. 100% Covered NONE Phenylketonuria (PKU) screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. 100% Covered NONE 100% Covered NONE 100% Covered NONE Vision screening for all children. 100% Covered NONE Prosthetics - An initial artificial limb or eye and subsequent repair, modification or replacement when Medically Necessary, such as when necessitated by: (1) a physical change in the site of attachment, (2) the normal growth processes of a child, (3) the fact that the existing prosthesis is unusable and cannot be repaired or modified to achieve proper fit and function. A breast prostheses following a Medically Necessary mastectomy and subsequent repair, modification or replacement when Medically Necessary due to: (1) a physical change in the mastectomy site, (2) the normal physical growth of the patient, or (3) the fact that the existing prosthesis is unusable and cannot be repaired or modified to achieve proper fit and function. Subsequent modification or replacement is also covered if the attending Physician certifies, in writing, that it is necessary to achieve symmetrical appearance. ELIGIBLE MEDICAL EXPENSES, continued Radiation Therapy - Radium and radioactive isotope therapy. Rehabilitation Facility see Skilled Nursing Facility / Rehabilitation Facility Respiratory Therapy - Professional services of a licensed respiratory or inhalation therapist, when specifically prescribed by a Physician or surgeon as to type and duration, but only to the extent that the therapy is for improvement of respiratory function. Second (& 3rd) Surgical Opinion - A second surgical opinion consultation following a surgeon's recommendation for surgery. The Physician rendering the second opinion regarding the Medical Necessity of a proposed surgery must be qualified to render such a service, either through experience, specialist training or education, or similar criteria, and must not be affiliated in any way with the Physician who will be performing the actual surgery. 22