Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2012 Health Insurance Coverage
DG OUBLEOLD HCP EALTHARELAN For Employees of: CITY OF OAK PARK HEIGHTS (herein called the Plan Administrator or the Employer) SAMPLE, SAMPLE XGroup Number: XXXXX-XX XXX ADDRESSIdentification Number: ON FILE ADDRESS ADDRESS ADDRESS X17342-R6SVCGNC:2000-5362 / SVCGNC32A / tppprd ©2012, Blue Cross and Blue Shield of Minnesota ®® An independent licensee of the Blue Crossand Blue ShieldAssociation. The Blue Cross and Blue Shield Association is an association of independent Blue Cross and Blue Shield Plans. ANNUAL NOTIFICATIONS Women's Health and Cancer Rights Act Under the federalWomen’s Health and Cancer Rights Act of 1998and Minnesota law,you are entitled to the following services: 1.reconstruction of the breast on which the mastectomy wasperformed; 2.surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3.prosthesis and treatment for physical complications during all stages of mastectomy, including swelling of the lymph glands (lymphedema). Services are provided in a manner determined in consultation with the physician and patient. Coverage is provided on the same basis as any other illness. Pagei SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Important Notice From the Plan Administrator About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Blue Cross and Blue Shield of Minnesota (Blue Cross) and about your options under Medicare’s prescription drug coverage. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare's prescription drug coverage: 1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare prescriptiondrug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2.Blue Cross has determined that the prescription drug coverage offered by your Planis, on average for all members, expected to pay out as much as standard Medicare prescription drug coverage pays and is,therefore, considered Creditable Coverage.Because your existingcoverage ison average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and thth each year fromOctober15toDecember7. However, if you losecreditable prescription drug coverage through no fault of your own, you will be eligible for a two (2)-month Special Enrollment Period (SEP) to join a Medicare drug plan. Pageii SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Blue Cross coveragewill not be affected. You may keep your current Blue Cross coverage and this Plan will coordinate with your Medicare drug plan. If you do decide to join a Medicare drug plan and drop your current Blue Crossdrug coverage, be aware that you and your dependents might not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Blue Cross and do not join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditableprescription drug coverage, your monthly premium may go up by at least 1%of the Medicarebase beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19months without creditablecoverage, your premiummay consistently be at least 19%higher than the Medicarebase beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following Octoberto join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact Customer Service atthe telephone number listed in the Customer Service section. NOTE:You will receive this notice each year. You willalsoreceiveitbefore the next period you can join a Medicare drugplan,andifthiscoveragethroughBlue Cross changes. You may request a copyof this notice anytime. Pageiii SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the "Medicare & You"handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visitwww.medicare.gov x Call your State Health Insurance Assistance Program (see the inside back cover x of your copy of the "Medicare & You"handbook for their telephone number) for personalized help Call1-800-MEDICARE (1-800-633-4227),TTY users should call 1-877-486-2048 x If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to showwhether or not you have maintained creditable coverage and, therefore,whether you are required to pay a higher premium (a penalty). Pageiv SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Rights and Responsibilities You Have The Right Under This PlanTo: x be treated with respect, privacyand dignity; x receive quality health care that is friendly and timely; x haveavailable and accessible medically necessary covered services, including emergency services, 24 hours a day, seven (7) days a week; x be informed of your health problems and to receive information regarding treatment alternatives and their risk in order to make an informed choice regardless if the health plan pays for treatment; x participate with your health care providers in decisions about your treatment; x give your provider a health care directive ora living will (a list of instructions about health treatments to be carried out in the event of incapacity); x refuse treatment; x privacy of medical and financial records maintained by the Plan, the Claims Administratorand its health care providers in accordance with existing law; x receive information about the Plan, its services, its providers, and your rights and responsibilities; x make recommendations regarding these rights and responsibilities policies; x have a resource at the Plan, the Claims Administratoror at the clinic that you can contact with any concerns about services; x file an appeal withthe Claims Administratorand receive a prompt and fair review; and x initiate a legal proceeding when experiencing a problem withthe Planor its providers. YouHaveThe Responsibility Under This PlanTo: x know your health plan benefits and requirements; x provide, to the extent possible, information that the Plan, the Claims Administrator,and its providers need in order to care for you; x understand your health problems and work with your doctor to set mutually agreed upon treatment goals; x follow the treatment plan prescribed by your provider or to discuss with your provider why you are unable to follow the treatment plan; x provide proof of coverage when you receive services and to update the clinic with any personal changes; x pay copays at the time of service and to promptly pay deductibles, coinsurance and, if applicable, charges for services that are not covered; and x keep appointments for care or to give early notice ifyou need to cancel a scheduled appointment. Pagev SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TABLE OF CONTENTS ANNUAL NOTIFICATIONS...............................................................................................................I INTRODUCTION..............................................................................................................................1 CUSTOMER SERVICE.....................................................................................................................2 COVERAGE INFORMATION...........................................................................................................3 Choosing A Health Care Provider..................................................................................................3 Your Benefits.................................................................................................................................4 Continuity of Care..........................................................................................................................4 Payments Made in Error................................................................................................................5 Liability for Health Care Expenses.................................................................................................6 Inter-Plan Programs.......................................................................................................................6 General Provider Payment Methods..............................................................................................8 Recommendations by Health Care Providers..............................................................................11 Services that are Investigative or not Medically Necessary.........................................................11 Fraudulent Practices....................................................................................................................11 Time Periods................................................................................................................................11 Medical Policy Committee............................................................................................................11 NOTIFICATION REQUIREMENTS.................................................................................................12 Prior Authorization.......................................................................................................................12 Preadmission Notification............................................................................................................13 Preadmission Certification...........................................................................................................13 Emergency Admission Notification..............................................................................................14 CLAIMS PROCEDURES................................................................................................................15 Claims Filing................................................................................................................................15 Right of Examination....................................................................................................................15 Release of Records.....................................................................................................................15 Claims Payment...........................................................................................................................15 No Third-Party Beneficiaries........................................................................................................16 APPEAL PROCESS.......................................................................................................................17 Introduction..................................................................................................................................17 Definitions....................................................................................................................................17 Oral Appeals................................................................................................................................17 Written Appeals...........................................................................................................................17 Process for Appeals that do not Require a Medical Determination..............................................18 External Review...........................................................................................................................18 Process for Appeals When Utilization Review is Necessary........................................................19 Determinations.............................................................................................................................19 Appeals........................................................................................................................................20 External Review...........................................................................................................................20 BENEFIT CHART...........................................................................................................................21 Benefit Features, Limitations, and Maximums.............................................................................21 Benefit Descriptions.....................................................................................................................22 Ambulance................................................................................................................................23 Pagevi SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Bariatric Surgery.......................................................................................................................24 Behavioral Health Mental Health Care......................................................................................26 Behavioral Health Substance Abuse Care................................................................................30 Chiropractic Care......................................................................................................................33 Dental Care...............................................................................................................................35 Emergency Room.....................................................................................................................37 Home Health Care....................................................................................................................38 Home Infusion Therapy.............................................................................................................39 Hospice Care............................................................................................................................40 Hospital Inpatient......................................................................................................................41 Hospital Outpatient...................................................................................................................42 Maternity...................................................................................................................................43 Medical Equipment, Prosthetics, and Supplies.........................................................................45 Physical, Occupational, and Speech Therapy..........................................................................47 Physician Services....................................................................................................................49 Prescription Drugs and Insulin..................................................................................................52 Preventive Care........................................................................................................................55 Reconstructive Surgery.............................................................................................................56 Reproduction Treatments.........................................................................................................57 Skilled Nursing Facility..............................................................................................................59 Transplant Coverage................................................................................................................60 BENEFIT SUBSTITUTION.............................................................................................................62 GENERAL EXCLUSIONS..............................................................................................................63 ELIGIBILITY...................................................................................................................................68 Eligible Employees.......................................................................................................................68 Eligible Dependents.....................................................................................................................68 Preexisting Condition Limitation for Employees and Covered Dependents -age 19 and older...69 Effective Date of Coverage..........................................................................................................69 Special Enrollment Periods..........................................................................................................70 Coverage Effective Date for Late Entrants...................................................................................71 TERMINATION OF COVERAGE....................................................................................................72 Termination Events......................................................................................................................72 Retroactive Termination...............................................................................................................72 Certification of Coverage.............................................................................................................72 Extension of Benefits...................................................................................................................73 Continuation and Conversion.......................................................................................................73 COORDINATION OF BENEFITS...................................................................................................81 Definitions....................................................................................................................................81 Order of Benefits Rules................................................................................................................82 Effect on Benefits of This Plan.....................................................................................................83 Right to Receive and Release Needed Information.....................................................................83 Facility of Payment.......................................................................................................................83 Right of Recovery........................................................................................................................83 REIMBURSEMENT AND SUBROGATION....................................................................................84 GENERAL PROVISIONS...............................................................................................................85 Pagevii SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Plan Administration......................................................................................................................85 Termination or Changes to the Plan............................................................................................86 Funding........................................................................................................................................86 Controlling Law............................................................................................................................86 Privacy of Protected Health Information.......................................................................................86 GLOSSARY OF COMMON TERMS...............................................................................................87 Pageviii SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 INTRODUCTION This Summary Plan Description (SPD) contains a summary of the City of Oak Park HeightsDouble Gold Health Care Plan for benefits effective 01-01-2012. Coverage under this Plan for eligible employeesand dependentswill begin as defined in the Eligibility section. All coverage for dependents and all references to dependents in this Summary Plan Description are inapplicable for employee-only coverage. This Plan, financed and administered by the South Central Service Cooperative-CCOGAand City of Oak Park Heights, is a self-insured medical plan. Blue Cross and Blue Shield of Minnesota (Blue Cross), under contract with the South Central Service Cooperative -CCOGAis the Claims Administrator and provides administrative services only. The Claims Administrator does not assume any financial risk or obligation with respect to claims. Payment of benefits is subject to all terms and conditions of this SPD, including medical necessity. This Plan is not subject to ERISA. This Plan provides benefits for covered services you receive from eligible health care providers. You receive the highest level of coverage when you use In-Network Providers. In-Network Providers are providers that have entered into a specificnetwork contract with the ClaimsAdministratoror the local Blue Cross and/orBlue Shield Plan to provide you quality health services at favorable prices. The Plan also provides benefits for covered services you receive from Out-of-Network Providers. In some cases, you receive a reducedlevel of coverage when you use these providers. Out-of-NetworkProvidersinclude Out-of-Network Participating Providers and Nonparticipating Providers. Out-of-Network Participating Providers haveentered into a specificnetwork contractwith the Claims Administratoror the local Blue Cross and/or Blue Shield Plan but are not In- Network Providers.Nonparticipating Providers have not entered into a network contractwith the Claims Administrator or the local Blue Cross and/or Blue Shield Plan. You may pay a greater portion of your health care expenses when you use Nonparticipating Providers. IMPORTANT! When receiving care, present your Identification(ID)card to the provider who is rendering the services. It is also important that you read this entire Summary Plan Description carefully. It explains the Plan, eligibility, notification procedures, covered expenses, and expenses that are not covered. If you have questions about your coverage, please contact the Claims Administrator at the address or telephone numbers listed on the following page. Page1 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 CUSTOMER SERVICE Questions? The Claims Administrator'sCustomerService staff is available to answeryourquestions about your coverage and direct your calls for prior authorization, preadmission notification, preadmission certification,and emergency admission notification.Our customer service staff will provide interpreter services to assist you if needed. This includes spoken language and hearing interpreters. Monday through Thursday:7:00AM–7:00 PM United StatesCentral Time Friday:9:00 AM –6:00 PM United States Central Time Hours are subject to change without prior notice. Customer Service Claims Administrator:(651) 662-5517 or toll-free 1-888-878-0136 Telephone Number Blue Cross andBlue www.bluecrossmn.com Shieldof Minnesota Website BlueCard Toll-free1-800-810-BLUE (2583) Telephone Number This number is used to locate providers who participate with Blue Cross and Blue Shield plans nationwide. BlueCard Website www.bcbs.com This website is used to locate providers who participate with Blue Cross and Blue Shield plans nationwide. Claims Administrator's Claims review requests,andwritteninquiries may be mailed to the address below: Mailing Address Blue Cross and Blue Shield of Minnesota P.O.Box 64338 St. Paul, MN 55164 Prior authorization requests should be mailed to the following address: Blue Cross and Blue Shield of Minnesota Medical Review Department P.O. Box 64265 St. Paul, MN 55164 Pharmacy Toll-free1-800-509-0545 Telephone Number This number is used to locate a participatingpharmacy. Page2 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 COVERAGE INFORMATION ChoosingAHealth Care Provider You may choose any eligible provider of health services for the care you need. The Planmay pay higher benefits if you choose In-NetworkProviders.Generally, you will receive the best benefit from your health plan when you receive care from In-Network Providers. ThePlanfeatures a large network of Participating Providers, and each provider is an independent contractor and is not the Claims Administrator’s agent. If you want to know more about the professionalqualifications of a specific health care provider, call the provider or clinic directly. In-Network Providers When you choose In-NetworkProviders, you get the most benefits for the least expense and paperwork. Minnesota In-Network Providers are providers in the Aware Network.In-Network Providers outside Minnesota are providers in the BlueCardNetwork.Minnesota In-Network Providers are required to take care of prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification requirements (see "Notification Requirements" section) and send your claims to the Claims Administrator and the Claims Administrator sends payment to the provider for covered services you receive. In-Network Providers outside Minnesota are required to send your claims to the Claims Administrator and the Claims Administrator sends payment to the provider for covered services you receive. In-Network Providers outside Minnesota are not required to take care of notification requirements. Your provider directory lists In-Network Providers and may change as providers initiateor terminate their network contracts. For benefit information, pleaserefer to the "BenefitChart." To receive the highest level of benefits for Behavioral Health Mental Health Care and Behavioral Health Substance Abuse Care services, you must use a Behavioral Health SelectNetwork Provider as your MinnesotaIn-Network Provider. To receive thehighest level of benefits for Chiropractic Care, you must use a Blue Select Chiropractic Network Provider as your MinnesotaIn-Network Provider. To receive the highest level of benefits for hospital/facility bariatric surgery services, eligible members age 18 and oldermust use a Blue Distinction Centers for Bariatric Surgery as your In-Network Provider. Out-of-Network Providers Out-of-Network Participating Providers Out-of-NetworkParticipatingProvidersareproviders who have a specificnetwork contract with the Claims Administrator or the local Blue Cross and/or Blue Shield Plan (Participating Providers), but are not In-Network Providers. Out-of-NetworkParticipatingProvidersmaytake care of prior authorization, preadmission notification, preadmission certification, and/or emergency admissionnotification requirements (see "Notification Requirements" section)andmayfile claims for you.Verify with your provider if these are services they will performfor you. Most out- of-state Out-of-Network Participating Providers accept the ClaimsAdministrator's payment based on the Allowed Amount. The Claims Administrator recommends that you contact the out-of-stateOut-of-Network Participating Provider and verify if they accept payment based on the Allowed Amount to determine if you will have additional financial liability. Page3 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Nonparticipating Providers Nonparticipating Providers have not entered into a network contract with the Claims Administrator or the local Blue Cross and/or Blue Shield Plan. You are responsible for providing prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification when necessary (see "Notification Requirements" section)and submitting claims for services received from Nonparticipating Providers. Refer to the "Liability for Health Care Expenses" provision for a description of charges that are your responsibility.Please note that you may incur significantly higher financial liability when you use Nonparticipating Providers compared to the cost of receiving care from In-Network Providers.In addition, participating facilities may have nonparticipating professionals practicing at the facility. Your Benefits This SPD outlines the coverage under this Plan. Please be certain to check the"Benefit Chart"section to identify covered benefits. You must alsorefer to the "General Exclusions" section to determine services that are not covered. The "Glossary of Common Terms" section defines terms used in this SPD. All services must be medically necessary to be covered, and even though certain noncovered services may be medically necessary, there is no coverage for them. If you have questions, call Customer Service using the telephone number on the back of your ID card. Continuity of Care Continuity of Care for New Members If you are a member of a group that is new to Blue Cross, this section applies to you. If you are currently receiving care from an Out-of-Networkfamily practice or specialty physician, you may request to continue to receivecarefrom this physicianfor a special medical need or condition, for a reasonable period of time before transferring to anIn-Network physicianas required under the terms of your coverage with this Plan. The Claims Administrator will authorize this continuation of care for a terminal illness in the final stages or for the rest of your life if a physician certifies that your life expectancy is 180 days or less. The Claims Administrator will also authorize this continuation of care if you are engaged in a current course of treatment for any of the following conditions or situations: Continuation for up to 120 daysif you: 1.havean acute condition; 2.havealife-threatening mental or physical illness; 3.haveaphysical or mental disability rendering you unableto engage in one or more major life activities provided that the disability has lasted or can be expected to last for at least one year, or that has a terminal outcome; 4.haveadisabling or chronic condition in an acute phase or that is expected to last permanently; 5.are receiving culturally appropriate services from a provider with special expertise in delivering those services; or, 6.are receiving services from a provider that are delivered in a language other than English. Continuation through the postpartumperiod (six (6) weeks post delivery) for a pregnancy beyond the first trimester. Transition to In-NetworkProviders At your request, the Claims Administrator will assist you in making the transition from anOut-of-Networkto an In-NetworkProvider. Please contact the Claims Administrator's CustomerService staff for a written description of the transition process, procedures, criteria, and guidelines. Limitation Continuity of Care applies only if your provider agrees to: 1) accept the Claims Administrator'sAllowed Amount; 2) adhere to all of the Claims Administrator's prior authorization requirements; and 3) provide the Claims Administrator with necessary medical information related to your care. Termination by Provider If your provider terminates its contract with the Claims Administrator, we will not authorize continuation of care with, or transition of care to, that provider. Your transition to an In-Network Provider must occur on or prior to the date of such termination for you to receive In-Network benefits. Page4 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 ProviderTermination for Cause If the Claims Administrator has terminated its relationship with your provider for cause, the Claims Administrator will not authorize continuation of care with,or transition of care to,that provider. Your transition to an In-Network Provider must occur on or prior to the date of such termination for you to continue to receive In-Network benefits. Continuity of Care for Current Members If you are a current member or dependentwithBlue Cross, this section applies to you. If the relationship between your In-Networkclinic or physician and the Claims Administrator ends, rendering your clinic or provider Out-of-Networkwith the Claims Administrator, and the termination was bythe Claims Administratorandwasnot for cause, you may request to continue to receive care for a special medical need or condition, for a reasonable period of time before transferring to anIn-NetworkProvider as required under the terms of your coverage with this Plan. The Claims Administrator will authorize this continuation of care for a terminal illness in the final stages or for the rest of your life if a physician certifies that your life expectancy is 180 days or less. The Claims Administrator will also authorize this continuation of care if you are engaged in a current course of treatment for any of the following conditions or situations: Continuation for up to 120 daysif you: 1.havean acute condition; 2.havealife-threatening mental or physical illness; 3.haveaphysical or mental disability rendering you unable to engage in one or more major life activities provided that the disability has lasted or can be expected to last for at least one year, or that has a terminal outcome; 4.haveadisabling or chronic condition in anacute phase or that is expected to last permanently; 5.are receiving culturally appropriate services from a provider with special expertise in delivering those services; or, 6.are receiving services from a provider that are delivered in a language otherthan English. Continuation through the postpartum period (six (6) weeks post delivery) for a pregnancy beyond the first trimester. Transition to In-NetworkProviders At your request, the Claims Administrator will assist you in making the transition from anOut-of-Networkto an In-NetworkProvider. Please contact the Claims Administrator's CustomerService staff for a written description of the transition process, procedures, criteria, and guidelines. Limitation Continuity of Care applies only if your provider agrees to: 1) accept the Claims Administrator's Allowed Amount; 2) adhere to all of the Claims Administrator's prior authorization requirements; and 3) provide the Claims Administrator with necessary medical information related to your care. Termination by Provider If your provider terminates its contract with the Claims Administrator, we will not authorize continuation of care with, or transition of care to, that provider. Your transition to an In-Network Provider must occur on or prior to the date of such termination for you to receive in-network benefits. ProviderTermination for Cause If the Claims Administrator has terminated its relationship with your provider for cause, the Claims Administrator will not authorize continuation of care with,or transition of care to,that provider. Your transition to an In-Network Provider must occur on or prior to the date of such termination for you to continue to receive In-Network benefits. Payments Made in Error Payments made in error or overpayments may be recovered by the Claims Administrator as provided by law. Payment made for a specific service or erroneous payment shall not make the Claims Administrator or the employer liable for further payment for the same service. Page5 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Liability for Health Care Expenses Charges That Are Your Responsibility In-Network Providers When you use In-NetworkProviders for covered services, payment is based on the Allowed Amount. You are not required to pay for charges that exceed the Allowed Amount. You are required to pay the following amounts: 1.deductiblesand coinsurance; 2.copays; 3.charges that exceed the benefit maximum;and, 4.charges for services that are not covered. Out-of-Network Providers Out-of-NetworkParticipating Providers When you use Out-of-Network Participating Providers for covered services, payment is based on the Allowed Amount. You may not be required to pay for charges that exceed the Allowed Amount. All Out-of-Network Participating Providers in Minnesota accept the ClaimsAdministrator's payment based on the Allowed Amount. Most Out-of- Network Participating Providers outside Minnesota also accept the ClaimsAdministrator's payment based on the Allowed Amount. However, contact your Out-of-Network Participating Provider outside Minnesota to verify if they accept the Claims Administrator's payment based on the Allowed Amount (to determine if you will have additional financial liability).You are required to pay the following amounts: 1.charges that exceed the Allowed Amount ifthe Out-of-Network ParticipatingProvideroutside Minnesota does not accept our payment based on the Allowed Amount; 2.deductibles and coinsurance; 3.copays; 4.charges that exceed the benefit maximum; and, 5.charges for services that are not covered. Nonparticipating Providers When you use Nonparticipating Providers for covered services, payment is still based on the AllowedAmount. However, because a Nonparticipating Provider has not entered into a network contractwith the Claims Administrator or the local Blue Cross and/or Blue Shield Plan,the Nonparticipating Provider is not obligated to accept the Allowed Amount as payment in full. This means that you may have substantial out-of-pocket expense when you use a Nonparticipating Provider. You are required to pay the following amounts: 1.chargesthat exceed the AllowedAmount; 2.deductiblesand coinsurance; 3.copays; 4.charges that exceed the benefit maximum; 5.charges for services that are not covered, including services that the Claims Administrator determines are not covered based on claims coding guidelines; and, 6.charges for services that are investigative or not medically necessary. Inter-Plan Programs Out-of-Area Services Blue Cross has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as "Inter-Plan Programs."Whenever you obtain health care services outside of Blue Cross’ service area, the claims for these services may be processed through one of these Inter-Plan Programs, which include the BlueCard Program and may include negotiated National Account arrangements available between Blue Cross and other Blue Cross and Blue Shield Licensees. Page6 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Typically, when accessing care outside Blue Cross'service area, you will obtain care from health care providers that have a contractual agreement (i.e., are "participating providers") with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances, you may obtain care from Nonparticipating Providers. Blue Cross'payment practices in both instances are describedbelow. ® BlueCardProgram ® Under the BlueCardProgram, when you access covered health care services within the geographic area served by a Host Blue, Blue Cross will remain responsible for fulfilling Blue Cross'contractual obligations. However, the HostBlue is responsible for contracting with and generally handling all interactions with its Participating Providers. Whenever you access covered health care services outside Blue Cross’ service area and the claim is processed through the BlueCard Program, the amount you pay for covered health care services is calculated based on the lower of: x the billed covered charges for your covered services; or, x the negotiated price that the Host Blue makes available to Blue Cross. Often, this "negotiated price"willbe a simple discount that reflects an actual price that the Host Blue pays to your health care provider. Sometimes, it is an estimated price that takes into account special arrangements with your health care provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care providers after taking into account the same types oftransactions as with an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over-or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price Blue Cross uses for your claim because they will not be applied retroactively to claims already paid. Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered health care services according to applicable law. Nonparticipating Providers Outside Blue Cross'Service Area 1.Member Liability Calculation When covered health care services are provided outside of Blue Cross'service area by Nonparticipating Providers, the amount you pay for such services will generally be based on either the Host Blue's Nonparticipating Provider local payment or the pricing arrangements required by applicable state law. Where the Host Blue's pricing is greater than the Nonparticipating Provider’s billed charge or if no pricing is provided by a Host Blue, we generally will pay based on the definition of "Allowed Amount"as set forth in the"Glossary of Common Terms" section of this SPD. In these situations, you may be liable for the difference between the amount that the Nonparticipating Provider bills and the payment Blue Cross will make for the covered services as set forth in this paragraph. 2.Exceptions In certain situations, Blue Cross may use other payment bases, such as billed covered charges, the payment we would make if the health care services had been obtained within our service area,or a special negotiated payment, as permitted under Inter-Plan Programs Policies, to determine the amount Blue Cross will pay for services rendered by Nonparticipating Providers. In these situations, you may be liable for the difference between the amountthat the Nonparticipating Provider bills and the payment Blue Cross will make for the covered services as set forth in this paragraph. Page7 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 GeneralProvider Payment Methods Participating Providers The Claims Administrator,contracts with a large majority of doctors, hospitals and clinics in Minnesota to be part of its network. Other Blue Cross and/or Blue Shield Plans contract with providers in their states as well. (Each Blue Cross and/or Blue Shield Plan is an independent licensee of the Blue Cross and BlueShield Association.) Each provider is an independent contractor and is not an agent or employee of the Claims Administrator, another Blue Cross and/or Blue Shield Plan, or the Blue Cross and Blue Shield Association. These health care providers are referred to as "Participating Providers." All Minnesota Participating Providershave agreed to accept as full payment (less deductibles, coinsurance and copayments) an amount thatBlue Cross has negotiated with its Participating Providers (the "Allowed Amount").Most Participating Providers outside Minnesota have also agreed to accept as full payment (less deductibles, coinsurance and copayments) an amount that the Blue Cross and/or Blue Shield Plan has negotiated with its Participating Providers.However, some Participating Providers in a small number of states may not be required to accept the Allowed Amount as payment in full for your specific plan and will be subject to the Nonparticipating Provider payment calculation noted below. We recommend that you verifywith your out-of-state Participating Provider if they accept the Allowed Amount as payment in full.The Allowed Amount may vary from one provider to another for the same service. Several methods are used to pay participatinghealth care providers. If theprovider is "participating" they are under contract and the method of payment is part of the contract. Most contracts and payment rates are negotiated or revised on an annual basis. As an incentive to promote high quality, cost effective care and as a way to recognize that those providers participate in certain quality improvement projects, providers may be paid extra amounts following the initial adjudication of a claim based on the quality of the provider's care to their patients and further based on claims savings that the provider may generate in the course of rendering cost effective care to its member patients. Certain providers also may be paid in advance of a claim adjudication in recognition of their efficiency in managing the total cost of providing high quality care to members and for implementing quality improvement programs. In order to determine quality of care, certain factors are measured to determine a provider's compliance with recognized quality criteria and quality improvement. Areas of focus for quality may include, but are not limited to:services for diabetes care;tobacco cessation;colorectal cancer screening;andbreast cancer screening, among others. Cost of care is measured using quantifiable criteria to demonstrate that a provider is meeting specific targets to manage claims costs. These quality and cost of care payments to providers are determined on a quarterly or annual basis and will not directly be reflected in a claims payment for services rendered to an individual member. Payments to providers for meeting quality improvement and cost of care goals and for recognizing efficiency are considered claims payments. Non-Institutional or Professional (i.e., doctor visits, office visits) ParticipatingProvider Payments x Fee-for-Service -Providers are paid for each service or bundle of services. Payment is based on the amount of the provider's billed charges. Discounted Fee-for-Service -Providers are paid a portion of their billed charges for each service or bundle of services. Payment may be a percentage of the billed charge or it may be based on a fee schedule that is developed using a methodology similar to that used by the federal government to pay providers for Medicare services. Discounted Fee-for-Service, Withhold and Bonus Payments -Providers are paid a portion of their billed charges for each service or bundle of services, and a portion (generally 5-20%) of the provider's payment is withheld. As an incentive to promote high quality and cost-effective care, the provider mayreceive all or a portion of the withhold amount based upon the cost-effectiveness of the provider's care. In order to determine cost-effectiveness, a per memberper month target is established. The target is established by using historical payment information to predict average costs. If the provider's costs are below this target, providers are eligible for a return of all or a portion of the withhold amount and may also qualify for an additional bonus payment. Payment for high cost cases and selected preventive and other services may be excluded from the discounted fee- for-service and withhold payment. When payment for these services is excluded, the provider is paid on a discounted fee-for-service basis, but no portion of the provider's payment is withheld. Page8 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Institutional (i.e., hospital and other facility) ParticipatingProvider Payments x Inpatient Care x Payments for each Case (case rate) -Providers are paid a fixed amount based upon the member's diagnosis at the time of admission, regardless of the number ofdays that the member is hospitalized. This payment amount may be adjusted if the length of stay is unusually long or short in comparison to the average stay for that diagnosis ("outlier payment"). The method is similar to the payment methodology used by the federal government to pay providers for Medicare services. x Payments for each Day (per diem) -Providers are paid a fixed amount for each day the patient spends in the hospital or facility. x Percentage of Billed Charges -Providers are paid a percentage of the hospital's or facility's billed charges for inpatient or outpatient services, including home services. Outpatient Care x Payments for each Category of Services -Providers are paid a fixed or bundled amount for each category of outpatient services a member receives during one (1) or more related visits. x Payments for each Visit -Providers are paid a fixed or bundled amount for all related services a member receives in an outpatient or home setting during one (1) visit. x Payments for each Patient -Providers are paid a fixed amount per patient per calendar year for certain categories of outpatient services. Pharmacy Payment Four (4) kinds of pricing are compared and the lowest amount of the four (4) is paid: x the average wholesale price of the drug, less a discount, plus a dispensing fee; x the pharmacy's retail price; x the maximum allowable cost we determine by comparing market prices (for generic drugs only); or, x the amount of the pharmacy's billed charge. Nonparticipating Providers When you use a Nonparticipating Provider, benefits are substantially reduced and you will likely incur significantly higher out-of-pocket expenses. A Nonparticipating Provider does not have any agreement with the Claims Administrator or anotherBlue Cross and/or Blue Shield Plan. For services received from a Nonparticipating Provider (other than those described under "Special Circumstances" below), the Allowed Amount will be one of the following, to be determined by the Claims Administrator at its discretion: (1) based upon a Minnesota nonparticipating provider fee schedule posted at theClaims Administrator’s website; (2) apercentage, not less than 100%, of the Medicareallowedcharge for the same or similar service; (3) a percentage of billed charges; (4) pricing determined by another Blue Cross or Blue Shield plan; or (5) pricing based upon a nationwide provider reimbursement database.The Allowed Amountfor a Nonparticipating Provider is usually less than the Allowed Amountfor a Participating Provider for the same service and can be significantly less than the Nonparticipating Provider’s billed charges. You will be paid the you are responsible for paying the Nonparticipating Provider. benefit under the Plan and The onlyexception to this is stated in CLAIMS PROCEDURES, Claims Payment.This amount can be significant and the amount you pay does not apply toward any Out-of-Pocket Maximum contained in the Plan. In determining the Allowed Amount for Nonparticipating Providers,the Claims Administratormakes no representations that this amount is a usual, customary or reasonable charge from a provider. See the Allowed Amount definition for a more complete description of how payments will be calculated for services provided by Nonparticipating Providers. Page9 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 x Example of payment for Nonparticipating Providers The following table illustrates the different out-of-pocket costs you may incur using Nonparticipating versus Participating Providers for most services. The example presumes that the member deductible has been satisfied and that the Plan covers 80 percent of the Allowed Amount for Participating Providers and 60 percent of the Allowed Amount for Nonparticipating Providers. It also presumes that the Allowed Amount for a Nonparticipating Provider will be less than for a Participating Provider. The difference in the Allowed Amount between a Participating Provider and Nonparticipating Provider could be more or less than the 40 percent difference in the following example. Participating ProviderNonparticipating Provider Provider Charge:$150$150 Allowed Amount:$100$60 Claims AdministratorPays:$80 (80percent of the Allowed Amount)$36 (60 percent of the Allowed Amount) CoinsuranceMember Owes:$20 (20percent of the Allowed Amount)$24 (40 percent of the Allowed Amount) Difference Up to Billed None (provider has agreed to write this $90($150minus $60) ChargeMember Owes:off) TotalMemberPays:$20$114 The Claims Administratorwill in most cases pay the benefits for anycovered health care services received from a Nonparticipating Provider directly to the member based on the Allowed Amounts and subject to the other applicable limitations in the Plan. An assignment of benefits from a member to a Nonparticipating Provider generally will not be recognized. Special Circumstances x When you receive care from certain nonparticipating professionals at a participatingfacility such as a hospital, outpatient facility,or emergency room, the reimbursement to the nonparticipating professional may include some of the costs that you would otherwise be required to pay (e.g.,the difference between the AllowedAmount and the provider's billed charge). This reimbursement applies when nonparticipating professionals are hospital-based and needed to provide immediate medical or surgical care and you do not have the opportunity to select the provider of care. This reimbursement also applies when you receive care in a nonparticipatinghospital as a result of a medical emergency. Exampleof Special Circumstances Your doctor admits you to the hospital for an elective procedure. Your hospital and surgeon are Participating Providers. You also receive anesthesiology services, but you are not able to select the anesthesiologist. The anesthesiologist is not a Participating Provider. When the claim for anesthesiology services is processed, the Claims Administrator may pay an additional amount because you needed care, but were not able to choose the provider who would render such services. The above is a general summary of our provider payment methodologies only. Provider payment methodologies may change from time to time and every current provider payment methodology may not be reflected in this summary. Please note that some of these payment methodologies may not apply to your particular plan. Detailed information about payment allowances for services rendered by Nonparticipating Providers in particular is available on the Claims Administrator'swebsite. Page10 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Recommendations by Health Care Providers Referrals are not required. Your provider may suggest that you receive treatment from a specific provider or receive a specific treatment. Even thoughyour provider may recommend or provide written authorization for a referral or certain services, the provider may be an Out-of-Network Provider or the recommended servicesmay be covered at a lesser level of benefits or bespecifically excluded. When these services are referred or recommended, a written authorization from your provider does not override any specificnetwork requirements;notificationrequirements;or,Planbenefits, limitations orexclusions. Services that are Investigative or not Medically Necessary Services or supplies that are investigative or not medically necessary are not covered. No payment ofbenefits will be allowed under this Plan including payments for services you have already received. The terms "investigative" and "medically necessary" are defined in the "Glossary of Common Terms" section. Fraudulent Practices Coverage for you or your dependents will be terminated if you or your dependentengage in fraud ofany type including, but not limited to:submitting fraudulent misstatements aboutyour medical historyor eligibility statuson the application for coverage; submittingfraudulent, altered, or duplicate billings for personal gain; and/or allowinganother party not eligible for coverageunder the Plan to use your or your dependent’s coverage. Time Periods When the time of day is important for benefits or determining when coveragestarts and ends, a day begins at 12:00 a.m.United States Central Time and ends at 12:00 a.m. United States Central Time the following day. Medical Policy Committee The Claims Administrator’s Medical Policy Committee determines whether new or existing medical treatment should be covered benefits. The Committee is made up of independent community physicians who represent a variety of medical specialties. The Committee’s goal is to find the right balance between making improved treatments available and guarding against unsafe or unproven approaches. The Committee carefully examines the scientific evidence and outcomes for each treatment being considered. Page11 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 NOTIFICATION REQUIREMENTS The Claims Administrator reviews services to verify that they are medically necessary and that the treatment provided is the proper level ofcare. All applicable terms and conditions of your Plan including exclusions, deductibles, copays, and coinsurance provisions continue to apply with an approved prior authorization, preadmission notification, preadmission certification,and/oremergency admission notification. Prior authorization,preadmission notification,preadmissioncertification, and/or emergency admission notificationare required. Prior Authorization Prior authorizationis a process that involves a benefits review and determination of medical necessity before a service is rendered. MinnesotaIn-NetworkProvidersare required toobtain prior authorization for you. You are required toobtain prior authorization when you useIn-Network Providers outside Minnesota and Out-of- Network Providers. Some of theseproviders may obtain prior authorization for you. Verify with your providers if this is If it is found, at the point the claim is processed, that services were not a service they will performfor you. medically necessary, you are liable for all of the charges. The Claims Administratorrequiresthat you or the provider contact themat least 10 working days prior to the provider scheduling the care/servicesto determine if the services are eligible. The Claims Administratorwill notify you of theirdecision within 10 working days, provided that the prior authorization request contains all the information needed to review the service. For prior authorization of urgently needed care, please refer to the "Expedited Review Determination" process in the "Appeal Process" section. The prior authorization list is subject to change due to changes in the ClaimsAdministrator’s medical policy. The most current list is available on theClaimsAdministrator’s website or by calling Customer Service. x Cosmetic versus medically necessary proceduresincluding,but not limited to: brow ptosis repair; brow ptosis repair; excision of redundant skin (including panniculectomy); reduction mammoplasty; rhinoplasty; scar excision/revision; mastopexy x Coverage of routine care related to cancer clinical trials x Dental and oral surgery including, but not limited to: services that are accident-related for the treatment of injury to sound and healthy naturalteeth; temporomandibular joint (TMJ) surgical procedures; orthognathic surgery x Drugs including, but not limited to: growth hormones; intravenous immunoglobulin (IVIG); oral fentanyl; subcutaneous immunoglobulin; rituximab for off-label usage; NPlate; Promacta; Tysabri; Cinryze; intravitrel implants; insulin-like growth factors; chelation therapy; botulinum toxin injections for off-label usage x Durable Medical Equipment (DME), prosthetics and supplies including, but not limited to: unlisted DME codes over$1,000;functionalneuromuscular electrical stimulation; manual and motorized wheelchairs and scooters; respiratory oscillatory devices;heavy duty and enclosedhospitalbeds;pressure reducing support surfaces (group 2 and 3); wound healing treatment; implantablehearing devices or prosthetics; continuous glucose monitors; amino acid-based elemental formula; bone growth stimulators; communication assist devices; microprocessor controlled prosthetics x Genetic testing including, but not limited to: hereditarybreast cancer and/or ovarian cancer x Home health care x Home infusion care involving drugs for which we requireprior authorization x Hospice care x Humanitarian Use Devices (defined as devices that are intended to benefit patients by treating or diagnosing disease or condition that affects fewer than 4,000 individuals in the United States per year, classified under the FDA HumanitarianDevice Exemption) Page12 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 x Imaging services including, but not limited to: Breast Magnetic Resonance Imaging (MRI); CT colonography (virtual colonoscopy) x Reproduction treatments x Surgical procedures including, but not limited to: bariatric surgery; hyperhidrosis surgery; sex reassignment surgery; spinal cord stimulators; subtalar arthroereisis for treatment of foot disorders; surgical treatment of obstructive sleep apnea and upper airway resistance syndrome; vagus nerve stimulation (for all conditions); spinal fusion; pelvic floor stimulation x Transplants , except kidney and cornea The Claims Administrator reserves the right to revise, update and/or add to this list at anytime without notice. The current list is available on the Claims Administrator’s websiteor by calling Customer Service. The Claims Administrator prefers that all requests for prior authorization be submitted in writingtoensure accuracy.Please refer to the "Customer Service" section for the telephone number and appropriate mailing address for prior authorization requests. Preadmission Notification Preadmission notification is a process whereby the provider, or you, inform us that you will be admitted for inpatient hospitalization services. This notice is requiredin advance of being admitted for inpatient care for any type of nonemergencyadmissionand for partial hospitalization. MinnesotaIn-NetworkProvidersare required toprovide preadmission notification to the Claims Administrator for you. If you are going to receive nonemergency care from In-Network Providers outside Minnesota orOut-of-Network Providers, you are required toprovidepreadmission notification to the Claims Administrator.Someof theseproviders may provide preadmission notification for you. Verify with your providers if this is a service they will performfor you. You are also required to obtain prior authorization for the services related to the inpatient admission. Please refer to "Prior Authorization" in this section.If it is found, at the point the claim is processed, that services were notmedically necessary, you are liable for all of the charges. Preadmission notification is requiredfor the followingadmissions/facilities: 1.Hospitalacute care admissions; 2.Residential behavioral health treatment facilities; and, 3.Mental health and substance abuse admissions. To provide preadmission notification, call the CustomerServicetelephonenumber provided in the "Customer Service"section. They will direct your call. Preadmission Certification Preadmission certification is a process to provide a review and determination related to a specific request for care or services. Preadmission certification includes concurrent/length-of-stay review for inpatient admissions. This notice is required in advance of being admitted for inpatient care for any type of nonemergency admission and for partial hospitalization. Minnesota In-Network Providers are required toprovide preadmission certification for you. If you are going to receive nonemergency care from In-Network Providers outside Minnesota or Out-of-Network Providers, you are required to provide preadmission certification to the Claims Administrator. Some ofthese providers may provide preadmission certification for you. Verify with your provider if this is a service they will perform for you. You are also required to obtain prior authorization for the services related to the inpatient admission. Please referto "Prior Authorization" in this section. If it is found, at the point the claim is processed, that services were not medically necessary, you are liable for all of the charges. Preadmission certification is required for the following admissions/facilities: 1.Acute rehabilitation (ACR) admissions; Page13 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 2.Long-term acute care (LTAC) admissions; and, 3.Skilled nursing facilities. To provide preadmission certification, call the Customer Service telephone number in the "Customer Service" section. They will direct your call. Emergency Admission Notification In order to avoid liability for charges that are not considered medically necessary, you are required to provide emergency admission notification to the Claims Administratoras soon as reasonably possible after anadmission for pregnancy,medical emergency,or injury that occurred within 48 hours of theadmission. MinnesotaIn-Network Providers are required toprovideemergency admission notification for you. If you receive care fromIn-Network Providers outside Minnesota orOut-of-NetworkProviders,you are required to provideemergency admission notification to the Claims Administrator.Someof theseproviders may provide If it is emergencyadmission notification for you. Verify with your provider if this is a service theywillperformfor you. found, at the point the claim is processed, that services were not medically necessary, you are liable for all of the charges. To provide emergency admission notification, call the CustomerServicetelephonenumber providedin the "Customer Service"section. They will direct your call. Page14 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 CLAIMS PROCEDURES Claims Filing You are not responsible for submitting claims for services received from ParticipatingProviders. These providers will submit claims directly to the Claims Administrator for you and payment will be made directly to them. If you receive services from Nonparticipating Providers, you may have to submit the claims yourself. If the provider does not submit the claim for you, send the claim to the Claims Administrator at the address provided in the Customer Service section. Claims should be filed in writing within 30 days after a covered service is provided. If this is not reasonably possible, the Plan will accept claims for up to 12months after the date of service. Normally, failure to file a claim within the required time limits will result in denial of your claim. These time limits are waived if you cannot file the claim because you are legally incapacitated. You may be required to provide copies of bills, proof of payment, or other satisfactory evidence showing that you have incurred a covered expense that is eligible for reimbursement. The Claims Administrator will notify you of the resolution of the claim on an Explanation of Health Care Benefits (EHCB) form within 30 days of the date the Claims Administrator receives the claim. If, due to matters beyond its control, the Claims Administrator is unable to make a determination within 30 days, the Claims Administrator may take an additional 15 days to make a determination and will inform you in advance of the reasons for the extension. If you do not receive a written explanation within 30 days (or 45 days if there has been an extension) you may consider the claim denied, and you may request a review of the denial. If benefits are denied in whole or in part, the reason for the denial will be listed on the bottom of the EHCB form. You have the right to know the specific reasons for the denial, the provision of the Plan on which the denial was based, and if there is any additional information the Claims Administrator needs to process the claim. You also have the right to an explanation of the claims review procedure and the steps you need to take if you wish to have your claim reviewed. If you have questions that the EHCB form does not answer, please contact the Claims Administrator at the address or telephone numbers provided in the Customer Service section. Right of Examination The Claims Administrator and the Plan Administrator each have the right to ask you to be examined by a provider during the review of any claim. The Plan pays for the exam whenever the exam is requested by either the Claims Administrator or the Plan Administrator. Failure to comply with this request may result in denial of your claim. Release ofRecords You agree to allow all health care providers to give the Claims Administrator needed information about the care they provide to you. The Claims Administrator may need this information to process claims, conduct utilization review and quality improvement activities, and for other health plan activities as permitted by law. The Claims Administrator keeps this information confidential, but the Claims Administrator may release it if you authorize release, or if state or federal law permits or requiresrelease without your authorization. If a provider requires special authorization for release of records, you agree to provide this authorization. Your failure to provide authorization or requested information may result in denial of your claim. Claims Payment When you or your dependents usean In-NetworkProvider for covered services, the Plan pays the provider. When you or your dependents use a Nonparticipating Providereither inside or outside the state of Minnesota for covered services, the Plan pays you. You may not assign your benefits to a Nonparticipating Provider, except when parents are divorced. In that case, the custodial parent may request, in writing, that the Plan pay a Nonparticipating Provider for covered services for a child. When the Planpays the provider at the request of the custodial parent, the Plan has satisfied its payment obligation. This provision may be waived for:ambulance providers in Minnesota and border counties of contiguous states;and,certain out-of-state institutional and medical/surgical providers. Page15 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 The Plan does not pay claims to providers or toeligibleemployeesand/ordependentsfor services received in countries that are sanctioned by the United States Department of Treasury’s Office of Foreign Assets Control (OFAC), except for medical emergency services when payment of such services is authorized by OFAC. Countries currently sanctioned by OFAC include Cuba, Iran, and Syria. OFAC may add or remove countries from time to time. No Third-Party Beneficiaries The benefits described in your SPD are intended solely for the benefit of you and your covered dependents. No one else may claim to be a third-party beneficiary of this SPD. No one other than you or your dependent may bring a lawsuit, claim or any other cause of action related in any way to this SPD. Page16 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 APPEAL PROCESS Introduction The Claims Administratorhas a process to resolve appeals.You can call or write the Claims Administrator with your appeal.The Claims Administrator will send an appeal form to you upon request. If you need assistance, the Claims Administrator will complete the written appeal form and mail it to you for your signature.The Claims Administrator will work to resolve your appeal as soon as possible using the appeal process outlined below. If your appeal concerns a covered health care service or claim, including medical necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit, you may request an external review of the final decision the Claims Administrator makes about your appeal after you have exhausted the Claims Administrator's appeal process. In addition, you may file your appeal with the Minnesota Commissioner of Commerce at any time by calling 651-296-4026 or toll-free 1-800-657-3602. Definitions Adverse Benefit Determination means a denial, reduction, termination, or failure to make payment in whole or in part for a benefit, including those related to eligibility, rescission of coverage, utilization review, or investigative status. Appealmeans any grievance that is not the subject of litigation concerning any aspect of the provision of health services under your SPD. If the appeal is from an applicant, the appeal must relate to the application. If the appeal is from a former member, the appealmust relate to the provision of health services during the period of time the appellant was a member. Any appeal that requires a medical determination in its resolution must have the medical determination aspect of the appeal processed under the utilization review process described below. Appellantmeans a member, applicant, or former member, or anyone acting on his or her behalf, who submits an appeal. Membermeans an individual who is covered by a health benefit plan. Oral Appeals If you call or appear in person to notify the Claims Administratorthat you would like to file an appeal, the Claims Administrator will try to resolve your oral appeal within 10 calendar days. If the Claims Administrator'sresolution of your oral appeal is wholly or partiallyadverse to you, the Claims Administrator will provide you an appeal form that will include all the necessary information to file your appeal in writing. If you need assistance, the Claims Administrator will complete the written appeal form and mail it to you for your signature. Written Appeals You may submit your appeal in writing, or you may request an appeal form that will include all the necessary information to file your appeal. The Claims Administrator will notify you thatthe Claims Administrator has received your written appeal. The Claims Administrator will inform you of the Claims Administrator’s decision and the reasons for the decision within 30 days of receiving your appeal and all necessary information. If the Claims Administrator is unable to make a decision within 30 days due to circumstances outside the Claims Administrator’s control, the Claims Administrator may take up to 14 additional days to make a decision. If the Claims Administrator takes more than 30 days to make a decision, the Claims Administrator will inform you of the reasons for the extension. You are entitled to examine all pertinent documents and to submit issues and comments in writing. If your health plan is subject to ERISA and the Claims Administrator’s appeal determination is wholly or partially adverse to you, you may file suit in federal district court or use the following appeal procedure. Page17 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Process for Appeals that do not Require a Medical Determination If the Claims Administrator’s decision regarding an appeal is partially or wholly adverse to you, you may file an appeal of the decision in writing and request either a hearing or a written reconsideration. Hearing Notification If you request a hearing, you or any person you choose may present testimony or other information. The Claims Administrator will provide you written notice of the Claims Administrator’s decision and all key findings within 45 days after the Claims Administrator receives your written request for a hearing. If you request a written reconsideration,you may provide the Claims Administrator any additional information you believe is necessary. The Claims Administrator will provide you written notice of the Claims Administrator’s decision and all key findings within 30 days after the Claims Administrator receive your request for a written reconsideration. If you request, the Claims Administrator will provide you a complete summary of the appeal decision. WrittenReconsideration You may submit your reconsiderationinwriting, or you may request a form that will include all the necessary information to file your reconsideration. The Claims Administrator will notify you that we have received your written appeal. During the course of the Claims Administrator's review, the Claims Administrator will provideyou with any new evidence that the Claims Administrator considersorrelies upon, as well as any new rationale for a decision. Within 30 days of receiving your reconsiderationand all necessary information, the Claims Administrator will notify you in writing of the Claims Administrator's decision and the reasons for the decision. If the Claims Administrator is unable to make a decision within 30 days due to circumstances outside the Claims Administrator's control, the Claims Administrator may take up to 14 additional days to make a decision. If the Claims Administrator takes more than 30 days to make a decision, the Claims Administrator will inform you in advance of the reasons for the extension. You may present testimony in the form of written correspondence, including explanations or other information from you, staff persons, administrators, providers, or other persons. You may also present testimony by telephone to a Claims Administrator Appeal Liaison. External Review If your appeal concerns a covered health care service or claim, or medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit, and you believe the Claims Administrator's appeal determination is wholly or partially adverse to you, you or anyone you authorize to act on your behalf, may submit the appeal to external review. External review of your appeal will be conducted by an independent organization under contract with the state of Minnesota. The written request must be submitted to the Minnesota Commissioner of Commerce along with a filing fee. The Commissioner may waive the fee in cases of financial hardship. Minnesota Department of Commerce Attention: Consumer Concerns/Market Assurance Division th 85 7Place East, Suite 500 St. Paul, MN55101-2198 The external review entity will notify you and the Claims Administrator that it has received your request for external review. Within 10 business days of receiving notice from the external review entity, you and the Claims Administrator must provide the external review entity any information to be considered. Both you and the Claims Administrator will be able to present a statement of facts and arguments. You may be assisted or represented by any person of your choice at your expense. The external review entity will send written notice of its decision to you, the Claims Administrator, and the Commissioner within 40 days of receiving the request for external review. The external review entity's decision is binding on the Claims Administrator, butnot binding on you. Page18 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Process for Appeals When Utilization Review is Necessary When a medical determination is necessary to resolve your appeal, the Claims Administrator will process your appeal using these utilization review appeal procedures. Utilization review applies a well-defined process to determine whether health care services are medically necessary and eligible for coverage. Utilization review includes a process to appeal decisions not to cover a health care service. Utilization review applies only when the service requested is otherwise covered under this health plan. In order to conduct utilization review,the Claims Administrator will need specific information. If you or your attending health care professional do not release necessary information, approvalof the requested service, procedure, or admission to a facility may be denied. Definitions Attending health care professionalmeans a health care professional with primary responsibility for the care provided to a sick or injured person. Concurrent reviewmeans utilization review conducted during a patient's hospital stay or course of treatment. Determination not to certifymeans that the service you or your provider has requested has been found to not be medically necessary, appropriate,or efficacious under the terms of this health plan. Prior authorizationmeans utilization review conducted prior to the delivery of a service, including an outpatient service. Providermeans a health care professional or facility licensed, certified orotherwise qualified under state law, in the state in which the services are rendered, to provide the health services billed by that provider.Provider also includes pharmacies, medical supply companies, independent laboratories, and ambulances. Utilization reviewmeans the evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures and facilities, by a person or entity other than the attending health care professional, for the purpose of determining the medical necessity of the services or admission. Determinations Standard review determination When a medical determination is required, the Claims Administrator's initial determination will be communicated to you and your provider within 10 business days of therequest provided that all information reasonably necessary to make a determination on your request has been made available to the Claims Administrator. When the Claims Administrator authorize services, the Claims Administrator will notify the provider by telephone and in writing. When the Claims Administrator determines not to authorize the services, the Claims Administrator will notify the attending health care professional and hospital by telephone, and notify the attending health care professional, hospital, and member in writing. When a determination is made not to authorize a service, notification by telephone will be made within one (1) working day. Notification will include notice of the right to appeal and how to submit an appeal. Expedited reviewdetermination The Claims Administrator will use an expedited review determination when the application of a standard review could seriously jeopardize your life or health or if the attending health care professional believes an expedited review is warranted. When an expedited review is requested, the Claims Administrator will notify the attending health care professional, hospital and member of the decision as expeditiously as the member's medical condition requires, but no later than 24hours from the initial request, unless more information is needed to determine whether the requested benefits are covered. If the expedited determination is to not authorize services, notification will include notice that you and your attending health care professional maysubmit an expedited appeal, and how to submit an expedited appeal. Page19 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Appeals Standard appeal You or your attending health care professional may appeal, in writing or by telephone, the Claims Administrator's decision to not authorize services. The decision will be made by a health care professional who did not make the initial decision. The Claims Administrator will notify you and your attending health care professional of the Claim's Administratordetermination within 30 days of receipt of your appeal. The request for appeal should include: 1.the member's name, identification number and group number; 2.the actual service for which coverage was denied; 3.a copy of the denial letter; 4.the reason why you or your attending health care professional believe coverage for the service should be provided; 5.any available medical information to support your reasons for reversing the denial; and, 6.any other information you believe will be helpful to the decision maker. Expedited appeal When the Claims Administrator does not authorize services under the expedited appeal procedure described above, and the attending health care professional believes that an expedited appeal is warranted, you and your attending health care professional may request an expedited appeal. You and your attending health care professional may appeal the determination over the telephone. The Claims Administrator'sappeal staff will include the consulting physician or health care provider if reasonably available. When an expedited appeal is completed, the Claims Administrator will notify you and your attending health care professional of the decision as expeditiously as the member's medical condition requires, but no later than 72 hours from the Claims Administrator'sreceipt of the expedited appeal request. If your health plan is subject to ERISA, and the Claims Administrator's appeal decision is wholly or partially adverse to you, you may file suit in federal district court, or use the external review procedure below. External Review If the standard or expedited appeal determination is to not authorize services, you or your attending health care professional may request external review as described above. This appeal process is subject to change if required or permitted by changes in state or federal law governing appeal procedures. Page20 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BENEFIT CHART This section lists covered services and the benefits the Plan pays. All benefit payments are based on the AllowedAmount. Coverage is subject to all other terms and conditions of this Summary Plan Description and must be medically necessary. Date Run: 12-13-11 Benefit Features, Limitations, and Maximums Networks: x In-Network Providers Aware Network Providers Minnesota Outside MinnesotaBlueCard Network Providers Benefit FeaturesYour Liability Copays x $75per visit Emergency room facility copay Prescription Drugs x PreferredGeneric Drugs $5 copay Retail Pharmacy $10 copay 90dayRx: x Participating Retail 90dayRx Pharmacy x Mail Service Pharmacy x Non-preferredGeneric Drugs $5 copay Retail Pharmacy $10 copay 90dayRx: x Participating Retail 90dayRx Pharmacy x Mail Service Pharmacy x GenRxPreferredBrand Name Drugs $35 copay Retail Pharmacy $70 copay 90dayRx: x Participating Retail 90dayRx Pharmacy x Mail Service Pharmacy x Non-preferredBrand NameDrugs $85 copay Retail Pharmacy $170 copay 90dayRx: x Participating Retail 90dayRx Pharmacy x Mail Service Pharmacy Page21 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Benefit FeaturesYour Liability Deductible Deductible carryover applies (The amount applied toward your deductible under this Plan during the last three (3) months ofthe calendar yearthat is applied toward your deductible,under this Plan,for the next calendaryear.This amount will not be applied toward the Out-of-Pocket Maximum for the next calendar year.) (Does not include applicableprescription drugmember cost-sharing.) x $300 per person per calendar year Out-of-Network Providers $900 per family per calendar year Benefit FeaturesLimitations and Maximums Out-of-Pocket Maximums x $2,500 per person per calendar year All Providerscombined The following items are applied toward themedicalOut-of-Pocket Maximum: x coinsurance x deductibles x medicalvisitcopays The following items are NOT applied toward themedicalOut-of-Pocket Maximum: x applicableprescription drugmembercost-sharing x deductiblecarryover x $150 per person per calendar year Prescription Drug Out-of-Pocket Maximum (Does not include drugs used during inpatient admission) NOTE: Price differences between brand name and generic drugs may be your responsibility in certain instances. This amount is your responsibility and is not credited towards any Out-of-PocketMaximum. Lifetime Maximum: x Reproduction Treatments Medical services$8,000 per person PrescriptionDrugs$3,500 per person x Unlimitedper person Total benefitspaid to all providers combined Benefit Descriptions Please refer to the following pages for a more detailed description of Plan benefits. Page22 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 AMBULANCE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 80% Air or ground transportation licensed to providebasic or advanced life support from the place of departure to the nearest medicalfacility equipped to treat the condition x Medically necessary, prearranged or scheduled air or ground ambulance transportation requested by an attending physician or nurse NOTES: x Please see the "Notification Requirements"section. x If the Claims Administrator determines air ambulance was not medically necessary but ground ambulance would have been, the Plan pays up to the AllowedAmount for medically necessary ground ambulance. NOT COVERED: x transportation services that are not medically necessary for basic or advanced life support x transportation services that are mainly for your convenience x please refer to the "General Exclusions"section Page23 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BARIATRIC SURGERY In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Eligiblemembers age 18 and inpatientEligiblemembers age 18 and Medically necessary older: 100%whenyou use hospital/facility services for bariatric older:NO COVERAGE. Blue Distinction Centers for surgery from admission to discharge: Bariatric Surgery. Semiprivate room and board and general nursing care (private room is Eligiblemembers age 17 and Eligiblemembers age 17 and covered only when medically younger:younger:NO COVERAGE. 100%whenyou use necessary) In-Network Providers. Intensive care and other special care units Operating, recovery, and treatment rooms Anesthesia Prescription drugs and supplies used during a covered hospital stay Lab and diagnostic imaging x Eligiblemembers age 18 and outpatient Medically necessary Eligiblemembers age 18 and older: 100%whenyou use hospital/facility services for bariatric older:NO COVERAGE. Blue Distinction Centers for surgery: Bariatric Surgery. Scheduled bariatric surgery/anesthesia Lab and diagnostic imaging Eligiblemembers age 17 and Eligiblemembers age 17 and All other eligible outpatient hospital care younger:younger:NO COVERAGE. 100%whenyou use related to bariatric surgery provided on In-Network Providers. the day of surgery NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x Eligible members age 17 and younger have direct access to In-Network Providers for the highest level of benefits. x For professional services related to eligible bariatric surgery services, refer to "Physician Services." x Blue Distinction Centers for Bariatric Surgery are designated facilities within participating Blue Plan’s service areas that have been selected after a rigorous evaluation of clinical data that provide insight into the facility’s structures, processes, and outcomes of care. Nationally established evaluation criteria were developed with input from medical experts and organizations. These evaluation criteria support the consistent, objective assessment of specialty care capabilities. Blue Distinction Centers for Bariatric Surgery meet stringent quality criteria, as established by expert physician panels, surgeons,behaviorists, and nutritionists. The national Blue Distinction Centers for Bariatric Surgery have been developed in conjunction with other Blue Cross and Blue Shield plans and the Blue Cross and Blue Shield Association. x As technology changes, the coveredbariatric surgery procedures will be subject to modifications in the form of additions or deletions, when appropriate. x The Claims Administrator requests prior authorization be submitted in writing to: Blue Cross and Blue Shield of Minnesota Medical Review Department P.O. Box 64265 St. Paul, MN 55164 x For a list of Blue Distinction Centers for Bariatric Surgery contactCustomer Service or visit the Claims Administrator'swebsite. x For pre-operativeand post-operativebariatricservices,please refer to "Hospital Inpatient,""Hospital Outpatient," "PhysicianServices,"etc. Page24 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BARIATRIC SURGERY (continued) NOT COVERED: x please refer to the "General Exclusions"section Page25 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH MENTAL HEALTH CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Outpatienthealth care professional 100%for the office visit charge; 80% after youpay the charges for services including:100%for all other eligible deductible for the office visit serviceswhen you use a charge;80% after you pay the assessment and diagnostic services Behavioral Health Select deductible for all other eligible individual/group/family therapy Network Provider.services, plus you pay any (office/in-homemental health services) chargesbilled to youthat neuro-psychological examinations exceed the Allowed Amount when you use an Out-of- x Professional health care charges for Network ParticipatingProvider. services including: clinical based partial programs 80% after you pay the clinical based day treatment deductible for the office visit charge;80% after you pay the clinical based Intensive Outpatient deductiblefor all other eligible Programs (IOP) services, plus you pay any chargesbilled to youthat exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Outpatient hospital/outpatientbehavioral deductible, plus you pay any health treatment facility charges for chargesbilled to youthat services including: exceed the Allowed Amount. evaluation and diagnostic services individual/group therapy crisis evaluations observation beds family therapy x 100%when you use a Inpatient health care professional charges80% after you pay the Behavioral Health Select deductible, plus you pay any Network Provider. chargesbilled to you that exceed the Allowed Amount when you use an Out-of- Network ParticipatingProvider. 80% after you pay the deductible, plus you pay any chargesbilled to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Inpatient hospitalandinpatientresidential deductible, plus you pay any behavioral health treatment facility charges chargesbilled to you that for services including: exceed the Allowed Amount. hospital based partial programs hospital based day treatment hospital based Intensive Outpatient Programs (IOP) all eligible inpatient services emergency holds Page26 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH MENTAL HEALTH CARE (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100% when you use a Outpatient health care professional lab80% after you pay the Behavioral Health Select deductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%when you use a Outpatient health care professional 80% after you pay the Behavioral Health Select diagnostic imagingdeductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Outpatient hospital/facility lab deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x 100%80% after you pay the Outpatient hospital/facility diagnostic deductible, plus you pay any imaging charges billed to you that exceed the Allowed Amount. x 100%when you use a Inpatient health care professional lab and 80% after you pay the Behavioral Health Select diagnostic imaging deductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. Page27 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH MENTAL HEALTH CARE (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%80%after you pay the Inpatient hospital/facility lab and diagnostic deductible,plus you pay any imaging charges billed to you that exceed the Allowed Amount. NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the"Notification Requirements"section. x To receive the highest level of coverage you must use theBehavioral Health SelectNetwork.To locate an appropriate Behavioral Health Select Network Provider calltheCustomerServicetelephonenumber provided in the Customer Service sectionprior to obtaining treatment. x Court-ordered treatment formental health care that is based on an evaluation and recommendation for such treatment or services by a physician or a licensed psychologist is deemed medically necessary. x A court-ordered, initial exam for a dependent child under the age of 18 is also considered medically necessary without further review by the Claims Administrator. Court-ordered treatment for mental health care that is not based on an evaluation and recommendation as described above will be evaluated to determine medical necessity. Court-ordered treatment that does not meet the criteria above will be covered if it is determined to be medically necessary and otherwise covered under this Plan. x Outpatient family therapy is covered if rendered by a health care professional and the identified patient must be a covered member. The family therapy services must be for treatment of a behavioral health diagnosis. x Admissions that qualify as "emergency holds,"as the term is defined in Minnesota statutes, are considered medically necessary for the entirehold. x Coverage is provided for diagnosable mental health conditions, including autism and eating disorders. x Coverage provided for treatment of emotionally disabledchildren in a licensed residential behavioral health treatment facilityis coveredthe same as any other inpatient hospital medical admission. x For home health related services, please refer to "Home Health Care." x Psychoeducation is covered for individuals diagnosed with schizophrenia, bipolar disorder, and borderline personality disorder. Psychoeducational programs are delivered by an eligible provider to the patient on a group or individual basis as part of a comprehensive treatment program. Patients receive support, information, and management strategies specifically related to their diagnosis. x Coverage is provided for therapy conducted by televideo conferencing services. Eligible televideo conferencing services do not include email and physician/patient telephone consultations, except for eligible E-Visits. x Coverage is provided for crisis evaluations delivered by mobile crisis units. NOT COVERED: x services for mental illness that are not listed in the most recent edition oftheInternational Classification of Diseases x custodial care, nonskilled care, adult daycare or personal care attendants x services or confinements ordered by a court or law enforcement officer that are not medically necessary; services that are not considered medically necessary include, but are not limited to the following:custody evaluations;parenting assessments;education classes for Driving Under the Influence (DUI)/Driving While Intoxicated (DWI) offenses;competency evaluations;adoption home status;parental competency;and domestic violence programs x room and board for foster care, group homes,sheltercare,and lodging programs x halfway house services x servicesfor marriage/couples therapy/counseling not related to the treatment of a covered member's diagnosable mental health disorder x services for or related to marriage/couples training for the primary purpose of relationship enhancement including, but not limited to premarital education; or marriage/couples retreats, encounters, or seminars x educational services with the exception of nutritional education for individuals diagnosed with anorexia nervosa, bulimia or eating disorders NOS (not otherwise specified) x skills training Page28 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH MENTAL HEALTH CARE (continued) NOT COVERED: x therapeutic support of foster care (services designed to enable the foster family to provide a therapeutic family environment or support for the foster child's improved functioning) x services for the treatment of learning disabilities x therapeutic day care and therapeutic camp services x hippotherapy (equine movement therapy) x charges made by a health care professional for email and physician/patienttelephone consultations, except for eligible E-Visits x please refer to the "General Exclusions"section Page29 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH SUBSTANCE ABUSE CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Outpatient health care professional 100%forthe office visit charge; 80% after you pay the charges for services including:100%for all other eligible deductiblefor theoffice visit serviceswhen you use a charge;80% after you pay the assessment and diagnostic services Behavioral Health Select deductible, plus you pay any family therapy Network Provider.chargesbilled to you that opioidtreatment exceed the Allowed Amountfor all other eligible services when you use an Out-of-Network ParticipatingProvider. 80% after you pay the deductiblefor the office visit charge;80% after you pay the deductibleforall other eligible services, plus you pay any chargesbilled to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Outpatient hospital/outpatient behavioral deductible, plus you pay any health treatment facility charges for chargesbilled to youthat services including: exceed the Allowed Amount. Intensive Outpatient Programs (IOP) and related aftercare services x 100%whenyou use a Inpatient health care professional charges 80% after you pay the Behavioral Health Select deductible, plus you pay any Network Provider. chargesbilled to youthat exceed the Allowed Amount when you use an Out-of- Network ParticipatingProvider. 80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Inpatient hospital/residential behavioral deductible, plus you pay any health treatment facility charges chargesbilled to youthat exceed the Allowed Amount. Page30 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH SUBSTANCE ABUSE CARE (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%when you use a Outpatient health care professional lab 80% after you pay the Behavioral Health Select deductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100% when you use a Outpatient health care professional 80% after you pay the Behavioral Health Select diagnostic imagingdeductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. x 100%80% after you pay the Outpatient hospital/facility lab deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x 100%80% after you pay the Outpatient hospital/facility diagnostic deductible, plus you pay any imaging charges billed to you that exceed the Allowed Amount. x 100%when you use a Inpatient health care professional lab and 80% after you pay the Behavioral Health Select diagnostic imaging deductible,plus you pay any Network Provider. charges billed to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount when you use a Nonparticipating Provider. Page31 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BEHAVIORAL HEALTH SUBSTANCE ABUSE CARE (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%80%after you pay the Inpatient hospital/facility lab and diagnostic deductible, plus you pay any imaging charges billed to you that exceed the Allowed Amount. NOTES: x Priorauthorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x To receive the highest level of coverage you must use theBehavioral Health SelectNetwork.To locate an appropriate Behavioral Health Select Network Provider calltheCustomerServicetelephonenumber provided in the Customer Service sectionprior to obtaining treatment. x Court-ordered treatment for substance abuse care that is based on an evaluation and recommendation for such treatment or services by a physician or a licensed psychologist, a licensed alcohol and drug dependency counselor or a certified substance abuse assessor is deemed medically necessary. x A court-ordered, initial exam for a dependent child under the age of 18 is also considered medically necessary without further review by the Claims Administrator. Court-ordered treatment for substance abuse care that is not based on an evaluation and recommendation as described above will be evaluated to determine medical necessity. Court-ordered treatment will be covered if it is determined to be medically necessary and otherwise covered under this Plan. x Outpatient family therapy is covered if rendered by a health care professional and the identified patient must be a covered member. The family therapy services must be for the treatment of a behavioral health diagnosis. x Admissions that qualify as "emergency holds,"as the term is defined in Minnesota statutes, are considered medically necessary for the entire hold. x For home health related services, please refer to "Home Health Care." x Coverage is provided for therapy conducted by televideo conferencing services. Eligible televideo conferencing services do not include email and physician/patient telephone consultations, except for eligible E-Visits. NOT COVERED: x services for substance abuse or addictions that are not listed in the most recent edition of the International Classification of Diseases x custodial care, nonskilled care, adult daycare or personal care attendants x services or confinements ordered by a court or law enforcement officer that are not medically necessary; services that are not considered medically necessary include, but are not limited to the following:custody evaluations;parenting assessments;education classes for Driving Under the Influence (DUI)/Driving While Intoxicated (DWI) offenses;competency evaluations;adoption home status;parental competency;and domestic violence programs x room and board for foster care, group homes,shelter care,and lodging programs x halfway house services x substance abuse interventions, defined as a meeting or meetings, with or without the affected person, of a group of people who are concerned with the current behavioralhealth of a family member, friend or colleague, with the intent of convincing the affected person to enter treatment for the condition x charges made by a health care professional for email and physician/patient telephone consultations, except for eligibleE-Visits x please refer to the "General Exclusions"section Page32 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 CHIROPRACTIC CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Office visits from a doctor of chiropractic 100%when you use a Blue 80% after you pay the Select Chiropractic Networkdeductible, plus you pay any x Manipulations Provider.chargesbilled to youthat exceed the Allowed Amount when you use an Out-of- Network Participating Provider. When you use a Nonparticipating Provider, NO COVERAGE there is. x 100%when you use a Blue Therapies 80% after you pay the Select Chiropractic Network deductible, plus you pay any x Otherchiropractic services Provider. chargesbilled to youthat exceed the Allowed Amount when you use an Out-of- Network Participating Provider. When you use a Nonparticipating Provider, NO COVERAGE there is. x 100%when you use a Blue Lab 80%after you pay the Select Chiropractic Network deductible, plus you pay any Provider. chargesbilled to youthat exceed the Allowed Amount when you use an Out-of- Network Participating Provider. When you use a Nonparticipating Provider, NO COVERAGE there is. x 100%when you use a Blue Diagnostic imaging 80%after you pay the Select Chiropractic Network deductible, plus you pay any Provider. chargesbilled to you that exceed the Allowed Amount when you use an Out-of- Network Participating Provider. When you use a Nonparticipating Provider, NO COVERAGE there is. NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x You must use a Blue Select ChiropracticNetworkProvider to obtain the highest level of coverage. x Office visits include medical history, medical examination, medical decision making, counseling, coordination of care, nature of presenting problem, and the chiropractor's time. NOT COVERED: x services you receive from a Nonparticipating Provider Page33 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 CHIROPRACTICCARE (continued) NOT COVERED: x services for or related to vocational rehabilitation (defined as services provided to an injured employee to assist the employee to return either to their former employment or a new position, or services to prepare a person with disabilities for employment), except when medically necessary and provided by an eligible health care provider x services foror related to recreational therapy (defined as the prescribed use of recreational or other activities as treatment interventions to improve the functional living competence of persons with physical, mental, emotional and/or social disadvantages)oreducational therapy(defined as special education classes, tutoring, and other nonmedical services normally provided in an educational setting), or forms of nonmedical self-care or self-help training, including, but not limited to:health club memberships;aerobic conditioning;therapeutic exercises; work-hardening programs;etc., and all related material and products for these programs x services for or related to therapeutic massage x services for or related to rehabilitation services thatare notexpectedto make measurable or sustainable improvement within a reasonable period of time,unless they are medically necessary and part of specialized maintenance therapy to treat the member's condition x custodial care x please refer to the "General Exclusions"section Page34 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 DENTAL CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders This is not a dental plan. The following 100%for the office visit charge;80%after you pay the limited dental-related coverage is provided: 100% for all other eligibledeductibleforthe office visit services.charge; 80% after you pay the x Accident-related dental services from a deductible for all other eligible physician or dentist for the treatment of an services, plus you pay any injury to sound andhealthynatural teeth chargesbilled to you that x exceed the Allowed Amount. Treatment of cleft lip and palate when services are scheduled or initiated prior to the member turning age 19 including: dental implants removal of impacted teeth or tooth extractions related orthodontia related oral surgery bone grafts x Surgical and nonsurgical treatment of temporomandibular joint (TMJ) disorder and craniomandibular disorder including: orthognathic surgery related orthodontia NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x All of the above mentioned benefits are subject to medical necessity and eligibility of the proposed treatment. Treatment must occur while you are covered under this Plan. x Accident-related dental services, treatment and/or restoration of a soundandhealthy natural tooth must be initiated within 12 months of the date of injury or within 12 months of your effective date of coverage under this Plan. Coverage is limited to the initial treatment (or course of treatment) and/or initial restoration.Only services performed within 24 months from the date treatment or restoration is initiated are covered.Coverage for treatment and/or restoration is limited to re-implantation of original sound andhealthy natural teeth, crowns, fillings and bridges. x The Plan covers anesthesia and inpatient and outpatient hospital charges for dental care provided to a covered person who is a child under age five (5); is severely disabled; or has a medical condition that requires hospitalization or general anesthesia for dental treatment. x Forhospital/facility charges,please refer to "Hospital Inpatient"or"Hospital Outpatient." x Formedical services,please refer to "Hospital Inpatient,""Hospital Outpatient,""Physician Services,"etc. x Services for surgicaland nonsurgicaltreatment of temporomandibular joint (TMJ)disorder and craniomandibular disorder must be covered on the same basis as any other body joint and administered or prescribed by a physician or dentist. x Bone grafts for the purpose of reconstruction of the jaw is a covered service, but not for the sole purpose of supportinga dental implant, dentures or adental prosthesis. x A sound and healthy natural tooth is a viable tooth (including natural supporting structures) that is free from disease that would prevent continual function of the tooth for at least one (1) year. In the case of primary (baby) teeth, the tooth musthave a life expectancy of one (1) year. A dental implant is not a sound and healthy natural tooth. NOT COVERED: x all orthodontia, except as specified in the "Benefit Chart" x dental services to treat an injury from biting or chewing Page35 SVCGNC:2000-5362 / SVCGNC32A /tppprd X17342-R6 DENTAL CARE (continued) NOT COVERED: x dentures, regardless ofthe cause or the condition, and any associated services and/or charges, including bone grafts x dental implants, except as specified in the "Benefit Chart" x removal of impacted teeth and/or tooth extractions and any associated charges including but notlimited to: imaging studies and pre-operative examinations, except as specified in the "Benefit Chart" x accident-related dental services initiated after 12 months from the date of injury or 12 months of your effective date of coverage under this Planor occurring more than 24 months after the date of initial treatment x replacement of a damaged dentalbridge from an accident-related injury x osteotomies and other procedures associated with the fitting of dentures or dental implants, except as specified in the "Benefit Chart" x services for or related to oral surgery and anesthesia for removal of a tooth root without removal of the whole tooth, except as specified in the "Benefit Chart" x root canal therapy, except as specified in the "Benefit Chart" x services for or related to dental or oral care, treatment, orthodontics, surgery, supplies, anesthesia or facility charges, except as specified in the "Benefit Chart" x please refer to the "General Exclusions"section Page36 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 EMERGENCYROOM In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Outpatient hospital/facility charges100% after you pay the emergency room facility copay. emergency room x 100% Outpatient health care professional charges x 100% Professionallab x 100% Professionaldiagnosticimaging NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x When determining if a situation is a medical emergency, the Claims Administrator will take into consideration a reasonable layperson’s belief that the circumstances required immediate medical care that could not wait until the next business day. x Forinpatientservices, please refer to "HospitalInpatient"and"Physician Services." x For urgent care visits, please refer to "Hospital Outpatient"and"Physician Services." x The emergency room facility copay is waived if you are admitted within 24 hours. NOT COVERED: x please refer to the "General Exclusions"section Page37 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 HOME HEALTH CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100% Skilled careand other home care services 80% after you pay the ordered by a physician and provided by deductible, plus you pay any employees of a Medicareor Plan approved chargesbilled to youthat home healthcareagency including, but not exceed the Allowed Amount. limited to: intermittent skilled nursing care in your home by a: x licensed registered nurse x licensed practical nurse x medical technologist x licensed registered dietician x respiratory therapist physicaland occupational therapy by a licensedtherapistand speech therapy by a certified speech and language pathologist services of a home health aide or master's level social worker employed by the home health agency when provided in conjunction with services provided by the above listed agency employees use of appliances that are owned or rented by the home health agency home health care following early maternity discharge palliative care NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x Benefits for home infusion therapy and related home health care are listed under "Home Infusion Therapy." x For supplies and durable medical equipment billed by a Home Health Agency, please refer to "Medical Equipment, Prosthetics, and Supplies." x The Plan covers outpatient palliative care for members with a new or established diagnosis of progressive debilitating illness, including illness which may limit the member's life expectancy to two (2) years or less. The services must be within the scope of the provider's license to be covered. Palliative care does not include hospice or respite care. NOT COVERED: x charges for or related to care that is custodial or not normally provided as preventive care or for treatment of an illness/injury(please refer to "Custodial Care" and "Skilled Care" in the "Definitions" section) x treatment, services or supplies which are not medically necessary x services for or related to extended hours skilled nursing care, also referred to as private-duty nursingcare, except as required by Minnesota law x please refer to the "General Exclusions"section Page38 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 HOME INFUSION THERAPY In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 80% NO COVERAGE. Home infusion therapy services when ordered by a physician x Solutions and pharmaceutical additives, pharmacy compounding and dispensing services x Durable medical equipment x Ancillary medical supplies x Nursing services to: train you or your caregiver monitor the home infusion therapy x Collection, analysis, and reporting of lab tests to monitor response to home infusion therapy x Other eligible home health services and supplies provided during the course of home infusion therapy NOTE: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements" section. NOT COVERED: x services you receive from an Out-of-Network Provider x home infusion services or supplies not specifically listed as covered services x nursing services to administer therapy that you or another caregiver can be successfully trained to administer x services that do not involve direct patient contact, such as delivery charges and recordkeeping x please refer to the "General Exclusions"section Page39 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 HOSPICE CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100% NO COVERAGE. Hospice care for aterminalcondition provided by a Medicare-approved hospice provider or other preapproved hospice, including: inpatient respite care general inpatient care x 100% NO COVERAGE. Hospice care for a terminal condition provided by a Medicare-approved hospice provider or other preapproved hospice, including: routine home care continuous home care NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the"Notification Requirements"section. x Prior approval is requiredfor entrance into the hospice benefit, for any inpatient admission while the patient is receiving hospice benefits, for any patient living beyond six (6) months, and for determination of coverage for services unrelated to the terminal condition. x Benefits are restricted to patients with a terminal condition (i.e. life expectancy of six (6) months or less). The patient's primary physician must certify in writing a life expectancy of six (6)months or less. Hospice benefits begin on the date of admission to a hospice program with prior approval. x Inpatient respite care is for the relief of the patient's primary care giver and is limited to a maximum of five (5) consecutive days at a time. x General inpatient care is for control of pain or other symptom management that cannot be managed in a less intense setting. x Medical care services unrelated to the terminal condition are covered, but are separate from the hospice benefit. NOT COVERED: x services you receive from anOut-of-Network Provider x room and board expenses in a residential hospice facility x please refer to the "General Exclusions"section Page40 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 HOSPITAL INPATIENT In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%80% after you pay the Semiprivate room and board and general deductible, plus you pay any nursing care (private room is covered only chargesbilled to you that when medically necessary) exceed the AllowedAmount. x Intensive care and other special care units x Operating, recovery, and treatment rooms x Anesthesia x Prescription drugs and supplies used during a covered hospital stay x Lab x Diagnostic imaging x Communication services of a private duty nurse or apersonal care assistant up to 120 hours during ahospital admission NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x The Plan covers kidney and cornea transplants. Forkidney transplants done in conjunction with an eligible major transplant or other kinds of transplants, pleaserefer to "Transplant Coverage." x The Plan covers the following kidney donor services when billed under the donor recipient's name and the donor recipient is covered for the kidney transplant under the Plan: potential donor testing; donor evaluation and work-up; and hospital and professional services related to organ procurement. x The Plan covers anesthesia and inpatient hospital charges for dental care provided to a covered person who is a child under age five (5); is severely disabled; or has a medical condition that requires hospitalization or general anesthesia for dental treatment. x For hospital/facility charges for bariatric surgery, please refer to "Bariatric Surgery." NOT COVERED: x communication services provided on an outpatient basis or in the home x travel expenses for a kidney donor x kidney donor expenses for complications incurred after the organ is removed if the donor is not covered under this Plan x kidney donor expenses when the recipient is not covered for the kidney transplant under this Plan x services for or related to extended hours skilled nursing care, also referred to as private-duty nursingcare, except as required by Minnesota law x please refer to the "General Exclusions"section Page41 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 HOSPITAL OUTPATIENT In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%80% after you pay the Scheduled surgery/anesthesia deductible, plus you pay any x Radiation and chemotherapy chargesbilled toyouthat exceed the Allowed Amount. x Kidney dialysis x Respiratory therapy x Physical, occupational,and speech therapy x Diabetes outpatient self-management training and education, including medical nutrition therapy x Palliative care x All other eligible outpatient hospital care x 100%80% after you pay the Urgent care deductible, plus you pay any chargesbilled to you that exceed the Allowed Amount. x 100%80% after you pay the Lab deductible, plus you pay any chargesbilled to youthat exceedthe Allowed Amount. x 100%80% after you pay the Diagnostic imaging deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergencyadmission notification are required. Please see the "Notification Requirements"section. x The Plan covers anesthesia and outpatient hospital charges for dental care provided to a covered person who is a child under age five (5); is severely disabled; or has a medical condition that requires hospitalization or general anesthesia for dental treatment. x The Plan covers outpatient palliative care for patient'swith a new or established diagnosis of progressive debilitating illness, including illnesswhich may limit the patient's life expectancy to two (2) years or less. The services must be within the scope of the provider's license to be covered. Palliative care does not include hospice or respite care. x For hospital/facility charges for bariatric surgery, please refer to "Bariatric Surgery." NOT COVERED: x please refer to the "General Exclusions"section Page42 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 MATERNITY In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Health care professional services for: 100%for the office visit charge; 80%after you pay the 100% for all other eligible deductiblefor the office visit delivery in a hospital/facility services.charge;80% after you pay the postpartum care deductible for all other eligible services, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x 100%80% after you pay the Health care professional office and deductible, plus you pay any outpatient lab services for: charges billed to you that delivery in a hospital/facility exceed the Allowed Amount. postpartum care x 100%80% after you pay the Health care professional office and deductible, plus you pay any outpatient diagnostic imaging services for: charges billed to you that delivery in a hospital/facility exceed the Allowed Amount. postpartum care x 100%80% after you pay the Inpatient hospital/facilityservicesfor: deductible, plus you pay any delivery in a hospital/facility chargesbilled to youthat postpartum care exceed the Allowed Amount. x 100%80% after you pay the Outpatient hospital/facility services for: deductible, plus you pay any delivery in a hospital/facility charges billed to you that postpartum care exceed the Allowed Amount. x 100%80% after you pay the Outpatient hospital/facility lab services for: deductible, plus you pay any delivery in a hospital/facility charges billed to you that postpartum care exceed the Allowed Amount. x 100%80% after you pay the Outpatient hospital/facility diagnostic deductible, plus you pay any imaging services for: chargesbilled to you that delivery in a hospital/facility exceed the Allowed Amount. postpartum care NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x For prenatal careservices, please refer to "Preventive Care." x Please refer to the "Eligibility"section to determine when the baby'scoverage will begin. Page43 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 MATERNITY (continued) NOTES: x Under federal law, group health plans such as this Plan may not restrict benefits for any hospital length of stay inconnection with childbirth as follows: mother Inpatient hospital coverage for the , if covered under this certificate, is provided for a minimum of 48 hours following a vaginal delivery and 96 hours following a cesarean section. If the length of stay is less than these minimums, one (1) home health care visit within four (4) days after discharge from the hospital is covered under this Plan. Refer to "Home Health Care." newborn Inpatient hospital coverage for the , if added to the certificate, is provided for a minimum of 48 hours following a vaginal delivery and 96 hours following a cesarean section. If the length of stay is less than these minimums, one (1) home health care visit within four (4) days after discharge from the hospital is covered under this Plan. Refer to "Home Health Care." x Under federal law, the Plan may require that a provider obtain authorization from the Plan for prescribing a length of stay greater than the 48 hours (or 96 hours) mentioned above. NOT COVERED: x health care professional charges for deliveries in the home x services for or related to adoptionfees x services for or related to surrogate pregnancy, including diagnostic screening, physician services, reproduction treatments, prenatal/delivery/postnatal services x childbirth classes x services for or related to preservation,storageand thawing of human tissue including, but not limited to: sperm; ova;embryos;stem cells;cord blood;and any other human tissue, except as specified in the "Benefit Chart" x please refer to the "General Exclusions"section Page44 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 MEDICAL EQUIPMENT, PROSTHETICS,AND SUPPLIES In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 80%80%, plus you pay any charges Durable medical equipment (DME), billed to youthat exceed the including wheelchairs, ventilators, oxygen, Allowed Amount. oxygen equipment, continuous positive airway pressure (CPAP) devices and hospital beds x Medical supplies, including splints, nebulizers,surgical stockings, casts, and dressings x Insulin pumps, glucometers, and related equipment and devices x Blood, blood plasma, and blood clotting factors x Prosthetics, including breast prosthesis, artificial limbs, and artificial eyes x Special dietary treatment for Phenylketonuria (PKU) when recommended by a physician x Corrective lenses for aphakia x Hearing aids for children age 18 and younger who have a hearing loss that cannot be corrected by other covered procedures. Maximum of one (1) hearing aid for each ear every three (3) years. x Cochlear implants x Non-investigative bone conductive hearing devices x Scalp hair prosthesis (wigs) provided hair loss is due to alopecia areata. Maximum of $350 per person per calendar year. x Custom foot orthosesif you have a diagnosis of diabetes with neurological manifestationsof one (1) or both feet NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x Durable medical equipment is covered up to the Allowed Amountto rent or buy the item.Allowable rental charges are limited to the Allowed Amount to buy the item. x Coverage for durable medical equipment will not be excluded solely because it is used outside the home. x For coverage of insulin and diabetic supplies, pleaserefer to"Prescription Drugs and Insulin." x For hearing aid exam services, please refer to "Physician Services." NOT COVERED: x solid or liquid food, standard and specialized infant formula, banked breast milk, nutritional supplements and electrolyte solution, except when administered by tube feeding, orasprovided in this"Benefit Chart" Page45 SVCGNC:2000-5362 / SVCGNC32A/ tppprd X17342-R6 MEDICAL EQUIPMENT, PROSTHETICS,AND SUPPLIES (continued) NOT COVERED: x personal and convenience items or items provided at levels which exceedthe Claims Administrators determination of medically necessary x servicesorsupplies that are primarily and customarily used for a nonmedical purpose or used for environmental control or enhancement (whether or not prescribed by a physician), including, but not limited to: exercise equipment;air purifiers;air conditioners;dehumidifiers;heat/cold appliances;water purifiers;hypoallergenic mattresses;waterbeds;computers and related equipment;car seats;feeding chairs;pillows;food or weight scales;hot tubs;whirlpools;and incontinence pads or pants x modifications to home, vehicle, and/or the workplace, including vehicle lifts and ramps x blood pressure monitoring devices x communication devices,except when exclusively used for the communication of daily medical needs and without such communication the patient's medical condition would deteriorate x services for or related to lenses, frames, contact lenses, andotherfabricatedoptical devices or professional servicesfor the fitting and/or supply thereof,including the treatment of refractive errors such as radial keratotomy,except as specifiedinthe"Benefit Chart" x duplicate equipment, prosthetics, or supplies x footorthoses, except as specifiedinthe"Benefit Chart" x services for or related to hearing aids or devices, except as specified in the"Benefit Chart" x non-prescription supplies, such as alcohol, cotton balls and alcohol swabs x please refer to the "General Exclusions"section Page46 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Office visits from a physical therapist 100%80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x 100% Therapies from a physical therapist 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x Officevisits from anoccupational therapist 100%80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x 100% Therapies from an occupational therapist 80% after you pay the deductible, plus you pay any charges billed to you that exceed the Allowed Amount. x Office visits from a speech or language 100%80%after you pay the pathologist deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x 100% Therapies from a speech or language 80% after you pay the pathologist deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x For the level of coverage, refer For the level of coverage, refer Office visits from a physician to"Physician Services."to"Physician Services." NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x Forlab and diagnostic imaging services billed by a health care professional, please refer to "Physician Services." x Forphysical, occupational and speech therapy services billed by a hospital/facility, please refer to "Hospital Inpatient"and"Hospital Outpatient." x Office visits include a physical therapy evaluation or re-evaluation; occupational therapy evaluation or re- evaluation; or speech or swallowing evaluation. NOT COVERED: x services primarily educational in nature, except as specified in the "Benefit Chart" x services for or related to vocational rehabilitation (defined as services provided to an injured employee to assist the employee to return either totheir former employment or a new position, or services to prepare a person with disabilities for employment), except when medically necessary and provided by an eligible health care provider Page47 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY (continued) NOT COVERED: x services for or related to recreational therapy (defined as the prescribed use of recreational or other activities as treatment interventions to improve the functional living competence of persons withphysical, mental, emotional and/or social disadvantages) or educational therapy (defined as special education classes, tutoring, and other nonmedical services normally provided in an educational setting), or forms of nonmedical self-care or self-help training, including, but not limited to:health club memberships;aerobic conditioning;therapeutic exercises; work-hardening programs;etc., and all related material and products for these programs x services for or related to therapeutic massage x physical, occupational, and speech therapy services for or related to learning disabilities and disorders, except when medically necessary and provided by an eligible health care provider x services for or related to rehabilitation services that are not expected to make measurable or sustainable improvement within a reasonable amount of time, unless they are medically necessary and are part of specialized maintenance therapy for the member’s condition x custodial care x please refer to the "General Exclusions"section Page48 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PHYSICIAN SERVICES In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Office visit for illness 100%80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x Office visit for UrgentCare 100%80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x Urgent Care outpatient professional visit 100%80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x E-Visit 100%80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x Officevisitat aRetailHealthClinic 100%80% after you pay the deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x 100%80% after you pay the Diabetes outpatient self-management deductible, plus you pay any training and education, including medical chargesbilled to youthat nutrition therapy exceed the Allowed Amount. x Inpatient lab and diagnostic imaging x Inpatient hospital/facility visits during a covered admission x Outpatient hospital/facility visits x Anesthesia by a provider other than the operating, delivering, or assisting provider x Surgery, including circumcisionand sterilization x Assistant surgeon x Kidney and cornea transplants x Injectable drugs administered by a health care professional x Palliative care x Bariatric surgery to correct morbid obesity 100%80% after you pay the including: deductible, plus you pay any chargesbilled to youthat anesthesia exceed the Allowed Amount. assistantsurgeon Page49 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PHYSICIAN SERVICES (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100%80% after you pay the Allergy testing, serum, and injections deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x 100%80%after you pay the Office and outpatient lab deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. x 100%80% after you pay the Office and outpatient diagnosticimaging deductible, plus you pay any chargesbilled to youthat exceed the Allowed Amount. NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x If more than one (1) surgical procedure is performed during the same operative session, the Plan covers the surgical procedures based on the Allowed Amountfor each procedure. The Plan does not cover a charge separate from the surgery for pre-operativeand post-operative care. x The Plan covers treatment of diagnosedLyme disease on the same basis as any other illness. x If the following services are covered under your Plan, you are entitled to receive care at the In-Networklevel for the following services from providers who are not affiliated with the Claims Administrator: the voluntary planning of the conception and bearing of children; the diagnosis of infertility; the testing and treatment of a sexually transmitted disease; or the testing of AIDS or other HIV-related conditions. x The Plan covers certain physician services for preventive care. Please refer to "Preventive Care." x For kidney transplants done in conjunction with an eligible major transplant, please refer to "Transplant Coverage." x The Plan covers the following kidney donor services when billed under thedonor recipient's name and the donor recipient is covered forthe kidney transplant under thePlan: potential donor testing; donor evaluation and work-up; and hospital and professional services related to organ procurement. x Office visits include medical history, medical examination, medical decision making, counseling, coordination of care, nature of presenting problem, and the physician’s time. x E-Visit is an online evaluation and management service provided by a physician using the internet or similar secure communications network to communicate with an established patient. x A Retail Health Clinic provides medical services for a limited list of eligible symptoms (e.g., sore throat, cold). If the presenting symptoms are not on the list, the member will bedirected to seek services from a physician or hospital. Retail Health Clinics are staffed by eligible nurse practitioners or other eligible providers that have a practice arrangement with a physician. The list of available medical services and/or treatable symptoms is available at the Retail Health Clinic. Access to Retail Health Clinic services is available on a walk-inbasis. x The Plan covers outpatient palliative care for members with a new or established diagnosis of progressive debilitating illness, including illnesswhich may limit the member’s life expectancy to two (2) years or less. The services must be within the scope of the provider’s license to be covered. Palliative care does not include hospice or respite care. x The Plan covers hearing aid exams/fittings/adjustmentsfor children age 18 and younger. x For hospital/facility charges for bariatric surgery, please refer to "Bariatric Surgery." Page50 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PHYSICIAN SERVICES (continued) NOT COVERED: x repair of scars and blemishes on skin surfaces x separate charges for pre-operativeand post-operative care for surgery x internet or similar network communications for the purpose of: scheduling medical appointments; refilling or renewing existing prescription medications; reporting normal medical test results; providing education materials; updating patient information; requesting a referral; additional communication on the same day as an onsite medical office visit; and services that would similarly not be charged for an onsite medical office visit x cosmetic surgery to repair a physical defect x travel expenses for a kidney donor x kidney donor expenses for complications incurred after the organ is removed if the donor is not covered under this Plan x kidney donor expenses when the recipient is not covered for the kidney transplant under this Plan x physician dispensed self-administered prescription drugs for reproduction treatment x please refer to the "General Exclusions"section Page51 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PRESCRIPTION DRUGSAND INSULIN ParticipatingNonparticipating The Plan Covers:PharmacyPharmacy x Prescription drugs100% after you pay the 100% after you pay the applicable member cost-applicable member cost- insulin sharingwhen you present your sharing, plus youpay any prescribeddrug therapy supplies ID card or otherwise providecharges billed to you that including, but not limited to: blood/urine notice of coverage at the time exceed the Allowed Amount. testing tabs/strips, needles and of purchase.Please refer to You must pay the full amount syringes, lancets Prescription Drugs in the of the prescription at the time of prescription injectable drugs that are Benefit Chart.purchase and submit the claim self-administeredand do not require for reimbursement yourself. the services of a health care Once you have reached the Please refer to Prescription professional, except for designated Prescription DrugOut-of- Drugs in the Benefit Chart. Specialty drugs (see below) Pocket Maximum, your prescription is covered in full to smoking cessation drugs the end of the calendar year. amino acid-based elemental formula prescription prenatal vitamins prescription pediatric multivitamins with fluoride over-the-counter nicotine replacement products self-administered oral, transdermal, and intravaginal contraceptives NO COVERAGE. x DesignatedOver-the-Counter (OTC) drugs 100%when you present your with a prescription ID card or otherwise provide notice of coverage at the time of purchase. NO COVERAGE. x DesignatedSpecialty drugs purchased 100% after you pay the through a Specialty pharmacy network applicable member cost- supplier(see NOTES) sharingwhen you present your ID card or otherwise provide notice of coverage at the time of purchaseof a specialty drug at a Specialty pharmacy network supplier.Please refer to Prescription Drugs in the Benefit Chart. Once you have reached the Prescription DrugOut-of- Pocket Maximum, your prescription is covered in full to the end of the calendar year. NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required.Please see the "Notification Requirements"section. x TheGenRxPreferred drug listapplies to your Plan.For a list of drugs on your specified Preferred drug list,contactCustomer Service or visit the Claims Administrator's website. Page52 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PRESCRIPTION DRUGS AND INSULIN (continued) NOTES: x You must present your ID card or otherwise provide notice of coverage at the time of purchase to receive the highest level of benefits. If you do not present your ID card or otherwise provide notice of coverage at the time of purchase, the pharmacy will charge you the full amount of the prescription drug. You will be reimbursed based on the discounted pricing. Therefore, in addition to any applicable member cost-sharing, you will also be liable for the difference between the amount the pharmacy charges you for the prescriptiondrug at the time of purchase and any discounted pricing the Claims Administrator has negotiated with participating pharmacies for that prescription drug. x Youhave the option toobtainup to a 90-day authorized supply of ongoing, long-term prescription medications through a participating 90dayRx RetailPharmacy or MailServicePharmacy for your ongoing, long-term refills. You may visitthe Claims Administrator's website orcontactCustomer Service to locate a retail pharmacy participating in the 90dayRx Network or Mail Service Pharmacy. x Specialty drugs are designatedcomplex injectable and oral drugs generally covered up to a 31-day supply that have very specific manufacturing, storage, and dilution requirements. Specialty drugs are drugsincluding, but not limited todrugs used for:infertility;growth hormone treatment;multiple sclerosis;rheumatoid arthritis; hepatitisC;andhemophilia. A current list of designatedSpecialty prescription drugs and suppliers is available at the Claims Administrator's websiteor contact Customer Service.Specialty drugs are not available through 90dayRx. x Ifyou are prescribed a medication subject toStep Therapy,another eligible medication in the same or different drug class must have been prescribed and tried before themedication subject to Step Therapywill be paid under the drug benefit. Step Therapydrug categories are availableat the ClaimsAdministrator's websiteor contactCustomer Service. x Prescription drugs and diabetic supplies are covered in a 31-day supplyfrom a retail pharmacy, or up to a 90- day supply from 90dayRx.Some medications may be subject to a quantity limitation per day supply or to a maximum dosage per day. x Designatedover-the-counter (OTC) drugs are generallycovered up to a 31-day supply as an alternative for similar prescription medications, subject to package limitations, at a retail participating pharmacy.OTC drugs are not available through 90dayRx. x The Plan will cover prescription smoking cessation productsand Over-the-counter nicotinereplacement products with a prescriptionsubject to your prescription drug cost-sharing.Participant's in Stop-Smoking Support may use documented enrollment in place of a prescription for OTC nicotine replacement products. Some quantity limitationsmay apply. x If you choose a brand name drug when there is anequivalent generic drug, you will also pay the difference in cost between the brand name and the generic drug, in addition to the applicable member cost-sharing. x When you have reached yourPrescription DrugOut-of-Pocket Maximum, you still pay the difference in cost between the brand name and the generic drug, even though you are no longer responsible for the applicable prescription drug member cost-sharing. x The following diabetic supplies are coveredat the same level as prescription drugs when prescribed by a physician: blood/urine testing tabs/strips;needles and syringes;lancets and insulin. x The Plan will cover off label drugs used for cancer treatment as specified by law. x When identical chemical entitiesincluding OTC drugs and similar prescription alternativesarefrom different manufacturers or distributors, the Claims Administrator'sCoverageCommittee may determine that only one of those drug products is covered and the other equivalent products are not covered. x Antipsychotic drugs and Preferreddrugs prescribed to treat emotional disturbance or mental illness will be covered on the same basis (applicable level) as all other eligible prescription drugs, unlessthe drug was removed from eligibility for safety reasons. Please refer to Prescription Drugs in the "Benefit Chart." x To locate a participating pharmacy in your area, call the pharmacy information telephonenumber provided in the Customer Service section. x For drugs dispensed and used during an admission, please refer to"Hospital Inpatient." x For supplies or appliances, except as provided in this Benefit Chart, please refer to"Medical Equipment, Prosthetics and Supplies." x Self-administered injectable and oral prescription drugs for orrelated to reproduction treatmentsmust be obtained through a Specialty pharmacy network supplier andare subject to a lifetime maximum limit of $3,500 per person. x When you pay for your prescription drugs, insulin, and drug therapy supplies yourself, youare required to submit the drug receipt(s) with the claim form for reimbursement. Page53 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PRESCRIPTION DRUGS AND INSULIN (continued) NOTES: x The Plan Administrator and/or the Claims Administrator may receive pharmaceutical manufacturer volume discounts in connection with the purchase of certain prescription drugs covered under the Plan. Such discounts are the sole property of the Plan Administrator and/or Claims Administrator and will not be considered in calculating any coinsurance, copay, or benefit maximums. NOT COVERED: x Specialty drugs not purchased through a Specialty pharmacy network supplier x solid or liquid food, standard and specialized infant formula, banked breast milk, nutritional supplements and electrolyte solution, except if administered by tube feeding and as specified in the "Benefit Chart" x drugs removed from the Preferred drug listfor safety reasons may not be covered x charges for giving injections that can be self-administered x over-the-counter drugs,except as specifiedinthe"Benefit Chart" x vitamin or dietary supplements and, exceptasspecifiedinthe"Benefit Chart" x investigative or non-FDA approved drugs, except as required by law x over-the-countersmoking cessation drugswithout a prescription or documented enrollment in Stop-Smoking Support x non-prescription supplies such as alcohol, cotton balls and alcohol swabs x selected drugs or classes of drugs which have shown no benefit regarding efficacy, safety or side effects x please refer to the "General Exclusions"section Page54 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 PREVENTIVE CARE In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x 100% Health care professional preventivecare 80% after you pay the services include recommendations and deductible for the office visit criteria established by the United States charge;80% after you pay the Preventive Services Task Force (USPSTF), deductiblefor all other eligible Advisory Committee on Immunizations services, plus you pay any Practices (ACIP) of the Centers for Disease charges billed to you that Control and the Health Resources and exceed the AllowedAmount. Services Administration (HRSA) for: Adults Infants and children Prenatal care x 100% Outpatient hospital/facility preventive 80% after you pay the care services include recommendations deductible, plus you pay any and criteria established by the United charges billed to you that States Preventive Services Task Force exceed the AllowedAmount. (USPSTF), Advisory Committee on Immunizations Practices (ACIP) of the Centers for Disease Control and the Health Resources and Services Administration (HRSA) for: Adults Infants and children Prenatal care NOTES: x Preventive care services comply with state and federal statutes and regulations (i.e., cancer screening services). x Formore information regarding preventive care services, please visit the Claims Administrator's website or contact Customer Service. x You are entitled to receive care at the In-Network level for the following servicesif these services are covered under your Plan: screening for sexually transmitted disease or HIV. x Services to treat an illness/injury diagnosed as a result of preventive care services or preventive care services in excess of United States Preventive Services Task Force, Advisory Committee on Immunization Practices of the Centers for Disease Control, or Health Resources and Services Administration recommendations may be covered under other Plan benefits. Please refer to "Hospital Inpatient," "Hospital Outpatient," "Physician Services," etc. for appropriate benefit levels. NOT COVERED: x servicesfor or related to surrogate pregnancy, including diagnostic screening, physician services, reproduction treatments, prenatal/delivery/postnatal services x services for or related to preventive medical evaluations for purposes of medical research, obtaining employment or insurance, or obtaining or maintaining a license of any type, unless such preventive medical evaluation would normally have been provided in the absence of the third party request x educational classes or programs, except educational classes or programs required by law x services for or related to lenses, frames, contact lenses, and other fabricated optical devices or professional services for the fitting and/or supply thereof, including the treatment of refractive errors such as radial keratotomy, except as specified in the "Benefit Chart" x treatment, services or supplies which are investigative or not medically necessary x please refer to the "General Exclusions" section Page55 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 RECONSTRUCTIVE SURGERY In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x For the level of coverage, see For the level of coverage, see Reconstructive surgery which is incidental "Hospital Inpatient,""Hospital"Hospital Inpatient,""Hospital to or following surgery resulting from injury, Outpatient,"and"PhysicianOutpatient,"and"Physician sickness, or other diseases of the involved Services."Services." body part x Reconstructive surgery performed on a dependent child because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending physician x Treatment of cleft lip and palate when services are scheduled or initiated prior to the member turning age 19,including dental implants x Elimination or maximum feasible treatment of port wine stains NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x Under the federalWomen's Health and Cancer Rights Act of 1998and Minnesota law,you are entitled to the following services:reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prosthesis and treatment for physical complications during all stages of mastectomy, including swelling of the lymph glands (lymphedema). Services are provided in a manner determined in consultation with the physician and patient. Coverage is provided on the same basis as any other illness. x Congenital means present at birth. x Bone grafting for the purpose of reconstruction of the jaw and for treatment of cleft lip and palate is a covered service, but not for the sole purpose of supporting a dental implant, dentures or adental prosthesis. NOT COVERED: x repair of scars and blemishes on skin surfaces x dentures,regardless of the cause or condition, and any associated services and/or chargesincluding bone grafts x dental implants,and any associated services and/or charges, exceptas specified in the "Benefit Chart" x please refer to the "General Exclusions"section Page56 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 REPRODUCTION TREATMENTS In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Professional services for:100%for the office visit charge; 80%after you pay the 100%for all other eligible deductiblefor the office visit Artificial Insemination (AI) and servicestoalifetime maximum charge; 80% after you pay the Intrauterine Insemination (IUI) limit of $8,000 per person for all deductiblefor all other eligible procedures medical services for services, plus you pay any Non-investigative Assisted reproductiontreatments for all chargesbilled to youthat Reproductive Technologies (ART) networks combined.exceed the Allowed Amountto Drugs administered by a health care alifetime maximum limit of professional for eligible reproduction $8,000 per person for all treatments medical services for reproductiontreatments for all networks combined. x 100% to alifetime maximum 80% after you pay the Outpatient hospital/facility services for: limit of $8,000per person for all deductible, plus you pay any AI and IUI procedures medical services for chargesbilled to youthat Non-investigative ART reproduction treatments for all exceedthe Allowed Amountto Drugs administered by a health care networks combined.alifetime maximum limit of professional for eligible reproduction $8,000per person for all treatments medical services for reproduction treatments for all networks combined. x Professional lab services associated with 100% to alifetime maximum 80% after you pay the reproductiontreatments limit of $8,000per person for all deductible, plus you pay any medical services for chargesbilled to youthat reproduction treatments for all exceed the Allowed Amountto networks combined.alifetime maximum limit of $8,000per person for all medical services for reproduction treatments for all networks combined. x Hospital/facility lab services associated 100% to alifetime maximum 80% after you pay the withreproductiontreatments limit of $8,000per person for all deductible, plus you pay any medical services for chargesbilled to youthat reproduction treatments for all exceed the Allowed Amountto networks combined.alifetime maximum limit of $8,000per person for all medical services for reproduction treatments for all networks combined. x Professional diagnostic imaging services 100% to alifetime maximum 80% after you pay the forreproductiontreatments limit of $8,000per person for all deductible, plus you pay any medical services for chargesbilled to youthat reproduction treatments for all exceed the Allowed Amountto networks combined.alifetime maximum limit of $8,000per person for all medical services for reproduction treatments for all networks combined. Page57 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 REPRODUCTION TREATMENTS (continued) In-NetworkOut-of-Network The Plan Covers:ProvidersProviders x Hospital/facility diagnostic imaging services 100% to alifetime maximum 80% after you pay the forreproductiontreatments limit of $8,000per person for all deductible, plus you pay any medical services for chargesbilled to youthat reproduction treatments for all exceed the Allowed Amountto networks combined.alifetime maximum limit of $8,000per person for all medical services for reproduction treatments for all networks combined. x For the level of coverage refer For the level of coverage refer Self-administered injectable and oral to "Prescription Drugs and to "Prescription Drugs and prescription drugs Insulin"Insulin" NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements" section. x Please refer to the "Glossary of Common Terms" section for descriptions of AI, IUI, and ART. x Benefits are subject to alifetime maximum of $8,000 per person for all medical services for reproduction treatments for all networks combined. x For servicesrelated to infertility testing, please refer to "Physician Services." NOT COVERED: x services for or related to reproduction treatments when the number of embryos transferred exceeds the current guidelines developed by the Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of the American Society for Reproductive Medicine x services for or related to adoption fees and childbirth classes x services for or related to surrogate pregnancy, including diagnostic screening, physician services, reproduction treatments, prenatal/delivery/postnatal services x services for or related to reversal of sterilization x donor ova or sperm x services for or related to preservation,storage, and thawingof human tissue including, but not limited to: sperm; ova;embryos;stem cells;cord blood;and any other human tissue, except as specified in the "Benefit Chart" x physician dispensed self-administered prescription drugsfor reproduction treatment x please refer to the "General Exclusions" section Page58 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 SKILLED NURSING FACILITY In Network Out-of-Network The Plan Covers:ProvidersProviders x 80%80% after you pay the Skilled care ordered by a physician and deductible, plus you pay any eligible under Medicare guidelines chargesbilled to youthat x Semiprivate room and board exceed the Allowed Amount. x General nursing care x Prescription drugs usedduring a covered admission x Physical, occupational, and speech therapy NOTES: x Prior authorization, preadmission notification, preadmission certification, and/or emergency admission notification are required. Please see the "Notification Requirements"section. x You must be admitted within 30 daysafter hospital admission of at least three (3) consecutive days for the same illness. NOT COVERED: x charges for or related to care that is custodial or not normally provided as preventive care or for treatment of an illness/injury x treatment, services or supplies which are not medically necessary x please refer to the "General Exclusions"section Page59 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TRANSPLANT COVERAGE Blue Distinction CentersNon-Blue Distinction Centers for Transplant (BDCT) for Transplant (BDCT) The Plan Covers:ProvidersProviders The following medically necessary human 100%of the Transplant Participating Transplant organ, bone marrow, cord blood and peripheral Payment Allowancefor the Provider stem cell transplant procedures:transplant admission. 80% of theTransplant Payment x If you live more than 50 miles Allogeneic and syngeneic bone marrow Allowance after you pay the from a BDCT Provider, there transplant and peripheral stem cell deductiblefor the transplant may be travel benefitsavailable transplantprocedures admission,plus you pay any for expenses directly related to chargesbilled to youthat x Autologous bone marrow transplant and a preauthorized transplant. exceed the Allowed Amount. peripheral stem cell transplantprocedures For services not included in the For services not included in the x Heart Transplant Payment Transplant Payment Allowance, refer to the Allowance, refer to the x Heart-lung individual benefit sections that individual benefit sections that x Kidney-pancreas transplant performed apply to the services being apply to the services being simultaneously (SPK) performed to determine the performed to determine the correct level of coverage. correct level of coverage. x Liver-deceased donor and living donor x Lung-single or double Nonparticipating Transplant Provider x Pancreas transplant -deceased donor and living donor segmentalNO COVERAGE. Pancreas transplant alone (PTA) Simultaneous pancreas -kidney transplant (SPK) Pancreas transplant after kidney transplant (PAK) x Small-bowel and small-bowel/liver NOTES: x Kidneytransplants when not done in conjunction with an eligible major transplant noted above,and cornea transplants are eligible procedures that are covered on the same basis as any other illness. Please refer to "Hospital Inpatient"and"Physician Services." x Prior authorization is requiredfor human organ, bone marrow, cord blood and peripheral stem cell transplant procedures and should be submitted in writing to the Transplant Coordinator at P.O. Box 64179, St. Paul, Minnesota55164 or faxed to 651-662-1624. NOT COVERED: x travel benefits when you are using a Non-BDCT Provider x services you receive from a Nonparticipating Transplant Provider x services, supplies, drugs and aftercare for or related to artificial or nonhuman organ implants x services, supplies, drugs and aftercare for or related to human organ transplants not specifically listed above as covered x services, chemotherapy, radiation therapy (or any therapy that results in marked or complete suppression of blood producing organs), supplies, drugs and aftercare for or related to bone marrow and peripheral stem cell support procedures that are considered investigative or not medically necessary x living donor organ and/or tissue transplants unless otherwise specified in this SPD x transplantation of animal organs and/or tissue x please refer to the "General Exclusions"section Page60 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TRANSPLANT COVERAGE (continued) DEFINITIONS: x BDCT Providermeans a hospital or other institution that has a contract with the Blue Cross and Blue Shield Association* to provide humanorgan,bone marrow, cord blood, andperipheral stem cell transplantprocedures. These providers have been selected to participate in this nationwide network based on their ability to meet defined clinical criteria that are unique for each type of transplant. Once selected for participation, institutions are re-evaluated annually to insure that they continue to meet the established criteria for participation in this network. x Participating Transplant Providermeans a hospital or other institution that has a contract with Blue Cross and Blue Shield of Minnesota or with their local Blue Cross and/or Blue Shield Plan to provide humanorgan,bone marrow, cord blood, andperipheral stem cell transplantprocedures. x Transplant Payment Allowancemeans the amount the Plan pays for covered services to a BDCT Provider or a Participating Transplant Provider for services related to humanorgan,bone marrow, cord blood, andperipheral stem cell transplantprocedures in the agreement with that provider. *An association of independent Blue Cross and Blue Shield Plans. Page61 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 BENEFIT SUBSTITUTION Benefit substitution, a process of substituting one(1) covered benefit for another covered benefit, is used by the Claims Administrator'scare/case managers to facilitate care/case management plans for patients with complex health care needs. The benefit substitution process will be used only when: 1.a care/case management plan is developed in collaboration with the patient and the health care provider prior to the services being provided; and 2.a physician writes an order stating the services to be provided are medically necessary; and 3.the services being provided under the care/case management plan meet the skilled care requirements of the benefit to be used; and 4.the services do not exceed the Allowed Amountofthe benefit being used. The benefit substitution process cannot be applied retrospectively, and benefit substitution cannot be used to allow coverage for services or supplies excluded by the Plan. The decision to use the benefit substitution process is a collaborative decision between the Claims Administrator's care/case managers, the patient or patient's representative(s), and health care provider. Thedecision to use the benefit substitution process in a particular case in no way commits the Claims Administratorto do so at another point in the same case or in another case, nor does it prevent the ClaimsAdministratorfrom strictly applying the express benefits, limitations and exclusions of the Plan at any other time or for any other insured person. Page62 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 GENERAL EXCLUSIONS The Plan doesnot pay for: 1.Treatment, services,or supplies which are not medically necessary. 2.Charges for or related to care that is investigative, except for certain routine care for approved cancer clinical trials by approved investigators at qualified performance sites and approved by the Claims Administrator in advance of treatment. 3.Any portion of a charge for a covered service or supply that exceeds the Allowed Amount, except as specified in the "Benefit Chart." 4.Services that are provided without charge, including services of the clergy. 5.Services performed before the effective date of coverage, and services received after your coverage terminates, even though your illness started while coverage was in force. 6.Services for or related to therapeutic acupuncture, except for the treatment of chronic pain(defined as duration of at least six (6) months),or for the prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy. 7.Services that are provided for the treatment of an employment related injury for which you are entitled to make a worker's compensation claim unless the worker's compensation carrier has disputed the claim. 8.Charges that are eligible, paid or payable under any medical payment, automobile personal injury protection that is payable without regard to fault, including charges for services that are applied toward any deductible, copay or coinsurance requirement of such a policy. 9.Services a provider gives to himself/herself or to a close relative (such as spouse, brother, sister, parent, grandparent, and/or child). 10.Services needed because you engaged in an illegal occupation, or committed or attempted to commit a felony, unless the services are related to an act of domestic violence or the illegal occupation or felonious act is related to a physical or mental health condition. 11.Servicesto treat injuries which occur while on military duty that are recognized by the Veterans Administration as services related to service connected illnesses/injuries. 12.Treatment of preexisting conditions incurred during the preexisting condition limitation period. 13.Services for dependents if you have employee-only coverage. 14.Services that are prohibited by law or regulation. 15.Services which are not within the scope of licensure or certification of a provider. 16.Charges for furnishing medical records or reportsand associated delivery charges. 17.Services for or related to transportation, other than local ambulance service to the nearest medical facility equipped to treat the illness or injury, except as specified in the "Benefit Chart." 18.Travel, transportation, or living expenses, whether or not recommended by a physician, except as specified in the "Benefit Chart." 19.Services for or related to mental illness not listed in the most recent edition oftheInternational Classification of Diseases. 20.Services or confinements ordered by a court or law enforcement officer that are not medically necessary. Page63 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 21.Evaluations that are not performed for the purpose of diagnosing or treating mental health or substance abuse conditions such as: custody evaluations;parenting assessments;education classes for Driving Under the Influence (DUI)/Driving While Intoxicated (DWI) offences;competency evaluations;adoption home status; parental competency;and domestic violence programs. 22.Services for or related to room and board for foster care, group homes,shelter care,and lodging programs, halfway house services, and skills training. 23.Services for or related to marriage/couples training for the primary purpose of relationship enhancement including, but not limited to: premarital education; or marriage/couples retreats, encounters, or seminars. 24.Services for or related to marriage/couples therapy/counselingnot related to the treatment of a covered member's diagnosable mental health disorder. 25.Services for or related to therapeutic supportoffoster care (services designed to enable the foster family to provide a therapeutic family environment or support for the foster child's improved functioning); treatment of learning disabilities; therapeutic day care and therapeutic camp services; and hippotherapy (equine movement therapy). 26.Charges made by a health care professional for televideo conferencing services, email, and physician/patient telephone consultations, exceptfor eligible E-Visits and as specified in the "Benefit Chart." 27.Services for or related to substance abuse or addictions that are not listed in the most recentedition of the InternationalClassification of Diseases. 28.Services for or related to substance abuse interventions, defined as a meeting or meetings, with or without the affected person, of a group of people who are concerned with the current behavioral health of a family member, friend or colleague, with the intent of convincing the affected person to enter treatment for the condition. 29.Services for or related to therapeutic massage. 30.Dentures, regardless of the cause or condition, and any associated services and/or charges,including bone grafts. 31.Dental implants, and associated services and/or charges, except when related to services for cleft lip andpalate that are scheduled or initiated prior to the member turning age 19. 32.Services for or related to the replacement of a damaged dentalbridge from an accident-related injury. 33.Services for or related to oral surgery and anesthesia for the removal of impacted teeth. 34.Services for or related to oral surgery and anesthesia for removal ofa tooth root without removal ofthe whole tooth. 35.Services for or related to oral surgery and anesthesia for root canal therapy. 36.Services for or related to dental or oral care, treatment, orthodontics, surgery, supplies, anesthesia or facility charges, and bone grafts, except as specified in the "Benefit Chart." 37.Room and board expenses in a residential hospice facility. 38.Inpatient hospital room and board expense that exceeds the semiprivateroom rate, unless a private room is approved by the Claims Administratoras medically necessary. 39.Admission for diagnostic tests that can be performed on an outpatient basis. 40.Services for or related to extended hours skilled nursing care, also referred to as private-duty nursingcare, except as required by Minnesota law. 41.Personal comfort items such as telephone, television, etc. Page64 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 42.Communication services provided on an outpatient basis or in the home. 43.Services and prescription drugs for or related to gender selection services. 44.Services for or related to sex transformation/gender reassignment surgery, sex hormones related to surgery, related preparation and follow-up treatment, care and counseling, unless medically necessary as determined by the Claims Administratorprior to receipt of services. 45.Services for or related to reversal of sterilization. 46.Services for or related to adoption fees and childbirth classes. 47.Services for or related to surrogate pregnancy, including diagnostic screening, physician services, reproduction treatments, prenatal/delivery/postnatal services. 48.Donor ova or sperm. 49.Services for or related to preservation,storage, and thawingof human tissue including, but not limited to: sperm; ova;embryos;stem cells;cord blood;and any other human tissue, except as specified in the "Benefit Chart." 50.Solid or liquid food, standard and specialized infant formula, banked breast milk, nutritional supplements and electrolyte solution, except when administered by tube feeding and as specified inthe "Benefit Chart." 51.Servicesandsupplies that are primarily and customarily used for anonmedical purpose or used for environmental control or enhancement (whether or not prescribed by a physician), including, but not limited to: exercise equipment;air purifiers;air conditioners;dehumidifiers;heat/cold appliances;water purifiers;hot tubs; whirlpools;hypoallergenic mattresses;waterbeds;computers and related equipment;car seats;feeding chairs; pillows;food or weight scales;and incontinence pads or pants. 52.Modifications to home, vehicle, and/or the workplace, including vehicle lifts and ramps. 53.Blood pressure monitoring devices. 54.Foot orthoses, except as specified in the "Benefit Chart." 55.Communication devices, except when exclusively used forthe communication of daily medical needs and without such communication the patient’s medical condition would deteriorate. 56.Services for or related tolenses, frames, contact lenses, and other fabricated optical devices or professional services for the fitting and/or supply thereof, including the treatment of refractive errors such as radial keratotomy, except as specified in the "Benefit Chart." 57.Services for or related tohearing aids or devices, except as specified in the "Benefit Chart." 58.Nonprescription supplies such as alcohol, cotton balls, and alcohol swabs. 59.Services primarily educational in nature, except as specified in the "Benefit Chart." 60.Services for or related to vocational rehabilitation (defined as services provided to an injured employee to assist the employee to return to either their former employment or a new position, or services to prepare a person with disabilities for employment), except when medically necessary and provided by an eligible health care provider. 61.Physical, occupational and speech therapy services for or related to learning disabilities and disorders, except when medically necessary and provided by an eligible health care provider. 62.Servicesand feesfor or related to health clubs and spas. 63.Services for or related to rehabilitation services that are not expected to make measurable or sustainable improvement within a reasonable period of time, unless they are medically necessary and part of specialized maintenance therapy for the member's condition. Page65 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 64.Custodial care. 65.Services for or related to recreational therapy (defined as the prescribed use of recreational or other activities as treatment interventions to improve the functional living competence of persons with physical, mental, emotional, and/or social disadvantages), educational therapy (defined as special education classes, tutoring, and other nonmedical services normally provided in an educational setting), or forms of nonmedical self-care or self-help training, including, but not limited to: health club memberships;aerobic conditioning;therapeutic exercises;work hardening programs;etc., and all related material and products for these programs. 66.Services for or related to functional capacity evaluations for vocational purposes and/or the determination of disability or pension benefits. 67.Services for or related to the repair of scars and blemishes on skin surfaces. 68.Fees dues, nutritional supplements, food, vitamins, and exercise therapy, for or related to weight loss programs. 69.Services for or related to cosmetic health services or reconstructive surgery and related services, and treatment for conditions or problems related to cosmetic surgery or services, except as specified in the "Benefit Chart." 70.Services for or related to travel expenses for a kidney donor;kidney donor expenses for complications incurred after the organ is removed if the donor is not covered under this Plan; and kidney donor expenses when the recipient is not covered under thisPlan. 71.Services for or related to any treatment, equipment, drug, and/or device that the Claims Administrator determines does not meet generally accepted standards of practice in the medical community for cancer and/or allergy testing and/or treatment:services for or related to homeopathy, or chelation therapy that the Claims Administrator determines is not medically necessary. 72.Services for or related to gene therapy as a treatment for inherited or acquired disorders. 73.Services for or related to growth hormone replacement therapy except for conditions that meet medicalnecessity criteria. 74.Autopsies. 75.Charges for failure to keep scheduled visits. 76.Charges for giving injections that can be self-administered. 77.Internet or similar network communications for the purpose of: scheduling appointments; filling or renewing existing prescription medications; reporting normal medical test results; providing educational materials; updating patient information; requesting a referral; additional communication on the same day as an onsite medical office visit; and services that wouldsimilarly not be charged for in an onsite medical office visit. 78.Services for or related to smoking cessation program fees and/or supplies. 79.Charges for over-the-counter drugs, except as specified in the "Benefit Chart." 80.Vitamin or dietary supplements, except as specified in the "Benefit Chart." 81.Investigative or non-FDA approved drugs, except as required by law. 82.Over-the-counter smoking cessation drugswithout a prescription or documented enrollment in Stop-Smoking Support. 83.Services for or related to preventive medical evaluationsfor purposes of medical research, obtaining employment or insurance, or obtaining or maintaining a license of any type, unless such preventive medical evaluationwould normally have been provided in the absence of the third party request. Page66 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 84.Services for or related to reproduction treatments when the number of embryos transferred exceeds the current guidelines developed by the Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of theAmerican Society for Reproductive Medicine. 85.Charges forphysician dispensed self-administered prescription drugs for reproduction treatments. 86.Services, supplies, drugs and aftercare for or related to artificial or nonhuman organ implants. 87.Services, chemotherapy, radiation therapy (or any therapy that results in marked or complete suppression of blood producing organs), supplies, drugs and aftercare for or related to bone marrow and peripheral stem cell transplantproceduresthat are considered investigative or not medically necessary. 88.Services for or related to fetal tissue transplantation. Page67 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 ELIGIBILITY Eligible Employees Full-time employees working an average of 32 hours per week are eligible. This Plan covers only those employees who work in the United States (U.S.)or its Territories. Employees who work and reside in foreign countries are not eligible for coverage.Employees who are U.S. citizens or permanent residents of the U.S. working outside of the U.S. on a temporary basis are eligible. Eligible Dependents NOTE: If both you and your spouse are employees of the employer, you may be covered as either an employee or as a dependent, but not both. Your eligible dependent children may be covered under either parent’s coverage, but not both. Spouse 1.Married spouse. Dependent Children 1.Natural-borndependent children to age26. 2.Legallyadopted children and children placed with you for legal adoption to age 26.Date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support. 3.Stepchildrento age 26. 4.Dependentchildren for whomyou or your spouse have been appointed legal guardian to age 26. 5.Grandchildrento age 26for whom you provide the majority of financial support and who live with you or your spouse continuously from birth. 6.Otherwise eligible children of the employee whoare required to be covered by reason of a Qualified Medical Child Support Order (QMCSO), as defined inMinnesota statute §518A.41.The Plan has detailed procedures for determining whether an order qualifies as a QMCSO. You and your dependents can obtain, without charge, a copy of such procedures from the Plan Administrator. Disabled Dependents 1.Unmarrieddisabled dependent children who reach the limiting age while covered under this Plan if all of the following apply: a.primarily dependent upon you; b.are incapable of self-sustaining employment because of physical disability, developmental disability, mental illness, or mental disorders; c.for whom application for extended coverage as a disabled dependent child is made within 31 days after reaching the age limit. After this initial proof, the Claims Administrator may request proof again two (2) years later, and each year thereafter; and, d.must have become disabled prior to reaching limiting age. Page68 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 2.Disabled dependents if both of the following apply: a.incapable ofself-sustaining employment by reason of developmental disability, mental illness or disorder, or physical disability; and, b.chiefly dependent upon the group member for support and maintenance. Preexisting Condition Limitation forEmployees and Covered Dependents-age 19 and older A preexisting condition limitation applies toemployees and covered dependents-age 19 and older.A preexisting condition is defined as a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) monthsimmediately preceding the enrollment date. Newly Eligible Applicants – For such a condition, benefits for you and your covered dependents will be payable only after a period of 12consecutive months beginning from the enrollment date. This period will be reduced by any prior continuousqualifyingcreditable coverage, provided no gap in coverage greater than 63 days has occurred. At your request and with appropriate authorization the Claims Administrator will assist you in obtaining a certificate of creditable coverage from your prior plan. With timely application, this limitation does not apply to a newborn infant, or a child placed with you for adoption. Preexisting condition does not include genetic information alone in the absence of a diagnosis for a condition related to the genetic information, or an existing pregnancy. Late Entrants – For such a condition, benefits for you and your covered dependents will be payable only after a period of 18consecutive months beginning from the enrollment date.This period will be reduced by any prior continuous qualifyingcreditable coverage,provided no gap in coverage greater than 63 days has occurred. At your request and with appropriate authorization the Claims Administrator will assist you in obtaining a certificate of creditable coverage from your prior plan. Preexisting condition does not include genetic information alone in the absence of a diagnosis for a condition related to the genetic information, or an existing pregnancy. Effective Date of Coverage Coverage for you or your eligible dependents who were eligible on the effective date of the Plan will take effect on that date. Adding New Employees 1.If the Plan Administrator receives your application within 30 daysafter you become eligible, coverage for you and your eligible dependents startson the first of the month following the date of eligibility. 2.Ifthe Plan Administrator receives your application more than 30 days after you become eligible, you and your eligible dependents will be considered a Late Entrant unless you meet the requirements of the special enrollment period. Please refer to"Coverage Effective Date for Late Entrants"inthis section to determine when coverage will begin. Adding New Dependents This section outlines the time period for application and the date coverage starts. Adding spouse and/or stepchildren 1.If the Plan Administrator receives the application within 30days of the date of marriage, coverage for your spouse and/or stepchildren starts on the date of marriage. Page69 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 2.If the Plan Administrator receives the application more than 30 days after the date of marriage, your spouse and/or stepchildren will be considered Late Entrants unless your spouse and/or stepchildren meet the requirements of the SpecialEnrollmentPeriod. Please refer to"Coverage Effective Date for Late Entrants"inthis section to determine when coverage will begin. Adding newborns and children placed for adoption The Plan Administrator requests that you submit written application to add your newborn child or newborn grandchild within90 daysofthe date of birth. Coverage for your newborn child or newborn grandchild starts on the date of birth. The Plan Administrator requests that you submit written application to add your adopted child within 90 daysof the date of placement. Coverage for your adopted child starts on the date of placement. Adding disabled children or disabled dependents A disabled dependent may be added to the Plan if the disabled dependent is otherwise eligible under the Plan. Coverage starts the first of the month following the day the Plan Administrator receives the application. A disabled dependent will not be denied coverage and will not be subject to any preexisting condition limitation period. Special Enrollment Periods Special enrollment periods are periods when aneligible employee or dependent may enroll in the health plan under after they were first eligible for coverage certain circumstances .The eligible circumstances are: 1) a loss of other group health plan coverage; 2) loss of Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) coverage; 3) eligibility for premium assistanceunder Medicaid or CHIP; or 4) acquiring a new dependent. The request for enrollment must be within 30 days (unless otherwise noted) oftheeligible circumstance. Newborns, newborn grandchildren, and children placed for adoption are eligible as of the date of birth, adoption or placement for adoption -see "Eligible Dependents" in the "Eligibility" section. 1.Loss of Group Health Plan Coverage Employees or dependents who are eligible but not enrolled in the health plan may enroll for coverage in the health plan as special enrollees upon aloss of other health plan coverage if all of the following conditions are met: a.the employee or dependent was covered under a group health plan or other health insurance coverage at the time coverage was previously offered to the employee or dependent; b.the employee must complete any required written waiverofcoverage and state in writing that, at such time, other health insurance coverage was the reason for declining enrollment; c.the employee’sor dependent’s coverage is terminated because:his/her COBRA continuation has been exhausted (not due to failure to pay premium or for cause), he/she is no longer eligible for the plan due to a divorce, death of the employee, termination of employment, reduction in hours, cessation of dependent status, all employer contributions towards the coverage were terminated, the individual no longer lives or works in an HMO service area, or the individual incurs a claim that would meet or exceed a lifetime limit on all benefits; and d.the employee or dependent requestsenrollment not later than 30 days after the termination of coverage or employer contribution, or the meeting or exceeding of the lifetime limit on allbenefits. Coverageforemployeesor dependents (other than newborns, newborn grandchildren and children placed for adoptionsee "Eligibility" section) who are eligible to enroll in the Plan under the Special Enrollment Periods provision will be effective the day after the termination of prior coverage or the date of claim denial due to meeting or exceeding the lifetime limit on all benefits. Page70 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 2.Loss of Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) Coverage Employeesor dependents who are eligible but not enrolled in the health plan may enroll for coverage in the health plan as special enrollees upon the loss of Medicaid or CHIP coverage if all the following conditions are met: a.theemployeeor dependent was covered under Medicaid or CHIP at the time coverage was previously offered to the group member or dependent; b.theemployeemust complete any required written waiver of coverage and statein writing that, at such time, Medicaid or CHIP coverage was the reason for declining enrollment; and c.theemployeeor dependent must request enrollment no later than 60 days after the termination of Medicaid or CHIP coverage. 3.Eligibility for Premium Assistance Employeesor dependents who are eligible but not enrolled in the health plan may enroll for coverage in the health plan as special enrollees upon becoming eligible for premium assistance through the Medical Assistance (Medicaid) or Children's Health Insurance Program (CHIP) if all the following conditions are met: a.the employer must submit any required documentation indicating that the employeeand/or dependents are eligible for premium assistance through Medicaid or CHIP; and; b.theemployeeor dependent must request enrollment no later than 60 days after becoming eligible for premium assistance through Medicaid or CHIP. 4.Acquiring a New Dependent Eligible employees who are either enrolled or not enrolled in the health plan may enroll themselves and eligible dependents in the health plan as special enrolleeswhen the eligible employeemember experiences a marriage, birth, adoption or placement for adoption.These events provide the eligible employee, spouse or child(ren) the opportunity to apply for coverage under the Plan during Special Enrollment Periods. Coverage for employeesor dependents (other than newborns, newborn grandchildren and children placed for adoptionsee "Eligibility" section) who are eligible to enroll in the Plan under the SpecialEnrollment Periods provision will be effective on the date of marriage, birth, adoption or placement for adoption. Coverage Effective Date for Late Entrants Late entrants-age 19 and olderare subject to a preexisting condition limitation period described in the Preexisting Condition Limitations section. Credit will be given for prior continuous qualifyingcreditable coverage, provided no gap in coverage greater than 63 days has occurred. Coverage for late entrants startson the first of the month following the day the late application is received. Page71 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TERMINATION OF COVERAGE Termination Events Coverage ends on the earliest of the following dates: 1.For you and your dependents, the date on which the Plan terminates. 2.For you and your dependents, the last day of the month during which: a.requiredpremiumsfor coverage were paid, if payment is not received when due. Your payment of premiums to the employer does not guarantee coverage unless the Claims Administrator receives full payment when due. If the Claims Administrator terminates coverage for all employees in the Plan for nonpayment of the premiums, the Claims Administrator will give all employees a 30 day notice of termination prior to the effective date of cancellation using a list of addresses which is updated every 12 months. b.you are no longer eligible. c.you enter military services for duty lasting more than 31 days. d.you request that coverage be terminated. e.you retire. 3.For the spouse, the date the spouse is no longer eligible for coverage. This isthe last day of the month during which the employee and spouse divorceor legally separate. 4.For a dependent child, the date the dependent child is no longer eligible for coverage. This is the last day of the month during which: a.a covered stepchild is nolonger eligible because the employee and spouse divorceor legally separate. b.the dependent child reaches the dependent-child age limit. c.the dependent child becomes eligible for coverageas an employeeunder any employer-sponsoredhealth plan other than agroup health plan of a parent. d.the disabled dependent is no longer eligible. e.the dependent grandchild is no longer eligible. 5.The date charges are incurred that result in payment up to the lifetime maximum. Retroactive Termination If the Plan Administrator erroneously enrolled the employee or dependent in the Plan and subsequently requests that coverage be terminated retroactive to the effective date of coverage, coverage will remain in force to a current paid-to- date unless the Plan Administrator obtains and forwards to the Claims Administrator the employee’s or dependent’s written consent authorizing retroactive termination of coverage. If written consent is not obtained and forwarded to the Claims Administrator with the cancellation request, the Plan Administrator must pay the required charges for the employee’s or dependent’s coverage in full to thecurrent paid-to-date. Certification of Coverage When you or your covered dependents terminate coverage under the Plan, a certification of coverage form will be issued to you specifying your coverage dates under the health plan and any waiting periods you were required to satisfy. The certification of coverage form will contain all the necessary information another health plan will need to determine if you have prior continuous coverage that should be credited toward any preexisting condition limitation period. Health plans will require that you submit a copy of this form when you apply for coverage. Page72 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 The certification of coverage form will be issued to you if you request it before losing coverage or when you terminate coverage with the Plan and, if applicable, at the expiration of any continuation period. The Claims Administrator will also issue the certification of coverage form if you request a copy at any time within the 24 months after your coverage terminates.To request a CertificationofCoverage form, please contact the Claims Administrator at the address or telephonenumberlistedinthe Customer Service sectionor refer to your Identification (ID) card. Extension of Benefits If you or your dependent is confined as an inpatient on the date coverage ends due to the replacement of the Claims Administrator, the Plan will automatically extend coverage until the date you or your dependent is discharged from the facility or the date Plan maximums are reached, whichever is earlier. Coverage is extended only for the person who is confined as an inpatient, and only for inpatient charges incurred during the admission. For purposes of this provision, "replacement"means that the administrative service agreement with the Claims Administrator has been terminated and your employer maintains continuous group coverage with a new claims administrator or insurer. Continuation and Conversion You or your covered dependents may continue this coverage if coverage ends due to oneof the qualifying events listed below. You and your eligible dependents must be coveredon the daybefore the qualifying event in order to continue coverage. Qualifying Events If you are the employeeand are covered, you have the right to elect continuation coverage if you lose coverage because of any one (1) of the following qualifying events: x Voluntary or involuntary termination of your employment (for reasons other than gross misconduct). x Reduction in the hours of your employment (layoff, leave of absence, strike, lockout, change from full-time to part- time employment). x Total disability -Total disability means the employee'sinability to engage in or perform the duties of the employee'sregular occupation or employment within the first two (2) years of disability. After the first two (2) years, it means the employee'sinability to perform any occupation for which the employee is educated or trained. If you are the spouse/ex-spouseof a coveredemployee, you have the right to elect continuation coverage if you lose coveragebecause of any of the following qualifying events: x The death of the employee. x A termination of the employee'semployment (as described above) or reduction in the employee'shours of employment. x Entering of decree or judgment of divorce or legal separation from the employee. (This includesif the employee terminatescoverage in anticipation of thedivorceor legal separation. A laterdivorceor legal separation is considered a qualifying event even though youlost coverage earlier. You must notifythe Plan Administrator within 60 days after the later divorceor legal separationand establish that yourcoverage was terminatedin anticipation of the divorceor legal separation.Continuation coverage may be available for the period after the divorceor legal separation.) x Theemployeebecomes enrolled in Medicare. x Theemployeebecomes totally disabled (as defined above). Adependent childofa covered employeehas the right to elect continuation coverage if he or she loses coverage because of any of the following qualifying events: x The death of the employee. Page73 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 x The termination of the employee'semployment (as described above) or reduction in the employee'shours of employment with the employer. x Parents’ divorceor legal separation. x Theemployeebecomes enrolled in Medicare. x The dependent ceases to be a "dependent child"under the Plan. x The total disability of the employee(as defined above). Your Notice Obligations Youand your dependents must notify the employer of any of the following events within 60 days of the occurrence of the event: x Divorceor legal separation; x A dependent child no longer meets the Plan's eligibility requirements. If you or your dependents do notprovide this requirednotice, any dependent who loses coverageisNOTeligibleto elect continuation coverage. Furthermore, if you or your dependents do notprovide this requirednotice,you or your dependent must reimburseany claims mistakenly paid forexpenses incurred after the date coverage actually terminates. Note: Disability Extensions also require specific notice. See below for these notification requirements. When you notify the employer ofa divorce,legal separation,or a loss of dependent status,the employer will notify the affected family member(s) of the right to elect continuation coverage. If you notify the employer of a qualifying event or disability determination and the employer determines that there is no extension available, the employer will provide an explanation as to why you or your dependents are not entitled to elect continuation coverage. Employer's and Plan Administrator's Notice Obligations The employer has 30 days to notify the Plan Administrator of events they know have occurred, such as termination of employment or death of the employee. This notice to the Plan Administrator does not occur when the Plan Administrator is the employer. After plan administrators are notifiedof the qualifying event, they have 14days to send the qualifying event notice. Qualified beneficiaries have60 days to elect continuation coverage. The 60-day time frame begins on the date coverage endsdue to the qualifying event or the date of the qualifying-event notice, whichever is later. The employer will also notify you and your dependents of the right to elect continuation coverage after receiving notice that one of the following events occurred and resulted in a loss of coverage: the employee'stermination of employment (other than for gross misconduct), reduction in hours, death, or the employee'sbecoming enrolled in Medicare. Election Procedures You and your dependents must elect continuation coverage within 60 days after coverage ends, or, if later, 60 days after you or your family memberreceivenotice of the right to elect continuation coverage.If you or your dependents do not elect continuation coverage within this 60-day election period, you will lose your right to elect continuation coverage. You or your dependent spouse may elect continuation coverage for all qualifying family members; however, each qualified beneficiary is entitled to an independent right to elect continuation coverage. Therefore, aspouse/ex-spouse may not decline coverage for the other spouse/ex-spouseand a parent cannot decline coverage for a non-minor dependent child who is eligibleto continuecoverage. In addition, a dependent may elect continuation coverage even if the covered employee does not elect continuation coverage. You and your dependents may elect continuation coverage even if covered under another employer-sponsored group health plan or enrolled in Medicare. Page74 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 How to Elect Contact the employer to determine how to elect continuation coverage. Type of Coverage Generally, continuation coverage is the same coverage that you or your dependent had on the day before the qualifying event. Anyone who is not covered under the Plan on the day before the qualifying event isgenerally not entitled to continuation coverage. Exceptionsinclude: 1) whencoverage was eliminated in anticipation of a divorce or legal separation, the later divorce or legal separationisconsidered a qualifying event even though the ex- spouse/spouselost coverage earlier; and 2) achild born to or placed for adoption with the covered employee during the period of continuation of coverage may be added to the coverage for the duration of the qualified beneficiary's maximum continuation period. Qualified beneficiaries areprovided the same rights and benefits as similarly situated beneficiaries for whom no qualified event has occurred. If coverage is modified for similarly situated active employees or their dependents, then continuation coverage will be modified in the same way. Examplesinclude: 1) If the employer offers an open enrollment period that allows active employees to switch between plans without being considered late entrants, all qualified beneficiaries on continuation areallowed to switch plans as well; and 2) if active employees are allowed to add new spouses to coverage if the application for coverage is received within 30 days of the marriage, qualified beneficiaries who get married while on continuation areafforded this same right. Maximum Coverage Periods Continuation coverage terminates before the maximum coverage period in certain situations described later under the heading"Termination of Continuation Coverage Before the End of the Maximum Coverage Period."In other instances, the maximum coverage period can be extended as described under the heading "Extension of Maximum Coverage Periods." 18 Months. If you or your dependent loses coverage due to the employee'stermination of employment (other than for gross misconduct) or reduction in hours, then the maximum continuation coverage period is 18 months from thefirst of the month following termination or reduction in hours. 36 Months.If a dependent loses coverage because the employeebecame enrolled in Medicare or because of a loss of dependent status under the Plan, then the maximum coverage period (for spouse and dependent child) is three (3) years from the date of the qualifying event. Indefiniteunder Minnesota Law. If you or your dependents lose coverage because of the employee'stotal disability (as defined above), then the maximum coverage period is indefinite. If a dependent loses group health coverage because of the employee'sdeath,divorceor legal separation, then the maximum coverage period (for ex- spouse/spouse and dependent child) is indefinite. Continuation Premiums Premiums for continuation can be up to the group rate plus a two (2) percent administration fee. In the event of a dependent's disability, the premiums for continuation can be up to 150% of the group rate for months 19-29 if the disabled dependent is covered. If the qualifying event for continuation is the employee'stotal disability, the administration fee is not permitted. All premiums are paid directly to the employer. Extension of Maximum Coverage Periods Maximum coverage periods of 18 or 36 months can be extended in certain circumstances. x Disability Extension:This extension is applicable when the qualifying event is the employee'stermination of employment or reduction of hours, and the extension applies to all qualified beneficiaries. If your dependent who is a qualified beneficiary is determined by the Social Security Administration (SSA)to be disabled at any time during the first 60 days of continuation, then the continuation period for all qualified beneficiaries is extended to 29 months from the date coverage terminated. Page75 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Notice Obligation: For the 29-month continuation coverage period to apply, a qualified beneficiary must notify the Plan Administrator of the SSA disability within 60 days after the latest of: 1) the date of the Social Security disability determination; 2) the date of the employee'stermination of employment or reduction of hours; 3) the date on which the qualified beneficiary loses (or would lose) coverage under the Plan as a result of the qualifying event; and 4) the date on which the qualified beneficiary is informed, either through the certificate of coverage or the initial COBRA notice, of both the responsibility to provide the notice of disability determination and the plan's procedures for providing such notice to the administrator. Notice Obligation: The qualified beneficiary must notify the Plan Administrator of the Social Security disability determination before the end of the 18-month period following the qualifying event (the employee'stermination of employment or reduction of hours.) Notice Obligation: If during the 29-month extension period there is a "final determination"that a qualified beneficiary is no longer disabled, the qualified beneficiary must notify the Plan Administrator within 30 days after the date of this determination. This extension coverage ends for all qualified beneficiaries on the extension as of 1) the first day of the monthfollowing30 days after a final determination by the SSA that the formerly disabled qualified beneficiary is no longer disabled; or 2) the end ofthe coverage period that applies without regard to the disability extension. x : Multiple Qualifying EventsThis extension is applicable when the initialqualifying event is the employee's termination of employment or reduction of hours andis followed, within the original 18-month period (or 29-month period if there has been a disability extension), by a second qualifying event that has a 36-month or an indefinite maximum coverage period. The extension applies to the employee'sdependentswhoare qualified beneficiaries. Whena second qualifying event occursthat gives rise to a 36-month maximum coverage period for the dependent, the maximum coverage period (for the dependent) becomes three (3) years from the date of the initial termination or reduction in hours. For the 36-month maximum coverage period to apply, notice of the second qualifying event must be provided to the Plan Administrator within 60 days after the date of the event. If no notice is given within the required 60-day period, no extension will occur. Whena second qualifying event occurs that gives rise to an indefinite maximum coverage period for the dependent, then the maximum coverage period (for the dependent) becomes indefinite. For an indefinite maximum coverage period to apply, noticeof the second qualifying event must be provided to the Plan Administrator within 60 days after the date of the event. If no notice is given, no extension of continuation coverage will occur. x Pre-Termination or Pre-Reduction Medicare Enrollment:This extension applies when the qualifying event is the reduction of hours or termination of employment that occurs within 18 months after the date of the employee's Medicare enrollment. The extension applies to the employee'sdependents who are qualified beneficiaries. If the qualifying event occurs within 18 months after the employeebecomes enrolled in Medicare, regardless of whether the employee'sMedicare enrollment is a qualifying event (causing a loss of coverage under the group Plan), the maximum period of continuation for the employee'sdependents who are qualified beneficiaries is three (3) years from the date the employeebecame enrolled in Medicare. (Example: Employeebecomes enrolled in Medicare on January 1. Employee'stermination of employment is May 15. The employeeis entitled to 18 months of continuation from the date coverage is lost. The employee'sdependents are entitled to 36 months of continuation from the date the employeeis enrolled in Medicare.) If the qualifying event is more than 18 months after Medicare enrollment, is the same day as the Medicare enrollment or occurs before Medicare enrollment, no extension is available. x Employer's Bankruptcy:The bankruptcy rule technically is an initial qualifying event rather than an extending rule.However, because it would result in a much longer maximum coverage period than 18 or 36 months, it is included here. If the employer files Chapter 11 bankruptcy, it may trigger COBRA coverage for certain retirees and their related qualified beneficiaries. A retiree is entitled to coverage for life. The retiree's spouse and dependent children are entitled to coverage for the life of the retiree, and, if they survive the retiree, for 36 months after the retiree's death. If the retiree is not living when the qualifying event occurs, but the retiree's spouse is covered by the Plan, then that surviving spouse is entitled to coverage for life. Page76 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Termination of Continuation Coverage Before the End of Maximum Coverage Period Continuation coverage of the employeeanddependents will automatically terminate when any one of the following events occurs: x The employer no longer provides group health coverage to any of its employees. x The premium for the qualified beneficiary’s continuation coverage is not paid when due. x After electing continuation, you or your dependents become covered under another group health plan that has no exclusion or limitation with respect to any preexisting condition that you have.Your continuation coverage will terminate after any applicableexclusion or limitation no longer applies. x If duringa 29-month maximum coverage period due to disability,the SSA makes the final determination that the qualified beneficiary is no longer disabled. x Occurrence of any event (e.g., submission of fraudulent benefit claims) that permits termination of coverage for cause with respect to anycoveredemployeesor their dependents whether or not they are on continuation coverage. x Voluntarilycancelingyour continuation coverage. When termination takes effect earlier than the end of the maximum period of continuation coverage, a notice will be sent from the Plan Administrator. The notice will contain the reason continuation coverage has been terminated, the date of the termination, and any rights to elect alternativecoverage that may be available. Retirees of Political Subdivisions A retiree of a political subdivision who is receiving a disability benefit or an annuity from a Minnesota public pension plan (other than a volunteer firefighter plan), or who has met age and service requirements necessary to receive an annuity from such a plan along with the retiree’s dependents, may continue coverage indefinitely. Children Born to or Placed for Adoption With the Covered Employee During Continuation Period A child born to, adopted by or placed for adoption with a coveredemployeeduring a period of continuation coverage is considered to be a qualified beneficiary provided that the covered employeeis a qualified beneficiary and has elected continuation coverage for himself/herself. The child’s continuation coverage begins on the date of birth, adoption, or placement for adoption as outlined in the Eligibility section, and it lasts for as long as continuation coverage lasts for other family members of the employee. OpenEnrollment Rights and Special Enrollment Rights Qualified beneficiaries who have elected continuation will be given the same opportunity available to similarly-situated active employees to change their coverage options or to add or eliminate coverage fordependents at open enrollment. Special enrollment rights apply to those who have elected continuation. Except for certain children described above, dependents who are enrolled in a special enrollment period or open enrollment period do not become qualified beneficiaries–their coverage will end at the same time that coverage ends for the person who elected continuation and later added them as dependents. Address Changes, Marital Status Changes, Dependent Status Changes and Disability Status Changes Ifyour or your dependent’s address changes, you must notify the Plan Administrator in writing sothe Plan Administratormaymailyou or your dependent important continuation notices and other information. Also, if your marital status changes or if a dependent ceases to be a dependent eligible for coverage under the terms of the Plan, you or your dependent must notify the Plan Administrator in writing. In addition, you must notify the Plan Administrator if a disabled employeeor family member is no longer disabled. Page77 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Special Second Election Period Special continuation rights apply to certain employees who are eligible for the health coverage tax credit. These employees are entitled to a second opportunity to elect continuation coverage for themselves and certainfamily members (if they did not already elect continuation coverage) during a special second election period. This election period is the 60-day period beginning on the first day of the month in which an eligible employee becomes eligible for the healthcoverage tax credit, but only if the election is made within six (6) months of losing coverage. Please contact the Plan Administrator for additional information. The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustments assistance. Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Care Tax Credit Customer Contact Center toll-free at 1-866-628- 4282. Uniformed Services Employment and Reemployment Rights Act (USERRA) If you are called to active duty in the uniformed services, you may elect to continue coverage for you and your eligible dependents under USERRA. This continuation right runs concurrently with your continuation right under COBRA and allows you to extend an 18-month continuation period to 24 months. You and your eligible dependents qualify for this extension if you are called into active or reserve duty, whether voluntary or involuntary, in the Armed Forces, the Army National Guard, the Air National Guard, full-time National Guard duty (under a federal, not a state, call-up), the commissioned corps of the Public Health Services and any other category of persons designated by the President of the United States. Youremployermay have policies and procedures about USERRA. Contact your employerabout USERRA policies and procedures. Additional Events In addition to the events outlined above, you may choose to continue your coverage during an approved leave of absence or vacation by paying the monthly required chargesto your employerin the manner required by your employer. Coverage may be continued for six (6) months after the end of the Plan month during which the temporary leave began. Questions If you have general questions about continuation of coverage, please call the telephone number on the back of your ID card for assistance. Page78 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Overview The following chart is an overview of the information outlined in the previous section. For more detail refer to the previous sections. Maximum Qualifying Event/ExtensionWho May ContinueContinuation Period x Employee and dependentsEarlier of: Employment ends (for reasons 1.18 months;or other than gross misconduct) 2.Enrollment date in other group x Reduction in hours of coverage. employment (lay-off, leave of absence, strike, lockout, change from full-time to part-time employment) x Ex-spouse/spouseand any Earlier of: Divorceor legal separation dependent children wholose1.Enrollment date in other group coveragecoverage;or 2.Date coverage would otherwise end. x Surviving spouse and dependent Earlier of: Death of employee children1.Enrollment date in other group coverage;or 2.Date coverage would otherwise end if the employeehad lived. x Dependent childEarliest of: Dependent child loses eligibility 1.36 months;or 2.Enrollment date in other group coverage;or 3.Date coverage would otherwise end. x All dependents Earliest of: Dependents lose eligibility due 1.36 months;or to the employee's enrollment in 2.Enrollment date in other group Medicare coverage;or 3.Date coverage would otherwise end. x RetireeLifetime continuation. Retirees of the employerfiling Chapter 11 bankruptcy (includes Dependents Lifetime continuation until the retiree substantial reduction in dies, then an additional 36 months coverage within one (1) year of following retiree's death. filing) x Employee and dependents Earlier of: Total disability of employee 1.Date total disability ends;or 2.Date coverage would otherwise end. Extensions to 18-month maximum continuation period: x Total disability of dependent(s) Disabled dependent and all other Earliest of: covered family members1.29 months after the employee leaves employment;or 2.Date total disability ends;or 3.Date coverage would otherwise end. Page79 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Conversion/InterPlan Transfer (IPT) You or your dependents who are Minnesota residents may convert your coverage to an individual qualified plan. If you or your dependents reside outside of Minnesota, you may request an IPT to another Blue Cross and/or Blue Shield Plan. Conversion and IPT apply ifcoverage ends because: 1.you become ineligible; 2.your continuation coverage is exhausted; 3.no continuation coverage is available to you; or 4.the Plan ends and is not replaced by continuous group coverage. If your coverage ends because you become ineligible or leave the Plan, you must apply for conversion/IPTcoverage within 62days after your coverage (or continuation) ends. If your coverage ends because the Plan ends, you must apply for conversion/IPTcoverage within 62days after receiving notice of cancellation of the Plan. Conversion/IPTcoverage and premiumswill not be the same as thisPlan. Evidenceof good health is not required. Regardless of the reason coverage ends, you are not eligible for conversion/IPTif you do not apply within 62days of losing group coverage. Page80 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 COORDINATION OF BENEFITS This section applies when you have health care coverage under more than one (1) plan, as defined below. If this section applies, you should look at the Order of Benefits Rules first to determine which plan determines benefits first. Your benefits under this Plan are not reduced if the Order of Benefits Rulesrequire this Plan to pay first. Your benefits under this Plan may be reduced if another plan pays first. Definitions These definitions apply only to this section. 1."Plan"isany of the following that provides benefits or services for, or because of, medical or dental care or treatment: a.group insurance or group-type coverage, whether insured or uninsured. This includes prepayment, group practice, individual practice coverage, and group coverage other than school accident-type coverage; b.coverage under a government plan oronerequired or provided by law; or, c.individual coverage. "Plan"does not includea state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act as amended from time to time). "Plan" does not include any benefits that, by law, are excess to any private or other nongovernmental program. "Plan"does not includehospital indemnity, specified accident, specified disease, or limited benefit insurance policies. 2."This Plan"means the part of the Plan document that provides health care benefits. 3."Primary Plan/Secondary Plan"is determined by the Order of Benefits Rules. WhenThis Plan is a primaryplan, its benefits are determined before any other plan and without considering the other plan’s benefits. WhenThis Plan is a Secondary Plan, its benefits are determined after those of the other plan and may be reduced because of the other plan’s benefits. When you are covered under more than two (2) plans, This Plan may be a primaryplan to some plans, and may be a secondaryplan to other plans. Notes: a.If you are covered under this Plan and Medicare: This Plan will comply with Medicare Secondary Payor (MSP) provisions of federal law, rather than the Order of Benefits Rules in this section, to determine which Plan is a primary Plan and which is a Secondary Plan. Medicare will be primary and This Plan will be secondary only to the extent permitted by MSP rules.When Medicare is the Primary Plan, this Plan will coordinate benefits up to Medicare's Allowed Amount. b.If you are covered under this Plan and TRICARE: This Plan will comply with the TRICARE provisions of federal law, rather than the Order of Benefit’s Rules in this section, to determine which Plan is a Primary Plan and which is a Secondary Plan. TRICARE will be primary and This Plan will be secondary only to the extent permitted by TRICARE rules.When TRICARE is the Primary Plan, this Plan will coordinate benefits up to TRICARE's Allowed Amount. 4."Allowable expense"means the necessary, reasonable, and customary items of expense for health care, covered at least in part by one (1) or more plans covering the person making the claim. "Allowable expense"does not include an item or expense that exceeds benefits that are limited by statute or This Plan. "Allowable Expense" does not include outpatient prescription drugs, except those eligible under Medicare (see number 3 above). Page81 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 The difference between the cost of a private and a semiprivate hospital room is not considered an allowable expense unless admission to a private hospital room is medically necessary under generally accepted medical practice or as defined under This Plan. When a plan provides benefits in the form of services, the reasonable cash value ofeach service rendered will be considered both an allowable expense and a benefit paid. 5."Claim determination period"means a calendar year. However, it does not include any part of the year the person is not covered under This Plan, or any part of a year before the date this section takes effect. Order of Benefits Rules 1.General: When a claim is filed under This Plan and another plan, this Plan is a secondaryplan and determines benefits after the other plan, unless: a.the other plan has rules coordinating its benefits with This Plan’s benefits; and, b.the other plan’s rules and This Plan’s rules, in part 2. below, require This Plan to determine benefits before the other plan. 2.Rules:This Plan determines benefits using the first of the following rules that applies: a.Nondependent/dependent.the plan that covers the person as an employee, member, or subscriber (that is, other than as a dependent) determines its benefits before the plan that covers the person as a dependent. b.Dependent child of parents not separated,or divorced.WhenThisPlan and another plan cover the same child as a dependent of different persons, called "parents": 1)the plan that covers the parent whose birthday falls earlier in the year determines benefits before the plan that covers the parent whose birthday falls later in the year; but 2)if both parents have the same birthday, the plan that has covered the parent longer determines benefits before the plan that has covered the other parent for a shorter period of time. However, if the other plan does not have this rule for children of married parents, and instead the other plan has a rule based on the gender of the parent, and if as a result the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. c.Dependent child of parents divorced or separated.If two (2) or more plans cover a dependent child of divorced or separated parents, This Plan determines benefits in this order: 1)first, the plan of the parent with physical custody of the child; 2)then, the plan that covers the spouse of the parent with physical custody of the child; 3)finally, the plan that covers the parent not having physical custody of the child; or, 4)in the case of joint physical custody, b. above applies. However, if the court decree requires one (1) of the parents to be responsible for the health care expenses of the child, and the plan that covers that parent has actual knowledge of that requirement, that plan determines benefits first. This does not apply to any claim determination period or plan year during which any benefits are actually paid or provided before the plan has that actual knowledge. d.Active/inactive employee.The Plan that covers a person as an employee who is neither laid-off nor retired (or as that employee’s dependent) determines benefits before a plan that covers that person as a laid-off or retired employee (or as that employee’s dependent). If the other plan does not have this rule, and if as a result the plans do not agree on the order of benefits, then this rule is ignored. e.Longer/shorter length of coverage.If none of the above determines the order of benefits, the plan that has covered an employee, member, or subscriber longer determines benefits before the plan that has covered that person for theshorter time. Page82 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Effect on Benefits of This Plan 1.When this section applies: When the Order of Benefits Rules above require This Plan to be a SecondaryPlan, this part applies. Benefits of This Plan may be reduced. 2.Reduction in This Plan's benefits When the sum of: a.the benefits payable for allowable expenses under This Plan, without applying coordination of benefits;and b.the benefits payable for allowable expenses under the other plans, without applying coordination of benefits or a similar provision, whether or not claim is made, exceeds thoseallowable expenses in a claim determination period.In that case, the benefits of This Plan are reduced so that benefits payable under all plans do not exceed allowable expenses. When benefits ofThis Plan are reduced, each benefit is reduced in proportion and charged against any applicable benefit limit of This Plan.Benefits saved by This Plan due to coordination of benefits saving (credit reserve) are available for payment on future claims during this Plan year. Credit reserve will start over for the next Plan year. Right to Receive and Release Needed Information Certain facts are needed to apply these coordination of benefits rules. The Claims Administrator has the right to decide which facts are needed. The Claims Administrator may get needed facts from, or give them to, any other organization or person. They do not need to tell, or get the consent of, any person to do this. Each person claiming benefits under this Plan must provide any facts needed to pay the claim. Facility of Payment A payment madeunder another plan may include an amount that should have been paid under This Plan. If this happens,This Plan may pay that amount to the organization that made that payment. That amount will then be considered a benefit under This Plan. This Plan will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made"means reasonable cash value of the benefits provided in the form of services. Right of Recovery IfThis Plan pays more than it should have paid under these coordination of benefit rules, This Plan may recover the excess from any of the following: 1.the persons This Plan paid or for whom This Plan has paid; 2.insurance companies; and, 3.other organizations. The amount paid includes the reasonable cash value of any benefits provided in the form of services. Page83 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 REIMBURSEMENT AND SUBROGATION If the Plan pays benefits for medical or dental expenses you incur as a result of any act of any person, and you later obtaincompensation,you are obligated to reimburse the Plan for the benefits paid.If you or your dependents receive benefits under this Plan arising out of anillness or injury for which a responsible party is or may be liable, the Plan is also entitled to subrogate against any person, corporation and/or other legal entity, or any insurance coverage, including both first-and third-party automobile coverages. The Plan's right to reimbursement and subrogation is subject to you obtaining full recovery, as explained in Minnesotastatutes 62A.095 and 62A.096. The Plan's right to reimbursement and subrogation is subject to reduction for the Plan's pro rata share of costs, disbursements, and reasonable attorney fees incurred in obtaining the recovery unless the Plan is separately represented by itsown attorney. Notice Requirement You must provide timely written notice to the Plan Administrator of the pending or potential claimif you make a claim against a third party for damages that include repayment for medical and medicallyrelated expenses incurred for your benefit.The Plan Administrator, at its option, maytakeappropriate action to preserveitsrights under this reimbursement and subrogation section, including theright to intervene in any lawsuit you have commenced. The Plan Administrator may delegate such functions to the Claims Administrator. Duty to Cooperate You must cooperate with the Plan Administratorin assisting it to protect its legal rights under this provision. You agree that the limited period in which the Plan may seek reimbursement or to subrogate does not commence to run until you or your attorney has given notice to the Plan of your claim against a third party. Page84 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 GENERAL PROVISIONS Plan Administration Plan Administrator The general administration of thePlan and the duty to carry out its provisions is vested in the Employer. The board of directors will perform such duties on behalf of the Employer, provided it may delegate such duty or any portion thereof to a named person, including employees and agentsof the Employer, and may from time to time revoke such authority and delegate it to another person. Any delegation of responsibility must be in writing and accepted by the designated person. Notwithstanding any designation or delegation of final authoritywith respect to claims, the Plan Administrator generally has final authority to administer the Plan. Powers and Duties of the Plan Administrator The Plan Administrator will have the authority to control and manage the operation and administration of thePlan. This will include all rights and powers necessary or convenient to carry out its functions as Plan Administrator. Without limiting that general authority, the Plan Administrator will have the express authority to: 1.construe and interpret the provisions ofthe Plan and decide all questions of eligibility; 2.prescribe forms, procedures, policies, and rules to be followed by you and other persons claiming benefits under the Plan; 3.prepare and distribute information to you explaining the Plan; 4.receive fromyou and any other parties the necessary information for the proper administration of eligibility requirements under the Plan; 5.receive, review, and maintain reports of the financial condition and receipts and disbursements of the Plan; and 6.to retain such actuaries, accountants, consultants, third party administration service providers, legal counsel, or other specialists, as it may deem appropriate or necessary for the effective administration of the Plan. Actions of the Plan Administrator The Plan Administrator may adopt such rules as it deems necessary, desirable, or appropriate. All determinations, interpretations, rules, and decisions of the Plan Administrator shall be made in its sole discretion and shall be conclusive and binding upon all personshaving or claiming to have any interest or right under the Plan, except with respect to claim determinations where final authority has been delegated to the Claims Administrator. All rules and decisions of the Plan Administrator will be uniformly and consistently applied so that all individuals who are similarly situated will receive substantially the same treatment. The Plan Administrator or the Employer may contract with one (1) or more service agents, including the Claims Administrator, to assist in the handling of claims under the Plan and/or to provide advice and assistance in the general administration of the Plan. Such service agent(s) may also be given the authority to make payments of benefits under the Plan on behalf of and subject to the authority of the Plan Administrator. Such service agent(s) may also be given the authority to determine claims in accordance with procedures, policies, interpretations, rules, or practices made, adopted, or approved by the Plan Administrator. Nondiscrimination The Plan shall not discriminate in favor of "highly compensated employees"as defined in Section 105(h) of the Internal Revenue Code, as to eligibility to participate or as to benefits. Page85 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 Termination or Changes to the Plan No agent can legally change the Plan or waive any ofits terms. The Employer reserves the power at any time and from time to time (and retroactively if necessary or appropriate to meet the requirements of the Internal Revenue Code) to terminate, modify or amend, in whole or in part, any or all provisions of the Plan, provided however, that no modification or amendment shall divest an employee of a right to which he or she is entitled under the Plan. Any amendment to this Plan may be effected by a written resolution adopted by the Board OfDirectors. The Plan Administrator will communicate any adopted changes to the employees. Funding This Plan is a self-insured medical plan funded by contributions from the employer and/or employees.Funds for benefit payments are provided through a special arrangement with your local service cooperative according to the terms of its agreement with the Claims Administrator.Your contributions toward the cost of coverage under the Plan will be determined by the employer each year. The Claims Administrator provides administrative services only and does not assume any financial risk or obligation with respect to providing benefits. The Claims Administrator’s payment of claims is contingent upon the Plan Administrator continuing to provide sufficient funds for benefits. Controlling Law Except as they may be subject to federal law, any questions, claims, disputes, or litigation concerning or arising from the Plan will be governed by the laws of the state of Minnesota. Privacy of Protected Health Information Protected Health Information (PHI) is individually identifiable information created or received by a health care provider or a health care plan. This information is related to your past, present, or future health or the payment for such health care. PHI includes demographic information that either identifies you or provides a reasonable basis to believe that it could be used to identify you. Restrictions on the Use and Disclosure of Protected Health Information The employer may not use or disclose PHI for employment-related actions or decisions. The employer may only use or further disclose PHI as permitted or required by law and will report any use or disclosure of PHI that is inconsistent with the allowed uses and disclosures. Separation Between the Employer and the Plan The employees, classes of employees or other workforce members below will have access to PHI only to perform the plan administration functions that the employer provides for the plan. The following may be given access to PHI: Human Resources Benefits Administrator.This list includes every employee or class of employees or other workforce members under the control of the employer who may receive PHI relating to the ordinary course of business. The employees, classes of employees or other workforce members identified above will be subject to disciplinary action and sanctions for any use or disclosure of PHI that is in violation of these provisions. The employer will promptly report such instances to the Plan and will cooperate to correct the problem. The employer will impose appropriate disciplinary actions on each employee or workforce member and will reduce any harmful effects of the violation. Page86 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 GLOSSARY OF COMMON TERMS Please refer to the Benefit Chart for specific benefit and payment information. TermDefinition 90dayRx Participating 90dayRx Retail Pharmacies and Mail Service Pharmacy used for the dispensing of a 90-day supply of long-term prescription drug refills. Admission A period of one (1) or more days and nights while you occupy a bed and receive inpatient care in a facility. Advanced Practice Licensed registered nurses who have gained additional knowledge and skills through an Nurses organized program of study and clinical experience that meets the criteria for advanced practice established by the professional nursing organization having the authority to certify the registered nurse in the advanced nursing practice. Advanced practice nurses include clinical nurse specialists (C.N.S.), nurse practitioners (N.P.), certified registered nurse anesthetists (C.R.N.A.), and certified nurse midwives (C.N.M.). Allowed Amount The amount upon whichthe Claims Administrator basespayment for a given covered service fora specific provider. The AllowedAmount may vary from one provider to another for the samecoveredservice. All benefits are based on the AllowedAmount, except as specifiedin the"Benefit Chart". The Allowed Amount for Participating Providers ForParticipatingProviders, the AllowedAmount is the negotiated amount of payment that the ParticipatingProvider has agreed to accept as full payment for a covered service at the time your claim is processed. The Claims Administrator periodically may adjust the negotiated amount of payment at the time your claim is processedfor covered services at Participating Providers as a result of expected settlements or other factors. The negotiated amount of payment with ParticipatingProviders for certain covered services may not be based on a specified charge for each service, and the Claims Administrator uses a reasonable allowance to establish a per-serviceAllowedAmount for such covered services. Through settlementsor other special arrangements with Participating Providers the Claims Administrator may prospectively or subsequently pay a different amount to a Participating Provider. Such payments will not affect or cause any change in the amount you paid at the time your claim was processed. Qualifications Applicable to AllNonparticipating Providers In determining the AllowedAmount for Nonparticipating Providers, the Claims Administrator makes no representations that this amount isintended to representa usual, customary or reasonable charge.TheAllowed Amountis the amount that the Plan will pay for a covered service. The Plan will pay this amount to you. The determination of the Allowed Amountis subject to all of the Claims Administrator's business rules as defined in the Claims Administrator Provider Policy and Procedure Manual. As a result, the Claims Administrator maybundle services or take multiple procedure discounts and/or reductions as a result of the procedures performed and billed on the claim. No fee schedule amounts include any applicable tax. Page87 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition The Allowed Amount for Nonparticipating Providersin Minnesota For Nonparticipating Provider servicesin Minnesota, except those described under Special Circumstances below, the Allowed Amount will be an amount based upon one of the following payment options to be determined by the Claims Administrator at its discretion: (1) a Minnesota Nonparticipating Provider fee schedule posted at theClaims Administrator’s website; (2) a percentage of the published Medicareallowedcharge for the same or similar service; (3) a percentage of billed charges; or(4) pricing using a nationwide provider reimbursement database. The payment option selected by the Claims Administrator may result in an Allowed Amountthat is a lower amount than if calculated by another payment option. The AllowedAmount for AllNonparticipating Provider Services Outside Minnesota For Nonparticipating Provider services outside of Minnesota, except those described under Special Circumstances below, the Allowed Amount will be an amount based upon one of the followingpayment options, to be determined by the Claims Administrator at its discretion: (1) a Minnesota Nonparticipating Provider fee schedule posted at the Claims Administrator’s website; (2) a percentage of the published Medicare allowed charge for the same orsimilar service; (3) a percentage of billed charges; (4) pricing determined by the Host Blue plan; or (5) pricing using a nationwide provider reimbursement database. The payment option selected by the Claims Administrator may result in an Allowed Amountthat is a lower amount than if calculated by another paymentoption. Special Circumstances When you receive care from certain nonparticipating professionals at a participating facility such as a hospital, outpatient facility,or emergency room, the reimbursement to the nonparticipating professional may include some of the costs that you would otherwise be required to pay (e.g., the difference between the Allowed Amount and the provider's billed charge). This reimbursement applies when nonparticipating professionals are hospital-based and needed to provide immediate medical or surgical care and you do not have the opportunity to select the provider of care. The extent of reimbursement in these circumstances may also be subject to federal law. If you havequestions about the benefits available for services to be provided by a Nonparticipating Provider, you will need to speak with your provider and you may call the Claims Administrator Customer Service at the telephone number on the back of your member ID card for more information. Artificial The introduction of semen from a donor (which may have been preserved as a specimen), into Insemination (AI) a woman's vagina, cervical canal, or uterus by means other than sexual intercourse. Assisted Fertility treatments in which both eggs and sperm are handled. In general, ART procedures Reproductive involve surgically removing eggs from a woman's ovaries, combining them with sperm in the Technologies (ART) laboratory, and returning them to the woman's body or donating them to another woman. Such treatments do not include procedures in which only sperm are handled (i.e., intrauterine, or artificial insemination), or procedures in which a woman takes medicine only to stimulate egg production without the intention ofhaving eggs retrieved. Attending Health A health care professional with primary responsibility for the care provided to a sick or injured Care Professional person. Average The average rate charged for semiprivate rooms. If the provider has no semiprivate rooms, the Semiprivate Room Claims Administrator uses the average semi-private room rate for payment of the claim. Rate Page88 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Behavioral Health Treatment for mental health disorders and substance abuse/addiction diagnoses as listed in Care Treatment themost recent edition of the International Classification of Diseases. Does not include developmental disability. Behavioral Health A health professional that participates in a special network for the provision of mental health or SelectNetwork substance abuse treatment services. Provider Behavioral Health A method of treating mental and substance abuse disorders that involves verbal and Therapy nonverbal communication about thoughts, feelings, emotions and behaviors in individual, group or family sessions in order to change unhealthy patterns of coping, relieve emotional distress and encourage improved interpersonal relations. Benefit Chart The schedule that lists benefits and covered services. BlueCardNetwork Providers who have entered intoa specificnetwork contractwith the local Blue Cross and/or Provider Blue Shield Planoutside of Minnesota. BlueCard Program A Blue Cross and Blue Shield program which allowsemployees and dependentsto access coveredhealthcare serviceswhile traveling outside of your service area. Employees and dependentsmust use Participating Providers ofa Host Blue and show your membership ID to secure BlueCard Program access. Blue Select A health care professional that participates in a special network for the provision of certain Chiropractic services. NetworkProvider stst Calendar Year The period starting on January 1ofeach year and ending at midnight December 31ofthat year. Care/Case A plan for health care services developed for a specificpatient by one of our care/case Management Plan managers after an assessment of the patient's condition in collaboration with the patient and the patient's health care team. The plan sets forth both the immediate and the ongoing skilled health care needs of the patient to sustain or achieve optimal health status. Certification of A form which will be issued when health coverage is terminated under this certificate. The Coverage Certification of Coverage form will contain the necessary information a new health plan will need to apply the appropriate credit toward the new health plan's preexisting condition limitation period. Claim A claim is a written submission from your provider (or from you when you use Nonparticipating Providers) to the Claims Administrator. Most claims are submitted electronically. The claim tellsthe Claims Administratorwhat services the provider delivered to you. In some cases, the Claims Administratormay require additional information from the provider or you before a determination can be made.When this occurs, work with your provider to return the information to the Claims Administratorpromptly. If the provider delivered a service that is a non-covered benefit, the claim will deny, meaning no payment is allowed. Providers are required to usecertain codes to explain the care they give you. The provider's medical record must support the codes being used. The Claims Administrator may not change the codes a provider uses on a claim. If you believe your provider has not used the right codes on your claim, you will need to talk to your provider. Claims Blue Cross and Blue Shield of Minnesota(Blue Cross). Administrator Page89 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Coinsurance The percentage of the Allowed Amountyou must pay for certain covered services after you have paid any applicable deductibles and copays and until you reach your out-of-pocket and/or intermediate maximum. For covered services from ParticipatingProviders, coinsurance is calculated based on the lesser of the Allowed Amountor the ParticipatingProvider’s billed charge.Because payment amounts are negotiated with ParticipatingProviders to achieve overall lower costs, the Allowed AmountforParticipatingProviders is generally, but not always, lower than the billed charge. However, the amount used to calculate your coinsurance will not exceed the billed charge. When your coinsurance is calculated on the billed charge rather than the Allowed AmountforParticipatingProviders, the percentage of the Allowed Amountpaid by the Claims Administrator will be greater than the stated percentage. For covered services from Nonparticipating Providers, coinsurance is calculated based on the Allowed Amount. In addition, you are responsible for any excess charge over the Allowed Amount. Your coinsurance and deductible amount will be based on the negotiated payment amount the Claims Administrator has established with the provider or the provider’s charge, whichever is less. The negotiated payment amount includes discounts that are known and can be calculated when the claim is processed. In some cases, after a claim is processed, that negotiated payment amount may be adjusted at a later time if the agreement with the provider so provides. Coinsurance and deductible calculation will not be changed by such subsequent adjustments or any other subsequent reimbursements the Claims Administrator may receive from other parties. Coinsurance Example: You are responsible for payment of any applicable coinsurance amounts for covered services. The following is an example of how coinsurance would work for a typical claim: For instance, when the Claims Administrator pays 80% of the Allowed Amountfor a covered service, you are responsible for the coinsurance, which is 20% of the Allowed Amount. In addition, you would be responsible for any excess charge over the Claims Administrator's Allowed Amountwhen a Nonparticipating Provider is used. For example, if a Nonparticipating Provider ordinarily charges $100 for a service, but the Claims Administrator's Allowed Amount is $95, the Claims Administrator will pay 80% of the Allowed Amount($76). You must pay the 20% coinsurance on the Claims Administrator's Allowed Amount($19), plus the difference between the billed charge and the Allowed Amount($5), for a total responsibility of $24. Remember,ifParticipatingProviders are used, your share of the covered charges (after meeting any deductibles) is limited to the stated coinsurance amounts based on the Claims Administrator'sAllowed Amount. If Nonparticipating Providers are used, your out-of-pocket costs will be higher as shown in the example above. Compound Drug A prescription where two or more drugs are mixed together. One of these must be a Federal legend drug. The end product must not be available in an equivalent commercial form. A prescription will not be considered a compound if only water or sodium chloride solution are added to the active ingredient. Comprehensive A multidisciplinary program including, at a minimum, the following components: Pain Management 1.a comprehensive physical and psychological evaluation; Program 2.physical/occupation therapies; 3.a multidisciplinary treatment plan; and 4.a method to report clinical outcomes. Page90 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Continuous The maintenance of continuous and uninterrupted creditable coverage by an eligible Qualifying employee or dependent. An eligible employee or dependent is considered to have maintained Creditable continuous qualifying creditable coverage if the individual applies for coverage within 63 days Coverage of the termination of his or her qualifying creditable coverage. Copay The dollar amount you must pay for certain covered services. The "Benefit Chart"lists the copays and services that require copays.A negotiated payment amount with the provider for a service requiring a copay will not change the dollar amount of the copay. Cosmetic Services Surgery and other services performed primarily to enhance or otherwise alter physical appearance without correcting or improving a physiological function. Covered Services A health service or supply that is eligible for benefits when performed and billed by an eligible provider. You incur a charge on the date a service is received or a supply or a drug is purchased. Custodial Care Services to assist in activities of daily living, such as giving medicine that can usually be taken without help, preparing special foods, helping someone walk, get in and out of bed, dress, eat, bathe and use the toilet. These services do not seek to cure, are performed regularly as part of a routine or schedule, and do not need to be provided directly or indirectly by a health care professional. Cycle One (1) partial or complete fertilization attempt extending through the implantation phase only. Day Treatment Behavioral health services that may include a combination of group and individual therapy or counseling for a minimum of three (3) hours per day, three (3) to five (5) days per week. Deductible The amount you must pay toward the Allowed Amountfor certain covered services each year before the Claims Administrator begins to paybenefits. The deductibles for each person and family are shown on the "Benefit Chart." Your coinsurance and deductible amount will be based on the negotiated payment amount the Claims Administrator has established with the provider or the provider’s charge, whichever is less. The negotiated payment amount includes discounts that are known and can be calculated when the claim is processed. In some cases, after a claim is processed, that negotiated payment amount may be adjusted at a later time if the agreement with the provider so provides. Coinsurance and deductible calculation will not be changed by such subsequent adjustments or any other subsequent reimbursements the Claims Administrator may receive from other parties. Dependent Your spouse, child to the dependent child age limit specified in the "Eligibility"section, child whom you or your spouse have adopted or been appointed legal guardian to the dependent child age limit specified in the "Eligibility" section,grandchild who meets the eligibility requirements as defined in the "Eligibility" section to the dependent child agelimitspecified in the"Eligibility" section,disabled dependent or dependent child as defined in the "Eligibility," section, or any other person whom state or federal law requires be treated as a dependent. Drug Therapy A disposable article intended for use in administering or monitoring the therapeutic effect of a Supply drug. Durable Medical Medical equipment prescribed by a physician that meets each of the following requirements: Equipment 1.able to withstand repeated use; 2.used primarily for a medical purpose; 3.generally not useful in the absence of illness or injury; 4.determined to be reasonable and necessary; and 5.represents the most cost-effective alternative. Page91 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition E-Visit An online evaluation and management service provided by a physician using the internet or similar secure communications network to communicate with an established patient. Emergency Hold A process defined in Minnesota law that allows a provider to place a person who is considered to be a danger to themselves or others, in a hospital involuntarily for up to 72 hours, excluding Saturdays, Sundays and legal holidays, to allow for evaluation and treatment of mental health and/or substance abuse issues. Enrollment Date The first day of coverage, or if there has been a waiting period, the first day of the waiting period (typically the date employment begins). Extended Hours Extended hours skilled nursing care, also referred to as private duty nursing care, are complex Skilled Nursing nursing care services provided in a member's home. Care Extended hours skilled nursing care services provide complex, direct,skilled nursing care to develop caregiver competencies through training and education to optimize themember's heath status and outcomes. The frequency of the nursing tasks is continuous and temporary in nature and isnot intended to be provided on a permanent, ongoing basis. Facility A provider that is a hospital, skilled nursing facility, residential behavioral health treatment facility, or outpatient behavioral health treatment facility licensed under state law in the state in which it is located to provide the health services billed by that facility. Facility may also include a licensed home infusiontherapy provider, freestanding ambulatory surgical center, or a home health agency when services are billed on a facility claim. Family Therapy Behavioral health therapy intended to treat an individual within the context of family relationships. The focus ofthe treatment is to identify problems or conflicts and to set specific goals for resolving them. Foot Orthoses Appliances or devices used to stabilize, support, align, or immobilize the foot in order to prevent deformity,protect against injury,orassist with function. Foot orthoses generally refer toorthopedic shoes, and devices or inserts that are placed in shoes includingheel wedges and arch supports. Foot orthoses are used to decrease pain, increase function, correct some foot deformities, and provide shock absorption to the foot. Orthoses can be classified as pre- fabricated or custom made. A pre-fabricated orthosis is manufactured in quantity and not designed for a specific patient. A custom-fitted orthosis is specifically made for an individual patient. Freestanding A provider who facilitates medical and surgical services to sick and injured persons on an Ambulatory outpatient basis. Such services are performed by or under the direction of a staff of licensed Surgical Center doctors of medicine (M.D.) or osteopathy (D.O.) and/or registered nurses (R.N.). A freestanding ambulatory surgicalcenter is not part of a hospital, clinic, doctor’s office, or other health care professional’s office. Group Home A supportive living arrangement offering a combination of in-house and community resource services. The emphasis is on securing community resources for most daily programming and employment. Group Therapy Behavioral health therapy conducted with multiple patients. Halfway House Specializedresidences for individuals who no longer require the complete facilities of a hospital or institution but are not yet prepared to return to independent living. Page92 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Health Care A health care professional, licensed for independent practice, certified or otherwise qualified Professional under state law, in the state in which the services are rendered, to provide the health services billed by that health care professional. Health care professionals include only physicians, chiropractors, mental health professionals, advanced practice nurses, physician assistants, audiologists, physical, speech and occupational therapists, licensed nutritionists, licensed registered dieticians, and licensed acupuncture practitioners. Health care professional also includes supervised employees of: MinnesotaRule 29 behavioral health treatment facility licensed by the MinnesotaDepartment of Human Services and doctors of medicine, osteopathy, chiropractic, or dental surgery. Home Health A Medicare-approved or other preapproved facility that sends health professionals and home Agency health aides into a person's home to provide health services. Hospice Care A coordinated set of services provided at home or in an institutional setting for covered individuals suffering from a terminaldisease or condition. Hospital A facility that provides diagnostic, therapeutic and surgical services to sick and injured persons on an inpatient or outpatient basis. Such services are performed by or under the direction of a staff of licensed doctors of medicine (M.D.), or osteopathy (D.O.). A hospital provides 24-hour-a-day professional registered nursing (R.N.) services. Host Blue A Blue Cross and/or Blue Shield organization outside of Minnesota that has contractual relationships with Participating Providers in its designated service area that require such Participating Providers to provide services to members of other Blue Cross and/or Blue Shield organizations. Illness A sickness, injury, pregnancy, mental illness, substance abuse, or condition involving a physical disorder. In-Network Provider In Minnesota, a provider that has entered into a specific network contract with the Claims Administrator. Outside of Minnesota, a provider that has entered into a specific network contract with the local Blue Cross and/or Blue Shield Plan. Please refer to the "Benefit Chart" and"Coverage Information" section for network details. Infertility Testing Services associated with establishing the underlying medical condition or cause of infertility. This may include the evaluation of female factors (i.e., ovulatory, tubal, or uterine function), male factors (i.e., semen analysis or urological testing) or both and involves physical examination, laboratory studies and diagnostic testing performed solely to rule out causes of infertility or establish an infertility diagnosis. Inpatient Care Care that provides 24-hour-a-day professional registered nursing (R.N.) services for short- term medical and behavioral health services in a hospital setting. Intensive A behavioral health care service setting that provides structured multidisciplinary diagnostic Outpatient and therapeutic services. IOPs operate at least three (3) hours per day, three (3) days per Programs (IOP) week. Substance Abuse treatment is typically provided in an IOP setting. Some IOPs provide treatment for mental health disorders. Intermediate The point where the Plan starts to pay 100% for certain covered services for the rest of the Maximum applicable plan or calendar year. Your Allowed Amounts must total the intermediate maximum. IntermittentSkilled Intermittent skilled nursing care is defined as a visit by a registered nurse or licensed practical NursingCare nurse of up to four (4) consecutive hours in duration. Intrauterine A specific method of artificial insemination in which semen is introduced directly into the Insemination (IUI) uterus. Page93 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Investigative A drug, device, diagnostic procedure, technology, or medical treatment or procedure is investigative if reliable evidence does not permitconclusions concerning its safety, effectiveness, or effect on health outcomes. The Claims Administrator bases its decision upon an examination of the following reliable evidence, none of which is determinative in and of itself: 1.the drug or device cannot be lawfully marketed without approval ofthe U.S. Food and Drug Administration and approvalfor marketing has not been given at the time the drug or device is furnished; 2.the drug, device, diagnostic procedure, technology, or medical treatment or procedure is the subject of ongoing phase I, II, or III clinical trials (Phase I clinical trials determine the safe dosages of medication for Phase II trials and define acute effects on normal tissue. Phase II clinical trials determine clinical response in a defined patient setting. If significant activity is observed in any disease during Phase II, further clinical trials usually study a comparison of the experimental treatment with the standard treatment in Phase III trials. Phase III trials are typically quitelarge and require many patients to determine if a treatment improves outcomes in a large population of patients) 3.medically reasonable conclusions establishing its safety, effectiveness, or effect on health outcomes have not been established. For purposes ofthis subparagraph, a drug, device, diagnostic procedure, technology, or medical treatment or procedure shall not be considered investigative ifreliable evidence shows that it is safe and effective for the treatment of a particular patient. Reliable evidence shall also mean consensus opinions and recommendations reported in the relevant medical and scientific literature, peer-reviewed journals, reports of clinical trial committees, or technology assessment bodies, and professional expert consensus opinions of local and national health care providers. Late Entrant If applicable, an eligible employee or dependent who requests enrollment under the Plan following the enrollment period after which the individual first became eligible for coverage. Lateentrants will be subject to a preexisting condition limitation period, with credit for prior continuous qualifying creditable coverage. An individual will not be considered a late entrant if: 1.the individual was covered under qualifying creditable coverage at the time the individual was eligible to enroll for coverage under this Plan, declined enrollment on that basis, and presents to the Claims Administrator a certificate of termination of the qualifying coverage within 30 days; 2.the individual is applying for coverage within 30 days of the exhaustion of the maximum continuation period provided by state and federal law; 3.the individual is applying for coverage within 30 days of losing eligibility under other qualifying creditable coverage due to a divorce, legal separation, death, termination of employment, reduction in hours, or employer contributions toward the coverage was terminated; 4.the individual is a new spouse of an eligible employee applying for coverage within 30 days of becoming legally married; 5.the individual is a new dependent of an eligible employee for whom coverage is being requested within 30 days of becoming a new dependent; 6.the individual elects a different plan during an open enrollment period; or 7.the coverage being requested is the result of a court order for the addition of a dependent of an eligible employee within 30 days of the issuance of the order. Lifetime Maximum The cumulative maximum payable for covered services incurred by you during your lifetime or by each of your dependents during the dependent’s lifetime under all health plans sponsored by the Plan Administrator. The lifetime maximum does not include amounts which are your responsibility such as deductibles, coinsurance, copays, penalties, and other amounts. Refer to the Benefit Chart for specific dollar maximums on certain services. Page94 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Mail Service A pharmacy that dispenses prescription drugs through the U.S. Mail. Pharmacy Marital/Couples Behavioral health care services for the primary purpose of working through relationship Therapy issues. Marital/Couples Services for the primary purpose of relationship enhancements including, but not limited to: Training premarital education; or marriage/couples retreats,encounters or seminars. Medical Medically necessary care which a reasonable layperson believes is immediately necessary to Emergency preserve life, prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of the patient in serious jeopardy. Medically Health care services that a Physician, exercising prudent clinical judgment, would provide to a Necessary patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, "generally accepted standards of medical practice"means standards that are based on creditable scientific evidence published in peer- reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors. Medicare A federal health insurance program established under Title XVIII of the Social SecurityAct. Medicare is a program for people age 65 or older; some people with disabilities under age 65; and people with end-stage renal disease. The program includes Part A, Part B and Part D. Part A generally covers some costs of inpatient care in hospitals and skilled nursing facilities. Part B generally covers some costs of physician, medical, and other services. Part D generally covers outpatient prescription drugs defined as those drugs covered under the Medicaid program plus insulin, insulin-related supplies, certain vaccines, and smoking cessation agents. Medicare Parts A, B and D do not pay the entire cost of services and are subject to cost sharing requirements and certain benefit limitations. Mental Health Care A psychiatrist, psychologist, licensed independent clinical social worker, marriage and family Professional therapist, nurse practitioner or a clinical nurse specialist licensed for independent practice that provides treatment for mental health disorders, substance abuse, or addictions. Mental Illness A mental disorder as defined in the International Classification of Diseases. It does not include alcohol or drug dependence, nondependent abuse of drugs, or developmental disability. Minnesota Provider A health professional that participates in a special network for the provision of certain services. NetworkProvider Mobile Crisis Face-to-face, short term, intensive behavioral health care services initiated during a behavioral Services health crisis or emergency. This service may be provided on-site by a mobile team outside of an inpatient hospital setting or nursing facility. Services can be available 24 hours a day, seven (7) days a week, 365 days per year. Neuro- Examinations for diagnosing brain dysfunction ordamage and central nervous system Psychological disorders or injury. Services may include interviews, consultations and testing to assess Examinations neurological function associated with certain behaviors. Nonparticipating A provider that has not entered into a networkcontractwith the Claims Administrator or the Provider local Blue Cross and/or Blue Shield Plan. Page95 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Opioid Treatment Treatment that uses methadone as a maintenance drug to control withdrawal symptoms for opioid addiction. Out-of-Network AParticipatingProvider that is notconsideredIn-Network;and Nonparticipating Providers. Provider Out-of-Pocket The most each person must pay each year toward the Allowed Amountfor covered services. Maximum After a person reaches the out-of-pocket maximum, the Plan pays 100% oftheAllowed Amountfor covered services for that person for the rest of the year. The "Benefit Chart"lists the out-of-pocket maximum amounts. Outpatient A facility that provides outpatient treatment, by or underthe direction of, a doctor of medicine Behavioral Health (M.D.) or osteopathy (D.O.), for mental health disorders, alcoholism, substance abuse, or drug Treatment Facility addiction. An outpatient behavioral health treatment facility does not, other than incidentally, provide educational or recreational services as part of its treatment program. Outpatient Care Health services a patient receives without being admitted to a facility as an inpatient. Care received at ambulatory surgery centers is considered outpatient care. Palliative Care Any eligible treatment or service specifically designed to alleviate the physical, psychological, psychosocial, or spiritual impact of a disease, rather than providing a cure for members with a new or established diagnosis of a progressive, debilitating illness. Services may include medical, spiritual, or psychological interventions focused on improving quality of life by reducing or eliminating physical symptoms, enabling a patient to address psychological and spiritual problems, and supporting the patient and family. Partial Programs An intensive structured behavioral health care setting that provides medically supervised diagnostic and therapeutic services. Partial programs operate five (5) to six (6) hours per day, five (5) days per week although some patients may not require daily attendance. Participating A nationwide pharmaceutical provider that participates in a network for the dispensing of Pharmacy prescription drugs. Participating A provider that has entered into a specificnetwork contractwith the Claims Administrator or Provider thelocal Blue Cross and/or Blue Shield Plan. Pharmacy Value A program designed to reward ongoing appropriate drug usage by providing reduced member Based Benefit cost sharing for medications in specific categories or drug classes. Design Physician A doctor of medicine (M.D.), osteopathy (D.O.), dental surgery (D.D.S.), medical dentistry (D.M.D.), podiatric medicine (D.P.M.), or optometry (O.D.) practicing within the scope of his or her license. Place of Service Industry standard claim submission standards (established by the Medicare program) are used by clinic and hospital providers. Providers use different types of claim forms to bill for services based on the "place of service." Generally, the place of service is either a clinic or facility. The benefit paid for a service is based on provider billing and the place of service. For example, the benefits for diagnostic imaging performed in a physician's office may be different than diagnostic imaging deliveredin an outpatient facility setting. Plan The plan of benefits established by the Plan Administrator. Plan Year A 12-month period which begins on the effective date of the plan and each succeeding 12-month period thereafter. Page96 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Preexisting A condition the Claims Administrator has determined existed within a specified time period Condition preceding the enrollment date of your coverage. Conditions are considered to be preexisting if medical advice, diagnosis, care, or treatment was recommended or received. Preexisting condition does not include genetic information alone in the absence of a diagnosis for a condition related the genetic information, or an existing pregnancy. Preexisting The time periodbased on yourenrollment date ofyour coverageduringwhich services related Condition topreexisting conditions will not be covered services under the Plan. Limitation Period Preferred Drug List The Claims Administrator's Preferred drug listis a list of prescription drugs and drug therapy supplies used bypatients in an ambulatory care setting. Over-the-counter, injectable medications and drug therapysupplies are not included in your specifiedPreferred drug list unless they are specifically listed. Prescription Drug The most eachpersonmust pay toward the Allowed Amountforcoveredprescription drugs Out-of-Pocket per year. After a personreachesthe prescription drug out-of-pocket maximum, the Plan pays Maximum 100% of the Allowed Amountfor covered prescription drugsfor the rest of the year. The "Benefit Chart"lists the prescription drug out-of-pocket maximum amount. Prescription Drugs Drugs, including insulin, that are required by federal law to be dispensed only by prescription of a health professional who is authorized by law to prescribe the drug. Provider A health care professional licensed, certified or otherwise qualified under state law, in the state in which services are rendered to provide the health services billed by that provider and a health care facility licensed under state law inthe state in which it is located to provide the health services billed by that facility. Provider includes pharmacies, medical supply companies, independent laboratories, ambulances, freestanding ambulatory surgical centers, home infusion therapy providers, and also home health agencies. Qualifying Health coverage provided through an individual policy, a self-funded or fully-insured group Creditable health plan offered by a public or private employer, Medicare, MinnesotaCare, Medical Coverage Assistance(Medicaid), General Assistance Medical Care, the Minnesota Comprehensive Health Association (MCHA), TRICARE, Federal Employees Health Benefit Plan (FEHBP), Medical care program of the Indian Health Service of a tribal organization, a state health benefit risk pool, a Peace Corps health plan, Minnesota Employee Insurance Program (MEIP), Public Employee Insurance Program (PEIP), any plan established or maintained by a state, the United States government, or a foreign country that provides health coverage to individuals who are enrolled in the plan, the Children’s Health Insurance Program (CHIP), or any plan similar to any of the above plans provided in this state or in another state as determined by the MinnesotaCommissionersof Commerce or Health. Reproduction Treatment to enhance the reproductive ability among patients experiencing infertility, after a Treatment confirmed diagnosis of infertility has been established due to either female, male factors or unknown causes. Treatment may involve oral and/or injectable medication, surgery, artificial insemination, assisted reproductive technologies or a combination of these. Residential A facility licensed under state law in the state in which it is located that provides treatment, by Behavioral Health or under the direction of a doctor of medicine (M.D.) or osteopathy (D.O.), for mental health Treatment Facility disorders, alcoholism, substance abuse or substanceaddiction. The facility provides continuous, 24-hour supervision by a skilled staff who are directly supervised by health care professionals. Skilled nursing and medical care are available each day. A residential behavioral health treatment facility does not, other than incidentally, provide educational or recreational services as part of its treatment program. Respite Care Short-term inpatient or home care provided to the patient when necessary to relieve family members or other persons caring for the patient. Page97 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Retail Health Clinic A clinic located in a retail establishment or worksite. The clinic provides medical services for a limited list of eligible symptoms (e.g., sore throat, cold). If the presenting symptoms are not on the list, the member will be directed to seek services from a physician or hospital. Retail Health Clinics are staffed by eligible nurse practitioners or other eligible providers that have a practice arrangement with a physician. The list of available medical services and/or treatable symptoms is available at the Retail Health Clinic. Access to Retail Health Clinic services is available on a walk-in basis. Retail Pharmacy Any licensed pharmacy that you can physically enter to obtain a prescription drug. Semiprivate Room A room with two (2) beds. Services Health care service, procedures, treatments, durable medical equipment, medical supplies and prescription drugs. Skilled Care Services that are medically necessary and provided by alicensed nurse or other licensed health care professional. A service shall not be considered skilled care merely because it is performed by, or under the direct supervision of, a licensed nurse. Services such as tracheotomy suctioning or ventilator monitoring, thatcan be safely and effectively performed by a non-medical person (or self-administered) without direct supervision of a licensed nurse, shall not be regarded as skilled care, whether or not a licensed nurse actually provides the service. The unavailability of a component person to provide a non-skilled service shall not make it skilled care when a licensed nurse provides the service. Only the skilled care component of combined services that include non-skilled care are covered under the Plan. Skilled Nursing A Medicare-approved facility that provides skilled transitional care, by or under the direction of Facility a doctor of medicine (M.D.) or osteopathy (D.O.), after a hospital stay. A skilled nursing facility provides 24-hour-a-day professional registered nursing (R.N.) services. Skills Training Training of basic living and social skills that restore a patient's skills essential for managing his or her illness, treatment and the requirements of everyday independent living. Smoking Cessation Prescription drugs and over-the-counter products that aid in reducing or eliminating the use of Drugs nicotine. Specialty Drugs Specialty drugs are designatedcomplex injectable and oral drugs that have very specific manufacturing, storage, and dilution requirements. Specialty drugs are drugsincluding, but not limited todrugs used for:infertility;growth hormone treatment; multiple sclerosis;rheumatoid arthritis; hepatitisC;andhemophilia. Specialty Pharmacy A nationwide pharmaceutical specialty provider that participates in a network for the Network dispensing of certain oral medications and injectable drugs. Step Therapy Step Therapyincludes, but is not limited tomedications in specific categories or drug classes. If your physician prescribes one of these medications, there must be documented evidence that you have tried another eligible medication in the same or different drug class before the Step Therapymedication will be paid under the drug benefit. Substance Abuse Alcohol, drug dependence or other addictions as defined in the most current edition of the and/or Addictions International Classification of Diseases. Supervised Health care professional employed by a doctor of medicine, osteopathy, chiropractic, dental Employees surgery or a MinnesotaRule 29 behavioral health treatment facility licensed by the Minnesota Department of Human Services. The employing M.D., D.O., D.C., D.D.S., or mental health professional must be physically present and immediately available in the same office suite more than 50% of each day when the employed health care professional is providing services. Independent contractors are not eligible. Page98 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6 TermDefinition Supply Equipment that must be medically necessary for the medical treatment or diagnosis of an illness or injury or to improve functioning of a malformed body part. Supplies are not reusable, and usually last for less than one (1) year. Supplies do not include such things as: 1.alcohol swabs; 2.cotton balls; 3.incontinence liners/pads; 4.Q-tips; 5.adhesives; or 6.informational materials. Surrogate An arrangement whereby a woman who is not covered under this Plan becomes pregnant for Pregnancy the purpose of gestating and giving birth to a child for others to raise. Pregnancy may have been the result of conventional means, artificial insemination or assisted reproductive technologies. Televideo Interactive audio and video communications, permitting real-time communications between a Conferencing distant site health care professional and the patient whom is present and participating in the televideo visit at a remote facility. Terminally Ill An individual who has a life expectancy of six (6) months or less, as certified by the person's Patient primary physician. Therapeutic Camps A structured recreational program of behavioral health treatment and care provided by an enrolled family community support services provider that is licensed as a day program. The campsare accredited as a camp by the American Camping Association. Therapeutic Day A licensed program that provides behavioral health care services to a child who is at least 33 Care (Pre-School) months old but who has not yet attended the first day of kindergarten. The therapeutic components of a pre-school program must be available at least one (1) day a week for a minimum two (2)-hour time block. Services may include individual or group psychotherapy and a combination of the following activities: recreational therapy, socialization therapy and independent living skills therapy. Therapeutic Behavioral health training, support services, and clinical supervision provided to foster families Support of Foster caring for children with severe emotional disturbance. The intended purpose is to provide a Care therapeutic family environment and support for the child’s improved functioning. Treatment The management and care of a patient for the purpose of combating an illness. Treatment includes medical surgical care, diagnostic evaluation, giving medical advice, monitoring, and taking medication. Waiting Period The period of time that must pass before you or your dependents are eligible for coverage underthisPlan. Page99 SVCGNC:2000-5362 / SVCGNC32A / tppprd X17342-R6