medical - bba summary plan document (spd)

8/3/2019 Medical - BBA Summary Plan Document (SPD)

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An Independent Licensee of the Blue Cross and Blue Shield Association

NWN CORPORATION

Group Benefit PlanSummary Plan Description

Effective: January 1, 2012


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NWN CORPORATION

GROUP BENEFIT PLAN

INTRODUCTION

This is a summary of the NWN Corporation Group Benefit Plan (the Plan).

This booklet is provided to help you understand how the Plan works. It highlights what types ofexpenses are covered under the Plan, definitions you need to know, how to file claims and whatyour legal rights are under the Plan.

NWN Corporation is sponsoring this self-funded ERISA welfare plan for NWN Corporation whichprovides medical benefits for all covered employees and all covered dependents. Stop lossreinsurance has been purchased to protect the Plan Sponsor from unpredictable claims experience.

Each covered person is entitled to the benefits outlined in this Plan Document. To obtain benefitsfrom the Plan, the covered person must ultimately submit a diagnostic bill to the Contract

Administrator, Massachusetts Benefit Administrators LLC dba Blue Benefit Administrators ofMassachusetts, for processing. This claim submission is required for reimbursement to theemployee or direct payment to the service provider by the NWN Corporation Group Benefit Plan.

In any event where a question may arise as to a claim for benefits or denial of a claim for benefits,the Employer, the Contract Administrator (the third party administrator) and any other persons thatmay be associated with the Plans operation will be guided solely by this Plan document, which isalso the Summary Plan Description within the meaning of the Employee Retirement Income SecurityAct of 1974, as amended (ERISA).

A clerical error will neither invalidate the employees coverage if otherwise validly in force norcontinue coverage otherwise validly terminated.

Massachusetts Benefit Administrators LLC dba Blue Benefit Administrators of Massachusetts, anindependent licensee of the Blue Cross and Blue Shield Association, provides administrative claimspayment services only and does not assume any financial risk or obligation with respect to claims.


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TABLE OF CONTENTS

GENERAL INFORMATION 1

SCHEDULE OF BENEFITS 2

GENERAL PROVISIONS 11

PLAN ENROLLMENT 11

PREEXISTING CONDITION LIMITATION 13

COORDINATION OF BENEFITS 14

TERMINATION OF BENEFITS 16

MILITARY LEAVE 16

EXTENSION OF BENEFITS (COBRA) 17

PLAN DETAILS 22

MEDICAL COVERED EXPENSES 28

GENERAL MEDICAL EXCLUSIONS AND LIMITATIONS 37

CLAIM FILING PROCEDURES 42

CLAIM REVIEW PROCEDURES 43

MISCELLANEOUS PROVISIONS 51

ERISA STATEMENT OF RIGHTS 59

DEFINITIONS 61


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GENERAL INFORMATION

Name of the Plan: NWN Corporation Group Benefit Plan

Plan Sponsor/Plan Administrator: NWN Corporation271 Waverly Oaks Rd Ste 302

Waltham, MA 02452(781) 472-3495

Plan Number: 501

Group Number: 80814

Plan(s) Covered: Medical

Federal Tax Identification Number: 04-3532235

Plan Effective Date: January 1, 2012

Plan Anniversary Date: January 1st

Plan Year Ends: December 31st

Contract Administrator/Pre-Certification Administrator:

Massachusetts Benefit Administrators LLC dba Blue Benefit Administrators of MassachusettsP.O. Box 55917Boston, MA 02205-5917Customer Service & Pre-Certification: (877) 707-2583

Agency for Service of Legal Process: NWN Corporation

Contributions: The Plan is contributory.

Eligibility Requirements: All active full-time employees regularly performing at least thirty (30) hoursof service per week, but for purposes of this Plan, does not include the following classifications ofworkers as determined by the employer in its sole discretion:

Temporary or leased employees.

An Independent Contractor who signs an agreement with the employer as anIndependent Contractor or other Independent Contractors as defined in thisdocument.

A Consultant who is paid on other than a regular wage or salary by the employer.

A member of the employers Board of Directors, an owner, partner, or officer, unlessengaged in the conduct of the business on a full-time regular basis.

Dependent Childrens Coverage: Married or unmarried dependent children up to twenty-six (26)years of age.

Eligibility Date: First day of the month coinciding with or next following date of hire.

Termination Date: See Termination of Benefits section.


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NWN Corporation

High Deductible Plan

Schedule of Benefits

Benefit In-Network Out-of-Network

DeductibleThe amount an individual or family must pay each calendar year beforepayments begin for services. For two person or family coverage,expenses incurred by each person accumulates and is credited toward theone family deductible. The Plan will not pay benefits until the familydeductible amount has been completely satisfied by any combination ofcovered participants included under two person or family coverage.Includes medical and prescription drug charges.

$2,000 per individual$4,000 per family


Plan Coinsurance80% 60%

Out-of-Pocket Expense LimitThe maximum amount of money that any individual or family will have topay towards covered health expenses during any one calendar year.Includes medical and prescription drug charges.



Preventive Care100% Deductible; 60%

Physicians Office Visits (Primary Care or Specialist)Deductible; 80% Deductible; 60%

Outpatient Lab and X-Ray ServicesDeductible; 80% Deductible; 60%

High Tech Radiology Services (MRI, PET, CAT Scans)Deductible; 80% Deductible; 60%

Ambulance ServicesDeductible; 80%

In-Network Deductible;80%

Emergency Room ServicesDeductible; 80%


Outpatient Short Term Rehab TherapyPhysical Therapy, Occupational Therapy, Speech Therapy, AquaticTherapy, Respiratory Therapy, and Cardiac Rehabilitation (phase I & II)limited to a combined maximum of 60 visits per calendar year.

Deductible; 80% Deductible; 60%

Durable Medical EquipmentDeductible; 80% Deductible; 60%

Chiropractic CareMaximum of 20 visits per calendar year. Deductible; 80% Deductible; 60%

Convalescent Hospital/Extended Care Facility/Skilled Nursing

FacilityMaximum of 60 days per calendar year.



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NWN Corporation




Home Health CareMaximum of 100 visits per calendar year. Deductible; 80% Deductible; 60%

Hospice CareDeductible; 80% Deductible; 60%

Inpatient Hospital CareDeductible; 80% Deductible; 60%

Outpatient Facility Day SurgeryDeductible; 80% Deductible; 60%

Maternity Care Initial Office VisitDeductible; 80% Deductible; 60%

Outpatient Maternity Care (other than initial office visit)Includes subsequent office visits, labs, x-rays, and professional/facilityexpenses.


Inpatient Maternity Care - DeliveryDeductible; 80% Deductible; 60%

Infertility Treatment (for diagnosis only)Deductible; 80% Deductible; 60%

Nutritional EvaluationMaximum of 3 visits per calendar year (does not apply to diabetes). Deductible; 80% Deductible; 60%

Inpatient Mental Health/Substance Abuse ServicesDeductible; 80% Deductible; 60%

Outpatient Mental Health/Substance Abuse ServicesDeductible; 80% Deductible; 60%

ProstheticsDeductible; 80% Deductible; 60%

Second Surgical OpinionDeductible; 80% Deductible; 60%

Temporomandibular Joint DisorderDeductible; 80% Deductible; 60%

Tobacco Abuse Office VisitDeductible; 80% Deductible; 60%

Wigs, Toupees or Hairpieces Related to Cancer TreatmentMaximum of $500 per calendar year. Deductible; 80%


Transplant Services At A Centers of Excellence Transplant FacilityIncludes travel and lodging expenses incurred by the covered person (andthe covered persons parents or legal guardian(s) if the covered person isa minor or one companion if the covered person is not a minor.

100%

Transplant Services At Another Transplant FacilityDeductible; 80% Deductible; 60%


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NWN Corporation




Pre-Admission Certification Penalty $750 non-compliancepenalty

$750 non-compliancepenalty

Preventive Safe Harbor Generic Medications (Retail 30 Day

Supply):

See Note # 8100% Not Covered

Prescription Drug Benefit (Retail per 30 Day Supply)Generic DrugPreferred Name Drug

Non-Preferred Name Drug

Deductible; 80%Deductible; 70% to

$50/scriptDeductible; 50% to

$100/script

Not Covered

Preventive Safe Harbor Generic Medications (Mail Order 90

Day Supply):

See Note # 8100% N/A

Prescription Drug Benefit (Mail Order 90 Day Supply)Generic DrugPreferred Name Drug

Non-Preferred Name Drug

Deductible; 80%Deductible; 70% to

$150/scriptDeductible; 50% to

$300/script

N/A

Lifetime Benefit MaximumPer individual. Unlimited

NOTES:1. This Plan is participating with Blue Cross Blue Shield of Massachusetts preferred provider network as well

as the BlueCard Program. These preferred providers will bill the Contract Administrator directly and writeoff charges that exceed their contractual allowances.

2. All covered charges billed by non-participating providers will be subject to a maximum allowable benefit.3. All other covered benefits not listed above will be subject to deductible, then payable at 80% in-network

and subject to deductible, then payable at 60% out-of-network.4. All in and out-of-network benefit maximums are combined.5. All in and out-of-network deductible and coinsurance amounts are combined.6. Precertification penalties are not applied to the deductible or out-of-pocket maximum.7. For two person or family coverage, expenses incurred by each person accumulates and is credited toward

the one family deductible. The Plan will not pay benefits until the family deductible amount has beencompletely satisfied by any combination of covered participants included under two person or family

coverage.8. If a generic version of a drug is located on the Preventive Drug List, any drug on the list will not be

subject to the calendar year deductible and will be payable at 100%. All other drugs covered under thePlan will be subject to the deductible. A copy of the Preventive Drug List is available in your enrollmentmaterials.


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NWN Corporation

Deductible Plan



DeductibleThe amount an individual or family must pay each calendar year beforepayments begin for services.

$250 per individual$500 per family

$500 per individual$1,000 per family


Out-of-Pocket Expense LimitThe maximum amount of money that any individual or family will have topay towards covered health expenses during any one calendar year.




Physicians Office VisitsOne copayment per physician per day.

Primary Care Physician:

$25 copaymentSpecialist:

$50 copayment

Deductible; 60%

Outpatient Lab and X-Ray ServicesDeductible; 80% Deductible; 60%

High Tech Radiology Services (MRI, PET, CAT Scans)Deductible; 80% Deductible; 60%

Ambulance ServicesDeductible; 80%


Emergency Room ServicesDeductible; 80%


Outpatient Short Term Rehab TherapyPhysical Therapy, Occupational Therapy, Speech Therapy, Aquatic

Therapy, Respiratory Therapy, and Cardiac Rehabilitation (phase I & II)limited to a combined maximum of 60 visits per calendar year.


Durable Medical EquipmentDeductible; 80% Deductible; 60%

Chiropractic CareMaximum of 20 visits per calendar year. $50 copayment Deductible; 60%





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NWN Corporation

Deductible Plan



Home Health CareMaximum of 100 visits per calendar year. Deductible; 80% Deductible; 60%

Hospice CareDeductible; 80% Deductible; 60%

Inpatient Hospital CareDeductible; 80% Deductible; 60%

Outpatient Facility Day SurgeryDeductible; 80% Deductible; 60%

Maternity Care Initial Office VisitOne copayment per pregnancy.

First Visit:Primary Care Physician:


$50 copayment

Deductible; 60%


100% Deductible; 60%

Inpatient Maternity Care - DeliveryDeductible; 80% Deductible; 60%

Infertility Treatment (for diagnosis only) Primary Care Physician:$25 copayment

Specialist:$50 copayment

Deductible; 60%

Nutritional EvaluationMaximum of 3 visits per calendar year (does not apply to diabetes). Deductible; 80% Deductible; 60%

Inpatient Mental Health/Substance Abuse ServicesDeductible; 80% Deductible; 60%

Outpatient Mental Health/Substance Abuse Services$25 copayment Deductible; 60%

ProstheticsDeductible; 80% Deductible; 60%

Second Surgical Opinion Primary Care Physician:$25 copayment


Deductible; 60%

Temporomandibular Joint DisorderDeductible; 80% Deductible; 60%

Tobacco Abuse Office Visit Primary Care Physician:$25 copaymentSpecialist:

$50 copayment

Deductible; 80%


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NWN Corporation

Deductible Plan



Wigs, Toupees or Hairpieces Related to Cancer TreatmentMaximum of $500 per calendar year. Deductible; 80%



100%

Transplant Services At Another Transplant FacilityDeductible; 80% Deductible; 60%



Prescription Drug Benefit (Retail per 30 Day Supply)Generic DrugPreferred Name DrugNon-Preferred Name Drug

80%70% to $50/script50% to $100/script

Not Covered

Prescription Drug Benefit (Mail Order 90 Day Supply)Generic DrugPreferred Name DrugNon-Preferred Name Drug


N/A


NOTES:1. This Plan is participating with Blue Cross Blue Shield of Massachusetts preferred provider network as

well as the BlueCard Program. These preferred providers will bill the Contract Administrator directly andwrite off charges that exceed their contractual allowances.

2. All covered charges billed by non-participating providers will be subject to a maximum allowable benefit.3. All other covered benefits not listed above will be subject to deductible, then payable at 80% in-

network and subject to deductible, then payable at 60% out-of-network.4. All in and out-of-network benefit maximums are combined.5. All in and out-of-network deductible and coinsurance amounts are combined.6. Copayments and precertification penalties are not applied to the deductible or out-of-pocket maximum.


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NWN Corporation

Copay Plan



DeductibleThe amount an individual or family must pay each calendar year beforepayments begin for services.

None$500 per individual$1,000 per family


Out-of-Pocket Expense LimitThe maximum amount of money that any individual or family will have topay towards covered health expenses during any one calendar year.

None$6,000 per individual$12,000 per family


Physicians Office VisitsOne copayment per physician per day.

Primary Care Physician:


$50 copayment

Deductible; 60%

Outpatient Lab and X-Ray Services100% Deductible; 60%

High Tech Radiology Services (MRI, PET, CAT Scans)$375 copayment Deductible; 60%

Ambulance Services100% 100%

Emergency Room ServicesCopayment waived if admitted. $250 copayment $250 copayment

Outpatient Short Term Rehab TherapyPhysical Therapy, Occupational Therapy, Speech Therapy, AquaticTherapy, Respiratory Therapy, and Cardiac Rehabilitation (phase I & II)limited to a combined maximum of 60 visits per calendar year.

$50 copayment Deductible; 60%

Durable Medical Equipment100% Deductible; 60%

Chiropractic CareMaximum of 20 visits per calendar year. $50 copayment Deductible; 60%




!


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NWN Corporation

Copay Plan



Home Health CareMaximum of 100 visits per calendar year. 100% Deductible; 60%

Hospice Care100% Deductible; 60%

Inpatient Hospital Care $750 copayment peradmission

Deductible; 60%

Outpatient Facility Day Surgery $250 copayment persurgery

Deductible; 60%

Maternity Care Initial Office Visit

One copayment per pregnancy.

First Visit:

Primary Care Physician:$25 copayment


Deductible; 60%



Inpatient Maternity Care - Delivery $750 copayment peradmission

Deductible; 60%

Infertility Treatment (for diagnosis only) Primary Care Physician:$25 copayment


Deductible; 80%

Nutritional EvaluationMaximum of 3 visits per calendar year (does not apply to diabetes). 100% Deductible; 60%

Inpatient Mental Health/Substance Abuse Services $750 copayment peradmission

Deductible; 60%

Outpatient Mental Health/Substance Abuse Services$25 copayment Deductible; 60%

Prosthetics100% Deductible; 80%

Second Surgical Opinion Primary Care Physician:$25 copayment


Deductible; 60%

Temporomandibular Joint Disorder100% Deductible; 60%

Tobacco Abuse Office Visit Primary Care Physician:


$50 copayment

Deductible; 60%

"


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NWN Corporation

Copay Plan



Wigs, Toupees or Hairpieces Related to Cancer TreatmentMaximum of $500 per calendar year. 100% 100%


100%

Transplant Services At Another Transplant Facility $750 copayment peradmission

Deductible; 60%



Prescription Drug Benefit (Retail per 30 Day Supply)Generic DrugPreferred Name DrugNon-Preferred Name Drug


Not Covered

Prescription Drug Benefit (Mail Order 90 Day Supply)Generic DrugPreferred Name DrugNon-Preferred Name Drug


N/A


NOTES:1. This Plan is participating with Blue Cross Blue Shield of Massachusetts preferred provider network as well

as the BlueCard Program. These preferred providers will bill the Contract Administrator directly and writeoff charges that exceed their contractual allowances.

2. All covered charges billed by non-participating providers will be subject to a maximum allowable benefit.3. All other covered benefits not listed above will be payable at 100% in-network and subject to deductible,

then payable at 60% out-of-network.4. All in and out-of-network benefit maximums are combined.5. Copayments and precertification penalties are not applied to the deductible or out-of-pocket maximum.

#


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GENERAL PROVISIONS

PLAN ENROLLMENT

Eligibility: Only employees who satisfy the eligibility requirements set forth in the General

Information section are eligible for coverage under this Plan. The dependent(s) of a coveredemployee will become eligible for coverage on the date of the employees eligibility for coverage oron the date which the employee acquires the dependent.

If an employee and spouse are both eligible for coverage as employees under the Plan, only one (1)will be eligible to enroll dependent(s). Also, an employee cannot be covered as an employee and adependent.

Plan Enrollment: To become covered under the Plan, an employee must enroll themselves and/ortheir dependents for coverage within thirty (30) days of the eligibility date. The employee anddependents will be enrolled when a benefit enrollment form is completed, signed, and delivered tothe employer within the time limit. Should the enrollment occur more than thirty (30) days

following the eligibility date, the employee and/or dependents will only be eligible to enroll duringthe annual open enrollment period described below or, in certain circumstances, during a specialenrollment period. Should multiple plan options exist, an employee may switch plan options duringan annual open enrollment period or special enrollment period.

Annual Open Enrollment Period: There will be an annual open enrollment period during the one (1)month period preceding the Plans anniversary date. The effective date of coverage will be thePlans anniversary date. Any eligible employee or dependents enrolling on the Plans anniversarydate, who did not have coverage under the Plan prior to the open enrollment period, will be subjectto the Plans preexisting condition limitation provision.

Special Enrollment Periods: Individuals are eligible for special enrollment for the following reasons:

1. If an employee acquires a dependent through marriage, civil union, domestic partnership,birth, adoption, or placement for adoption, the dependent (and if not otherwise enrolled, theemployee and eligible dependents) may be enrolled under this Plan. The request to enrollmust be within thirty (30) days of the event. If enrollment is not requested within thirty(30) days following the event, the dependents will only be eligible to enroll during the annualopen enrollment period. The effective date of coverage in the case of marriage, civil union,or domestic partnership will be the first day of the first calendar month following the date ofmarriage, civil union, or domestic partnership. The effective of coverage in the case ofbirth, adoption, or placement for adoption will be the date of the event.

2. If an employee declines enrollment in the Plan for themselves or their dependents becausethe employee or dependents have other health coverage, the employee may in the future beable to enroll themselves and/or their dependents in the Plan, provided they are otherwiseeligible for coverage under the terms of the Plan, they meet certain conditions including anyone of those set forth below and they request enrollment within thirty (30) days of thatcondition being satisfied:

when enrollment was declined under this Plan for employee and/or dependentcoverage, the employee and/or dependent had COBRA continuation coverage underanother health plan, and COBRA continuation coverage under that other plan has sincebeen exhausted; or


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if the other coverage that applied to the employee and/or dependent when coveragewas declined was not COBRA continuation coverage, employer contributions towardthe other coverage have ceased, regardless of whether coverage under the otheremployers plan has terminated; or

if the other coverage that applied to the employee and/or dependent when coveragewas declined was not COBRA continuation coverage, the other coverage has been

terminated as a result of:a. loss of eligibility as a result of legal separation, dissolution of domestic

partnership, termination of a civil union, divorce, death, termination ofemployment, or reduction in the number of hours of employment, and any lossof eligibility after a period that is measured by reference to any of theforegoing; or

b. the employee and/or dependent moving out of an HMO service area if HMOcoverage terminates for that reason and, no other plan options are available tothe employee/dependent; or

c. the other plan ceasing to offer coverage to the group of similarly situatedindividuals that include the employee and/or dependent; or

d. the dependent losing dependent status per plan terms; ore. the other plan terminating a benefit package option and no substitution is

offered.

The effective date of coverage will be the first day of the month following the date of the loss ofthe other coverage. The Plans waiting period will not be applied. However, the preexistingcondition limitations provision will apply.

3. If an employees or dependents Medicaid or Childrens Health Insurance Program (CHIP)coverage is terminated as a result of loss of eligibility, or if the employee or dependentbecomes eligible for a state-granted premium subsidy towards employer health coverageunder either Medicaid or CHIP, the employee may request to be enrolled in this Plan. Theemployees request to enroll must be made within sixty (60) days of the date on which theemployee or dependent either (a) loses eligibility under Medicaid or CHIP or (b) becomes

eligible for a state-granted premium subsidy towards employer health coverage under eitherMedicaid or CHIP. The effective date of coverage will be the first day of the monthfollowing the employees request to enroll in this Plan.

Qualified Medical Child Support Orders: If an employee is required to provide benefits for hisdependent child under the direction of a court order and the employee is not enrolled in the Plan, theemployee may enroll himself and his dependent child provided enrollment is requested within thirty(30) days of issuance of the court order. The Plans open enrollment provision will not apply. Theeffective date of coverage will be the date of the court order. However, if the employee has not yetsatisfied the Plans waiting period, coverage will become effective after satisfaction of such waitingperiod.

Disability Leave: Coverage under the Plan will be continued by the employer following the date of

the disability leave of the employee for a period of three (3) months, or until employment isterminated by the employer or the employee.

General Leave of Absence: Coverage under the Plan will be continued by the employer followingthe date of an approved leave of absence for a period of three (3) months, or until employment isterminated by the employer or the employee.


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PREEXISTING CONDITION LIMITATION

Employees and their dependent(s) who enroll for coverage under this Plan will be subject to thefollowing preexisting condition limitation provision:

Should a covered person incur expenses for treatment, advice, or medication for an illness or

injury during the three (3) month period immediately preceding the individuals enrollmentdate, no benefits will be payable with respect to such illness or injury, until after theindividual has been enrolled under the Plan for a period of twelve (12) consecutive months.The enrollment date is the first day of coverage under the Plan or, if there is a waiting period,the first day of the waiting period. This date is frequently, but not always, the date of hire.

The following conditions exempt covered employees and their dependent(s) from the preexistingcondition limitation provision:

A. an individual has been continuously covered for at least twelve (12) monthsby creditable coverage, as defined herein, with a break in coverage of sixty-three (63) days or less; or

B. newborns or children who are adopted or placed for adoption and enrolled inany creditable coverage within thirty (30) days; or

C. pregnancy; or

D. genetic predisposition without a diagnosis; or

E. all individuals under nineteen (19) years of age.

Credit Toward Preexisting Period: Any individual seeking to reduce or eliminate a preexistingcondition limitation period based on creditable coverage may do so by providing a written certificate

of creditable coverage to the Contract Administrator. All covered individuals who werecontinuously covered by creditable coveragewith a break in coverage of sixty-three (63) days orless, as defined herein, prior to their enrollment under this Plan will be given credit for each monthof coverage toward this Plans preexisting condition limitation period.

If a covered individual had prior coverage for which they think they should have received acertificate but did not, or were given a certificate but lost it, they may ask the former plan or issuerto provide them with a certificate or replacement certificate. The Human Resource Department willassist in obtaining a certificate from any prior plan or issuer if necessary.


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COORDINATION OF BENEFITS (COB)

Should a covered person be enrolled in this Plan while enrolled in any other plan providing similarbenefits, Coordination of Benefits (COB) rules control whether benefits are payable under this Planbefore those of the other plans. The benefits payable under this Plan will not be reduced where theCOB rules provide that this Plan pays first. The benefits payable under this Plan may, however, be

reduced where the COB rules provide that another plan pays first. In any case, the total of allbenefits payable under all plans will not exceed 100% of the allowable expenses, and no plan willpay more than it would otherwise pay in the absence of the COB rules.

If a plan does not have its own COB rules, it will be primary to this Plan (that is, it will pay benefitsbefore this Plan does).

Even if a plan does have its own COB rules, the first of this Plans following COB rules to apply willdetermine which of the plans is primary:

1. Non-Dependent/Dependent Any plan under which the covered person is covered as anemployee, member or subscriber (that is, other than as a dependent) will pay first. Anyplan under which the covered person is covered as a dependent of the employee will paysecond.

2. Dependent Child/Parents Not Separated or Divorced If a dependent child is coveredunder the plans of both the childs parents, and the parents are not separated ordivorced (regardless of whether they were ever married), the plan of the parent whosebirth date occurs earlier in the calendar year will pay first, and the plan of the parentwhose birth date occurs later in the calendar year will pay second. If the birth dates ofthe parents are the same, the plan which has covered a parent for the longest period oftime will pay benefits before the plan of the other parent.

3. Dependent Child/Separated or Divorced Parents Where a dependent child is coveredunder the plans of both parents, the parents are separated or divorced from one another,

and there is otherwise no court decree setting forth the responsibility for the childshealth care costs:

a) the plan under which the child is covered as a dependent of the custodialparent will pay first;

b) the plan under which the child is covered as a dependent of the custodialparents spouse will pay second; and

c) the plan under which the child is covered as a dependent of thenoncustodial parent will pay third.

4. Active/Inactive Employee Any plan under which the covered person is covered as anactive employee (or as that employees dependent) will pay first. Any plan under whichthe covered person is covered as a laid off or retired employee (or as that employeesdependent) will pay second. If the other plan does not have this rule, and if, as a result,the plans do not agree on the order of benefits, this rule is ignored.


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5. Continuation Coverage Any plan under which the covered person is covered as anemployee (or as that employees dependent) will pay first. Any plan under which thecovered person is covered under a right of continuation as provided under federal orstate law (for example, under the Consolidated Omnibus Budget Reconciliation Act of1985), will pay second. If the other plan does not have this rule, and if, as a result, theplans do not agree on the order of benefits, this rule is ignored.

If none of the above rules determine the order of benefits, the plan which has covered the eligibleperson for the longest period of time will pay first; the plan which has covered the eligible personfor the shortest period of time will pay last.

Right to Receive and Release Needed Information: The Plan may release or receive any informationneeded to enforce this provision. Any person claiming benefits under this Plan must furnish the Planwith any information requested by the Plan to enforce the COB provisions in accordance with theHIPAA Privacy Requirements.

Right to Make Payments: Should another plan provide benefits which should have been paid by thisPlan, the Plan has the right to make payment to the other plan directly. That payment will satisfythe obligation of this Plan.

Right to Recovery: The Plan has the right to recover from the covered person any overpaymentmade if the Plan was not made aware of the other available benefits.

Coordination with Other Liability: This Plan will pay benefits secondary to the covered personspersonal automobile insurance (including, but not limited to, no-fault insurance and uninsuredmotorist coverage) or other liability insurance policies through which medical payments may bemade for expenses resulting from or in connection with an accidental injury.

Coordination with Prescription Claims: There is no coordination of benefits with prescription drugs.


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TERMINATION OF BENEFITS

An employees and/or a dependents coverage under the Plan will terminate:

1. on the date the Plan terminates; or

2. on the last day of the month in which an employee withdraws from the Plan; or

3. on the last day of the month in which an employee is terminated, unlesscontinuation of coverage, as provided herein, is elected; or

4. on the last day of the month in which a dependent withdraws from the Plan or adependent ceases to meet the definition of a dependent as defined herein ordependent coverage is discontinued under the Plan for any reason, unlesscontinuation of coverage, as provided herein, is elected; or

5. on the date an employee or dependent enters the military, naval, or air force of anycountry or international organization on a full-time, active duty basis other thanscheduled drills or other training not exceeding one (1) month in any calendar year(see Military Leave section below); or

6. on the last date of the period for which contribution has been made if the employeefails to make any required contribution.

The Plan Sponsor, in its sole discretion, may cause a covered persons coverage under the Plan toterminate if the covered person provides false information or makes misrepresentations inconnection with a claim for benefits; permits a non-participant to use a membership or otheridentification card for the purpose of wrongfully obtaining benefits; obtains or attempts to obtainbenefits by means of false, misleading or fraudulent information, acts or omissions; fails to makeany copayment, supplemental charge, or other amount due with respect to a benefit; behaves in amanner disruptive, unruly, abusive, or uncooperative to the extent that the Plan is unable to providebenefits to him or her; or threatens the life or well-being of personnel administering the Plan or ofproviders of services or benefits.

MILITARY LEAVE

The Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA") providesspecial continuation coverage to covered employees who otherwise lose health insurance coverageunder the Plan because they leave employment to serve in the uniformed services. Under USERRA,affected covered employees and their dependents must be offered the right to continue coverage forup to twenty-four (24) months. The employer may charge 102% of the applicable premium, providedthe length of the military leave is longer than thirty (30) days. However, on the date that the employee

completes his active duty and returns to full-time employment, the employee and his eligible dependentswill be re-enrolled in the Plan and coverage will be provided immediately. However, any limitations on theemployees or dependents coverage which were in affect before the active military duty leave willcontinue to apply.


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EXTENSION OF BENEFITS (COBRA)

Qualified beneficiaries may elect to continue coverage under the Plan when their coverageterminates due to a qualifying event. Depending on the type of qualifying event, qualifiedbeneficiaries can include the employee covered under the Plan and the employees covereddependents. These rights are protected under the Consolidated Omnibus Budget Reconciliation Act(COBRA) of 1986.

A child who is born to or placed for adoption with the covered employee during a period of COBRAcoverage will be eligible to become a qualified beneficiary. In accordance with the terms of the Planand the requirements of federal law, these qualified beneficiaries can be added to COBRA coverageupon proper notification to the Plan Administratorof the birth or adoption.

Continuation coverage is the same coverage that the Plan gives to other participants or beneficiariesunder the Plan who are not receiving continuation coverage. Each qualified beneficiary who electscontinuation coverage will have the same rights under the Plan as other participants or beneficiariescovered under the Plan.

The employee has the right to choose COBRA continuation of coverage under the Plan if coverage

terminates for any of the following qualifying events:

1. The employees termination of employment for reasons other than gross misconduct.

2. The employees retirement or reduction in hours of employment.

The employees spouse has the right to choose COBRA continuation of coverage under the Plan ifcoverage terminates for any of the following qualifying events:



3. The employees death.

4. The employees divorce, legal separation, termination of a civil union, or terminationof domestic partnership.

5. The employee becomes enrolled in Medicare benefits (Part A, Part B or both).

The employees dependent children have the right to choose COBRA continuation of coverage underthe Plan if coverage terminates for any of the following qualifying events:



3. The employees death.

4. The employees divorce, legal separation, termination of a civil union, or terminationof domestic partnership.

5. The employee becomes enrolled in Medicare benefits (Part A, Part B or both).


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6. The employees dependent child ceases to be an eligible dependent as such term isdefined in the Plan.

Similar rights may apply to certain retirees, spouses, and dependent children if the employercommences a bankruptcy proceeding and these individuals lose coverage.

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan

Administrator has been notified that a qualifying event has occurred. When the qualifying event isthe end of employment or reduction of hours of employment, death of the employee, or enrollmentof the employee in Medicare (Part A, Part B, or both), the employer must notify the ContractAdministratorof the qualifying event within thirty (30) days of any of these events on the formprovided by the Contract Administrator to the employer.

For the other qualifying events (divorce or legal separation of the employee and spouse, terminationof a civil union, or termination of a domestic partnership, or a dependent childs losing eligibility forcoverage as a dependent child), the qualified beneficiary must notify the Plan Administrator. ThePlan Administrator must be notified in writing within sixty (60) days after the qualifying eventoccurs.

Once the Plan Administratorreceives notice that a qualifying event has occurred, COBRA

continuation coverage will be offered to each of the qualified beneficiaries. The Plan Administratormust notify the qualified beneficiary in writing of their right to COBRA continuation of coveragewithin fourteen (14) days from the date the Plan Administrator is notified of a qualifying event.

The qualified beneficiary has sixty (60) days from the date of the written notice or qualifying event,whichever is later, to notify the Plan Administratorof their decision to elect COBRA continuation ofcoverage. To receive COBRA continuation of coverage, no evidence of insurability will be required,but a monthly premium will be charged. If continuation of coverage is not elected on a timely basis,group health insurance coverage will end.

If Medicare entitlement occurs prior to a qualifying event, then COBRA begins on the date ofMedicare entitlement.

For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation

coverage will begin on the day following the date of the qualifying event.COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event isthe death of the employee, the employees divorce or legal separation, dissolution of a civil union, ortermination of a domestic partnership, or a dependent child losing eligibility as a dependent child,COBRA continuation coverage lasts for up to thirty-six (36) months.

If a qualifying event that is a termination of employment or reduction of hours occurs withineighteen (18) months after the covered employee becomes enrolled in Medicare, then the maximumcoverage period for the spouse and dependent children who are qualified beneficiaries receivingCOBRA coverage will end thirty-six (36) months from the date the employee became enrolled inMedicare (but the covered employees maximum coverage period will be eighteen (18) months).This extension is available only if the covered employee becomes enrolled in Medicare withineighteen (18) months before the termination of employment or reduction of hours occurs.

When the qualifying event is the end of employment or reduction of the employees hours ofemployment, COBRA continuation coverage lasts for up to eighteen (18) months. There are twoways in which this eighteen (18) month period of COBRA continuation coverage can be extended.

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Disability extension of 18-month period of continuation coverage

If a qualified beneficiary is determined by the Social Security Administration to be disabled at anytime during the first sixty (60) days of COBRA continuation coverage and the Plan Administrator isnotified in a timely fashion, the employee and his covered dependents can receive up to anadditional eleven (11) months of COBRA continuation coverage, for a total maximum of twenty-nine(29) months. The qualified beneficiary must make sure that the Plan Administrator is notified in

writing of the Social Security Administrations determination within sixty (60) days of the date ofthe determination and before the end of the eighteen (18) month period of COBRA continuationcoverage. If a qualified beneficiary is determined by the Social Security Administration to no longerbe disabled, then the beneficiary must notify the Plan within thirty (30) days of determination by theSocial Security Administration.

Second qualifying event extension of 18-month period of continuation coverage

If the employees family experiences another qualifying event while receiving COBRA continuationcoverage, the spouse and dependent children can get additional months of COBRAcontinuationcoverage, up to a maximum of thirty-six (36) months. This extension is available to the spouse anddependent children if the former employee dies, gets divorced, legally separated, terminates a civil

union, or terminates a domestic partnership. This extension may be available to a spouse ordependents if the former employee enrolls in Medicare. The extension is also available to adependent child when that child stops being eligible under the Plan as a dependent child.In all ofthese cases, the qualified beneficiary must make sure that the Plan Administrator is notified in

writing of the second qualifying event within sixty (60) days of the second qualifying event.

In no event will COBRA coverage continue beyond thirty-six (36) months from the date of theoriginal qualifying event.

Monthly Premium

1. The monthly premium will be 102% or, if applicable, 150% of the applicablepremium (which for self-funded plans, is based on reasonable actuarial estimates oron past costs). All premium payments are due in advance and include the cost ofthe next month of COBRA continuation of coverage.

2. The initial premium payment is due within forty-five (45) days of electing COBRAcontinuation of coverage. The payment must cover all premiums due from the dateof the qualifying event.

3. The maximum grace period for payment of monthly COBRA coverage premiums willnot exceed thirty (30) days from the due date established by the Plan Administratoror their authorized agent.

Termination of COBRA continuation coverage

COBRA continuation of coverage may be terminated prior to the expiration of the applicable timeperiod as follows:

1. The Plan Administrator no longer provides group health and/or dental coverage toany of its employees.

2. The applicable monthly premium for COBRA coverage is not paid within thirty (30)days of the established due date.

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3. The person who has elected COBRA coverage becomes enrolled in Medicare benefits(Part A, Part B or both). COBRA coverage will terminate on the first day of thepersons birthday month. Should the persons birthday be on the first day of themonth, then COBRA coverage will terminate on the first day of the month prior tothe persons birthday.

4. The qualified beneficiary who has elected COBRA coverage becomes covered under

another group health and/or dental plan which does not contain any exclusion orlimitation with respect to any preexisting condition of such covered person.

(NOTE: Should COBRA continuation provide coverage for such preexistingconditions, COBRA continuation of coverage will be primary for the applicablepreexisting conditions only and will provide secondary coverage to all other coveredexpenses.)

5. The unique disability continuation period will end as of the first day of month thatbegins more than thirty (30) days after the date of final determination under theSocial Security Act that the qualified beneficiary is no longer disabled.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts the extent towhich group health plans may impose pre-existing condition limitations. HIPAA coordinatesCOBRA's other coverage cut-off rule with these new limits as follows.

If the covered employee becomes covered by another group health plan and that plan contains apre-existing condition limitation that affects the covered employee, the covered employee's COBRAcoverage cannot be terminated. However, if the other plan's pre-existing condition rule does notapply to the covered employee by reason of HIPAA's restrictions on pre-existing condition clauses,the Plan may terminate the covered employee's COBRA coverage.

The covered employee does not have to show that he or she is insurable to choose continuationcoverage. However, continuation coverage under COBRA is provided subject to the coveredemployee's eligibility for coverage; the Plan Administrator reserves the right to terminate the

covered employee's coverage retroactively if he or she is determined to be ineligible.

Trade Act of 2002

Pursuant to the Trade Act of 2002, special COBRA rights apply to employees who have beenterminated or experienced a reduction of hours and who qualify for a trade readjustment allowanceor alternative trade adjustment assistance under another federal law called the Trade Act of 1974.These employees are entitled to a second opportunity to elect COBRA coverage for themselves andcertain family members (if they did not already elect COBRA coverage), but only within a limitedperiod of sixty (60) days (or less) and only during the (6) six months immediately after their grouphealth plan coverage ended. In addition, the Trade Act of 2002 created a new tax credit for certainindividuals who become eligible for trade adjustment assistance (eligible individuals). Under the new

tax provisions eligible individuals can either take a tax credit or get advance payment of 65% ofpremiums paid for qualified health insurance, including continuation coverage. If you have questionsabout these new tax provisions, you may call the Health Care Tax Credit Customer Contact Centertoll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. Moreinformation about the Trade Act is also available at www.doleta.gov/tradeact/2002act_index.asp.

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If you qualify or may qualify for assistance under the Trade Act of 2002, contact the PlanAdministrator for additional information. You must contact the Plan Administrator promptly afterqualifying for assistance under the Trade Act of 2002 or you will lose your special COBRA rights.

Keep Plan Informed of Address Changes

In order to protect the participants familys rights, the participant should keep the Plan

Administrator informed of any changes in the addresses of family members. The participant shouldalso keep a copy, for his or her records, of any notices sent to the Plan Administrator.


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PLAN DETAILS

Preferred Provider Network Program

The Plan includes access to Blue Cross Blue Shield of Massachusetts preferred provider networkand the BlueCard Program in order to obtain discounts from participating providers for covered

medical care. The plan identification card identifies the selected preferred provider network and acurrent list of the participating providers will be furnished to covered persons automatically by thePlan Sponsor. Use of the network is voluntary and the benefits of utilizing participating providersinclude provider fee discounts, direct billing to the Plan for covered services, and network providerwrite-offs of any charges in excess of the discounted fee schedule.

If a covered person is referred by an in-network provider to a specialist and no provider exists forthat area of specialty within the preferred provider network, then the covered person may seekservices of an out-of-network specialist and benefits for covered services will be paid as thoughthey were furnished by an in-network provider.

Benefits related to covered services that begin at an in-network facility or provider, andsubsequently result in charges from an out-of-network facility or provider, will be paid at the in-network benefit level subject to the maximum allowable benefit. (Example: Laboratory work for asample that is drawn during a visit to an in-network physician or hospital, and the sample issubsequently sent to an out-of-network lab or pathologist, then the laboratory fees and pathologistfees will be paid at the in-network benefit level subject to the maximum allowable benefit.) Shouldthe covered person choose services from an out-of-network provider or facility, then the serviceswill be paid at the out-of-network benefit level.

The BlueCard Program

When you receive health care services through BlueCard outside the geographic area covered byBlue Cross Blue Shield of Massachusetts preferred provider network, claims processing iscoordinated with the out-of-area Blue Cross Blue Shield plans through the BlueCard Program. Theamount you pay for covered services is calculated on the lower of:

the actual billed charges for your covered services; or the negotiated price that the local Blue Cross Blue Shield Plan (Host Blue) passes on to us.

Often, this "negotiated price" will consist of a simple discount which reflects the actualprice paid by the Host Blue. However, sometimes it is an estimated price that factors into theactual price expected settlements, withholds, any other contingent payment arrangements and non-claims transactions with your health care provider or with a specified group of providers. Thenegotiated price may also be billed charges reduced to reflect an average expected savings withyour health care provider or with a specified group of providers. The price that reflects averagesavings may result in greater variation (more or less) from the actual price paid than will theestimated price. The negotiated price may also be prospectively adjusted to correct for over- orunderestimation of past prices. However, the amount you pay is considered a final price. Statutesin a small number of states may require the Host Blue to use a basis for calculating member liability

for covered services that does not reflect the entire savings realized, or expected to be realized, ona particular claim or to add a surcharge. Should any state statutes mandate member liabilitycalculation methods that differ from the usual BlueCard method noted above in paragraph one ofthis section or require a surcharge, the Contract Administrator would then calculate your liability forany covered health care services in accordance with the applicable state statute in effect at the timeyou received your care.


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Preventive Care: Charges for routine physical examinations, well-baby care, and well-adult care arecovered expenses. Charges can include examinations (including breast and pelvic), immunizations(including travel immunizations), consultations, laboratory tests, pap smears (including laboratoryfees) (1 exam per calendar year), x-rays, fecal blood cultures (1 per calendar year), PSA tests andprostate exams (1 exam per calendar year), colonoscopies, sigmoidoscopies, mammograms (seelimits below), and EKGs. Please see the applicable Schedule of Benefits section to determine

payment level. A current listing of additional preventive care services as required under The PatientProtection and Affordable Care Act can be accessed atwww.healthcare.gov by clicking on thePrevention & Wellness link.

Routine Mammogram Limits:

One (1) baseline mammogram for a covered person age 35 to age 40.

One (1) mammogram every other year for a covered person age 40 to age 50.

One (1) mammogram per calendar year for a covered person age 50 and older.

Physicians Office Visits (does not apply to High Deductible Plan): Charges for physicians officevisits when the employee or their dependent(s) incur expenses as a result of an illness or accidentalinjury are covered expenses. Please see the applicable Schedule of Benefits section to determinepayment level. The provision applies to any additional services provided at the time of the visit. Ifthere are services provided in the physicians office, but there is not an office visit charge, theservices will not be subject to the copayment mentioned above and will be payable at 100%.

Outpatient Lab and X-Ray Services: Charges for outpatient diagnostic laboratory exams and x-raysrendered in an outpatient laboratory, independent laboratory, or radiology facility are coveredexpenses. Please see the applicable Schedule of Benefits section to determine payment level.

High Tech Radiology Services (MRI, PET Scans, CAT Scans): Charges for high technology radiologyservices such as MRIs, PET Scans, and CAT Scans are covered expenses. Please see theapplicable Schedule of Benefits section to determine payment level.

Ambulance Services: Charges for medically necessary ground ambulance services for inpatients or

for outpatients receiving accident or illness care to and from the hospital or medical facility wheretreatment is given are covered expenses. Please see the applicable Schedule of Benefits sectionto determine payment level. Air ambulance is considered a covered expense if it is medicallynecessary and the ground ambulance is not advisable.

Emergency Room Services: Charges for emergency room services are covered expenses. Chargesmay include facility fees, physician fees, x-rays, laboratory tests, and other necessary services andsupplies, unless otherwise specified herein. Please see the applicable Schedule of Benefitssection to determine payment level. The amount the plan pays for out-of-network benefits (e.g.maximum allowable benefit), will be reduced by the in-network copayment or coinsurance that theindividual would be responsible for if the emergency services were provided in-network.

Outpatient Short Term Rehab Therapy: Charges for outpatient physical therapy, occupational

therapy, speech therapy, aquatic therapy, respiratory therapy, and cardiac rehabilitation (phase I &II) are covered expenses to a combined maximum of sixty (60) visits per covered person percalendar year. Please see the applicable Schedule of Benefits section to determine payment level.


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Durable Medical Equipment: Charges for durable medical equipment, as defined herein, are coveredexpenses. Please see the applicable Schedule of Benefits section to determine payment level.Durable medical equipment in excess of $750 requires pre-certification. Please see the Pre-Admission Certification Penalty section for details.

Chiropractic Care: Charges for home, office, and nursing home visits, as well as examinations, x-

rays, consultations, spinal manipulations, electrical stimulation, and interpretation are coveredexpenses to a maximum of twenty (20) visits per covered person per calendar year. Please see theapplicable Schedule of Benefits section to determine payment level.

Convalescent Hospital/Extended Care Facility/Skilled Nursing Facility: Charges for confinement in aconvalescent hospital/extended care facility/skilled nursing facility are covered expenses to amaximum of sixty (60) days per covered person per calendar year. Please see the applicableSchedule of Benefits section to determine payment level. Confinement in a convalescenthospital/extended care facility/skilled nursing facility requires pre-certification. Please see the Pre-Admission Certification Penalty section for details.

Home Health Care: Charges for home health care services are covered expenses to a maximum ofone hundred (100) visits per covered person per calendar year. Please see the applicable Scheduleof Benefits section to determine payment level. Home health care services require pre-certification.Please see the Pre-Admission Certification Penalty section for details.

Hospice Care: Charges for hospice care services are covered expenses. The covered person mustbe terminally ill with an anticipated life expectancy of about six (6) months. Please see theapplicable Schedule of Benefits section to determine payment level.

Inpatient Hospital Care: Charges for inpatient hospital services may include room and board,operating room, x-rays, physical therapy, radiation therapy, chemotherapy, prescription drugs,anesthesia, laboratory expenses, intensive care unit, physician charges, and other necessaryservices and supplies, unless otherwise specified herein, incurred during any period of hospitalconfinement are covered expenses. Please see the applicable Schedule of Benefits section to

determine payment level. Inpatient hospital admissions requires pre-certification. Please see thePre-Admission Certification Penalty section for details.

Outpatient Facility Day Surgery: Charges for outpatient surgery including charges for x-ray andlaboratory expenses, surgeon, assistant surgeon, anesthesiologists, and any other necessaryservices and supplies, unless otherwise specified herein, are covered expenses. Please see theapplicable Schedule of Benefits section to determine payment level.

Maternity Care Initial Office Visit: Charges for the initial office visit for maternity care are coveredexpenses. Please see the applicable Schedule of Benefits section to determine payment level.

Outpatient Maternity Care (other than initial office visit): Charges for outpatient maternity care,including charges for subsequent office visits (other than the initial visit), x-ray and laboratory

expenses, and professional/facility expenses are covered expenses. Please see the applicableSchedule of Benefits section to determine payment level.

Inpatient Maternity Care: Charges for inpatient maternity care are covered expenses. Please seethe applicable Schedule of Benefits section to determine payment level.


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Infertility Treatment (for diagnosis only): Charges for infertility treatment are covered expenses.Benefits include charges for diagnostic services. If another medical condition is identified throughthe course of diagnostic testing, any coverage of that condition will be subject to applicable planprovisions. Please see the applicable Schedule of Benefits section to determine payment level.Infertility services do not include genetic testing.

Nutritional Evaluation: Charges for nutritional evaluations are covered expenses to a maximum ofthree (3) visits per covered person per calendar year. The maximum does not apply to coveredpersons with diabetes. Please see the applicable Schedule of Benefits section to determinepayment level.

Inpatient Mental Health/Substance Abuse Services: Charges for inpatient mental health care andalcohol and/or drug addiction in a hospital, public or licensed mental hospital, drug/alcohol abusetreatment facility are covered expenses. Please see the applicable Schedule of Benefits section todetermine payment level. Inpatient mental health/substance abuse requires pre-certification. Pleasesee the Pre-Admission Certification Penalty section for details.

Outpatient Mental Health/Substance Abuse Services: Charges for outpatient mental health servicesprovided by a board certified physician, a licensed psychologist, clinical or certified social worker orcertified alcohol counselor (C.A.C.) are covered expenses. Please see the applicable Schedule ofBenefits section to determine payment level.

Prosthetics: Charges for the initial purchase, fitting, repair and replacement of fitted prostheticdevices (artificial body parts, including limbs, eyes and larynx) which replace body parts are coveredexpenses. Please see the applicable Schedule of Benefits section to determine payment level.

Second Surgical Opinion: Charges for second surgical opinions given by a board-certified specialistin the medical field relating to the surgical procedure being proposed are covered expenses. ThePhysician providing the second opinion must not be affiliated in any way with the Physician whorendered the first opinion. Please see the applicable Schedule of Benefits section to determinepayment level.

Temporomandibular Joint Syndrome: Charges for temporomandibular joint disorder (TMJ) serviceswhich include diagnostic services and surgical treatment are covered expenses. Please see theapplicable Schedule of Benefits section to determine payment level. Orthodontic services andnon-surgical treatment of temporomandibular joint disorder (TMJ) are not covered.

Tobacco Abuse Office Visit: Charges for office visits related to tobacco abuse are coveredexpenses. Please see the applicable Schedule of Benefits section to determine payment level.

Wigs, Toupees or Hairpieces Related to Cancer Treatment: Charges for wigs, toupees, andhairpieces for hair loss due to cancer treatment are covered expenses to a maximum of$500 percovered person per calendar year. Please see the applicable Schedule of Benefits section todetermine payment level.


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Pre-Admission Certification Penalty: The Plan requires that all non-emergency hospital admissions,organ & tissue transplants, home health care, and durable medical equipment in excess of $750 bepre-certified and authorized by the Contract Administrator. This does not include hospital stays inconnection with childbirth for the mother or newborn child which are forty-eight (48) hours or lessfor vaginal deliveries, or ninety-six (96) hours or less for cesarean section deliveries. When a doctorrecommends that the employee or dependent be admitted to a hospital or receive an organ & tissue

transplant, home health care, or durable medical equipment in excess of $750, it is the employeesresponsibility to notify the Plan and to obtain pre-certification and authorization of the hospitaladmission, organ & tissue transplant, home health care, or durable medical equipment in excess of$750. It is the employees responsibility to be sure that in the event of an emergency admission,the Contract Administrator is notified within seventy-two (72) hours. Failing to obtain pre-certification will not result in a rejection of the claim, but a penalty of $750 will be applied. In theevent that an employee or dependent incur expenses for services which have not been pre-certifiedand authorized, a thorough review will be conducted of the services to determine medical necessityat the point of claim. If the review process identifies care which is not medically necessary, serviceswill not be covered under the Plan.

In order for the Plan to approve the inpatient stay, the attending physician must certify to theContract Administrator that, in the physicians professional opinion, the stay is necessary for thecondition. The Plan reserves the right to request an independent medical opinion by a physician ofthe Plans choice.

Preventive Safe Harbor Generic Medications (applies to HSA Plan only): If a generic version of adrug is located on the Preventive Drug List, any drug on the list will not be subject to the calendaryear deductible and payable at 100%. All other drugs covered under the Plan will be subject to thedeductible. A copy of the Preventive Drug List is available in your enrollment materials.

Retail Prescription Drug Plan: The Plan includes a prescription drug program. Prescriptions filled atparticipating pharmacies are limited to a maximum thirty (30) day supply. Individual prescriptionsare subject to the coinsurance amounts listed below. The High Deductible Plan is subject to thecalendar year deductible, then subject to the coinsurance amounts listed below.

Generic Copayment Preferred Brand Copayment Non-Preferred Brand Copayment80% 70% to a 50% to a

maximum of $50 per script maximum of $100 per script

A list of participating pharmacies can be obtained by visiting www.restat.com.

Prescriptions purchased at non-participating pharmacies will not be covered expenses.

Compound drugs that are not available from a participating pharmacy will be considered a coveredexpense subject to the applicable participating pharmacy coinsurance.


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Mail Order Maintenance Prescription Drug Program: Maintenance drugs to treat illnesses should bepurchased through the mail order program. These illnesses usually include: diabetes, epilepsy,anemia, chronic constipation, arthritis, high blood pressure, tuberculosis, various gastric disease,emphysema, menopause, mental and nervous disorders, thyroid disease, adrenal disease, ulcers,and any other condition that requires continuous medication. Mail order prescriptions are limited toa maximum ninety (90) day supply. Mail order prescriptions are subject to the coinsurance amounts

listed below. The High Deductible Plan is subject to the calendar year deductible, then subject tothe coinsurance amounts listed below.

Generic Copayment Preferred Brand Copayment Non-Preferred Brand Copayment80% 70% to a 50% to a

maximum of $150 per script maximum of $300 per script

Specialty Pharmacy medications are recommended to manage specific high cost medications.Specialty Pharmacy prescriptions are limited to a maximum thirty (30) day supply. Services includeaccess to, and support for, most pharmaceutical and biologic products that have high acquisitioncosts, are difficult to manage, and present reimbursement challenges. These medications aresubject to the copayments listed above.


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MEDICAL COVERED EXPENSES

Expenses incurred for the following medical, health care services, and supplies will be considered acovered expense, provided the expenses are (i) medically necessary to treat an illness or injury orfurnished in connection with participation of a covered person in a Clinical Trial, as such term isdefined here, (ii) prescribed or approved by an attending physician, and (iii) incurred during a period

that coverage was in effect in accordance with the applicable provisions of the Plan. Payment ofsuch expenses will be subject to all applicable deductibles, coinsurance limits, the maximumindividual limit, and all other limitations described herein.

1. Inpatient hospital charges for room and board, operating room, x-rays, physical therapy,radiation therapy, chemotherapy, prescription drugs, anesthesia, laboratory expenses,intensive care unit, and other necessary services and supplies during any one (1) period ofhospital confinement, as shown below. Should the facility have no semi-private rooms orless expensive accommodations available, or the patients condition requires the employeeor the employees covered dependent to be isolated for their own health or the health ofothers, the private room rate will be allowed.

Room and Board:

semi-private room allowance....................semi-private room rateprivate room allowance............................semi-private room rateintensive care allowance..........................actual charge (not to exceed the maximum

allowable benefit)

2. Outpatient hospital charges for necessary services and supplies incurred as a result of anillness, accident, or as a result of outpatient surgery performed (if performed on the sameday), including charges for x-ray and laboratory expenses, physical therapy, radiationtherapy, and chemotherapy.

3. Charges for inpatient physician visits while the employee or their dependents are hospital

confined as a result of an illness or an accidental injury. No benefits will be paid for morethan one (1) visit per day by any one (1) physician or for the treatment received inconnection with, on, or after the date of an operation for which a surgical expense benefit ispayable under the Plan if such treatment is given by the physician who performed theoperation.

4. All charges of a professional anesthesiologist, radiologist, or pathologist.

5. Charges for pre-admission testing, exams, x-ray and laboratory examinations on anoutpatient basis made before a scheduled hospital admission and related to a conditionpreviously diagnosed.

6. Charges for medically necessary ground ambulance service for inpatients or for outpatientsreceiving accident or illness care to and from the hospital or medical facility where treatmentis given. Air ambulance is considered a covered expense if it is medically necessary and theground ambulance is not advisable.

7. Emergency room charges for treatment of an illness or an accidental injury.

8. Diagnostic x-rays and laboratory charges for expenses incurred as a result of an illness orinjury. No benefits are payable for dental care except as provided for in this Plan.

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9. Charges for therapy services ordered by a Physician and provided as part of the coveredpersons treatment plan. Services include:

Occupational therapy by a qualified occupational therapist.

Physical therapy by a qualified physical therapist. Respiratory therapy by a qualified respiratory therapist.

Aquatic therapy by a qualified physical therapist. Speech therapy by a qualified speech therapist including therapy for

stuttering due to a neurological disorder.

10. Charges for dental services to include:

The care and treatment of natural teeth and gums if an injury is sustained inan accident (other than one occurring while eating or chewing), excludingimplants.

Inpatient or outpatient hospital charges including professional services for x-ray, lab, and anesthesia while in the hospital.

Removal of all teeth at an inpatient or outpatient hospital or dentists office ifremoval of the teeth is part of standard medical treatment that is requiredbefore the covered person can undergo radiation therapy for a coveredmedical condition.

Services for dependent children under age nine (9) and covered persons withserious mental or physical conditions or significant behavior problems.

11. Charges for oral surgery includes:

Excision of partially or completely impacted teeth.

Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floorof the mouth when such conditions require pathological examinations.

Surgical procedures required to correct accidental injuries of the jaws,cheeks, lips, tongue, roof and floor of the mouth.

Reduction of fractures and dislocations of the jaw. External incision and drainage of cellulitus. Incision of accessory sinuses, salivary glands or ducts.

Excision of exostosis of jaws and hard palate.

12. Charges for physicians surgical services for treatment of an injury or illness, if performed inan inpatient or outpatient unit of a hospital, a free standing facility, a physicians office, or adentist or an oral surgeons services for the treatment of an accidental injury to soundnatural teeth will be considered a covered expense.

13. Charges for medically necessary private duty nursing care rendered on an outpatient basisby a registered graduate nurse (RN) or, services of a licensed practical nurse (LPN) whencertified by the attending physician and a registered graduate nurse (RN) is not available, butonly for nursing duties and excluding custodial care.

14. Charges for x-ray, laboratory, and radium expenses excluding dental x-rays, unless renderedfor the treatment of a fractured jaw, cysts, tumors or injury to sound natural teeth as aresult of an accident will be considered covered expenses.

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15. Charges for the professional services of a legally qualified physician for the care of acovered illness or accidental injury.

16. Charges for physicians home and office visits when the employee or his dependent incurexpenses as a result of an illness or accidental injury.

17. Charges for services of a surgeon and an assistant surgeon if two (2) or more proceduresare performed during the course of a single operation through the same incision or in thesame operative field. The fees will be limited to the maximum allowable benefit. Benefitsare payable for the professional services of a legally qualified physician in rendering technicalassistance to the operating surgeon when required in connection with a surgical procedureperformed on an inpatient basis (benefits will not exceed twenty-five (25%) of the maximumallowable benefit for the procedure performed when the assistant is a physician and fifteen(15%) when the assistant is a PA). However, no benefits are payable for surgical assistancerendered in a hospital where it is routinely available as a service provided by a hospitalintern, resident, or house officer.

18. Charges for medically necessary dressings and medicines, including fluoride for which aphysicians prescription is required and dispensed by a licensed pharmacy.

19. Charges for birth control methods.

20. Charges for diabetic supplies such as insulin, accustrips, lancets, and syringes necessary forthe administration of prescription drugs and professional instructions, not including printedmaterial for their use. Coverage includes diabetic self-management education programs andnutritional counseling.

21. Charges for oxygen and the rental of equipment for its administration.

22. Charges for rehabilitative care, as defined herein.

23. Charges for voluntary sterilizations.

24. Charges for durable medical equipment subject to all of the following:

The equipment must meet the definition of durable medical equipment asdefined herein. Examples include, but are not limited to, crutches,wheelchairs, hospital type beds and oxygen equipment.

The equipment must be prescribed by a Physician.

The equipment will be provided on a rental basis when available; however,such equipment may be purchased at the Plans option. Any amount paid torent the equipment will be applied towards the purchase price. In no casewill the rental cost exceed the purchase price of the item.

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The Plan will pay benefits for only ONE of the following: a manualwheelchair, motorized wheelchair or motorized scooter, unless necessary dueto growth of the person or changes to the persons medical condition requirea different product, ad determined by the Plan.

If the equipment is purchased, benefits will be payable for subsequent repairsincluding batteries or replacement only if required:

2

Due to the growth or development of a dependent child;2 When necessary because of a change in the covered persons

physical condition; or2 Because of deterioration caused from normal wear and tear.

The repair or replacement must also be recommended by the attending Physician. Inall cases, repairs or replacement due to abuse or misuse, as determined by the Plan,are not covered and replacement is subject to prior approval by the Plan.

25. Charges for orthotic appliances, devices, and casts, including the exam for requiredprescription and fitting, when prescribed to aid in healing, provide support to an extremity,or limit motion to the musculoskeletal system after injury. These devices can be used foracute injury or to prevent injury. Orthotic appliances and devices include custom moldedshoe orthotics, supports, trusses, elastic compression stockings, and braces.

26. Charges for the initial purchase, fitting, repair and replacement of fitted prosthetic devices(artificial body parts, including limbs, eyes and larynx) which replace body parts. Benefitsmay be payable for subsequent repairs or replacement only if required:

Due to the growth or development of a dependent child; or

When necessary because of a change in the covered persons physicalcondition; or

Because of deterioration caused from normal wear and tear.

The repair or replacement must also be recommended by the attending physician. In allcases, repairs or replacement due to abuse or misuse, as determined by the Plan, are not

covered and replacement is subject to prior approval by the Plan.

27. Charges for temporomandibular joint disorder (TMJ) services which include diagnosticservices and surgical treatment. Orthodontic services and non-surgical treatment oftemporomandibular joint disorder (TMJ) are not covered.

28. Charges for elective abortions.

29. Charges for blood, blood transfusions or dialysis.

30. Charges for maternity care including prenatal, delivery, and postpartum care as well ascharges arising from complications that may occur during maternity and delivery. Homebirths and midwifes are covered when performed by a licensed provider.

31. Convalescent Hospital/Extended Care Facility/Skilled Nursing Facility charges for not morethan sixty (60) days per calendar year, but not in excess of a daily charge for room andboard, services, and supplies equal to one-half (1/2) of the discharging hospitals semi-private room rate. The covered person must be under the care of an attending physicianwho determines the continuing need for the hospital or facility stay.


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32. Newborn care charges are a covered expense for an employees newborn dependents.Charges for care of newborn children to include hospital charges for nursery room and boardand miscellaneous expenses, charges by a pediatrician for attendance at a cesarean section,charges for physician examination for a newborn while hospital confined and charges forcircumcisions. Charges for the covered newborn will be processed under the mothersbenefits until the mother is discharged from the hospital following the delivery. If the

covered newborn needs to stay in the hospital longer than the mother following the delivery,those charges will be processed under the newborns benefits.

33. Chiropractic Care: Charges for home, office, and nursing home visits as well asexaminations, x-rays, consultations, spinal manipulations, electrical stimulation, andinterpretation are covered expenses.

34. Transplant Services at a Transplant Facility: The transplant of organs from human to human,including bone marrow, stem cell and cord blood transplants. Transplants include only thosetransplants that: (a) are approved for Medicare coverage on the date the transplant isperformed; and (b) are not otherwise excluded by this Plan. A transplant must be performedat a transplant facility, as defined herein, to be considered for reimbursement under thisPlan. Skin and cornea transplants are not reimbursable under the transplant benefit noted onthe Schedule of Benefits. However, skin and cornea transplant expenses will bereimbursable as any other illness under this Plan if deemed to be medically neceessary.

Donor charges are considered a covered expense provided the donor is a blood relative andcharges are not covered under any insurance policy the donor may hold. Donor charges arelimited to

a) evaluating the organ or tissue;b) removing the organ or tissue from the donor; andc) transporting the organ or tissue from within the United States and Canada to the

transplant site.

35. Hospice care charges, as defined herein. Treatment given at a Hospice Care Facility must

be in place of a stay in a Hospital or Extended Care Facility, and can include:

Assessment: includes an assessment of the medical and social needs of theterminally ill person, and a description of the care to meet those needs.

Inpatient Care: in a facility when needed for pain control and other acuteand chronic symptom management, psychological and dietary counseling,physical or occupational therapy and part-time home health care services.

Outpatient Care: Provides or arranges for other services as related to theterminal illness which include: services of a physician; physical oroccupational therapy; nutrition counseling provided by or under thesupervision of a registered dietitian.

Bereavement Counseling: Benefits are payable for bereavement counselingservices which are received by a covered persons close relative when

directly connected to the covered persons death and bundled with otherhospice charges. Counseling services must be given by a licensed socialworker, licensed pastoral counselor, psychologist or psychiatrist. Theservices must be furnished within six (6) months of death.

The covered person must be terminally ill with an anticipated life expectancy of about six (6)months. Services, however, are not limited to a maximum of six (6) months if continuedhospice care is deemed appropriate by the Physician.


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36. Preventive Care: Charges for routine physical examinations, well-baby care, and well-adultcare are covered expenses. Charges can include examinations (including breast and pelvic),immunizations (including travel immunizations), consultations, laboratory tests, pap smears(including laboratory fees) (1 per calendar year), x-rays, fecal blood cultures (1 per calendaryear), PSA tests and prostate exams (1 per calendar year), colonoscopies, sigmoidoscopies,mammograms, and EKGs. Routine mammograms are limited to:

One (1) baseline mammogram for a covered person age 35 to age 40. One (1) mammogram every other year for a covered person age 40 to age

50.

One (1) mammogram per calendar year for a covered person age 50 andolder.

37. Mental Health Care and Substance Abuse: Charges resulting from inpatient mental healthcare and alcohol and/or drug addiction in a hospital, public or licensed mental hospital,drug/alcohol abuse treatment facility or outpatient mental health services provided by aboard certified physician, a lice

medical - bba summary plan document (spd)

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